You are on page 1of 180

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
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/0.9ML 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/0.5ML Not Covered
ACTIMMUNE SOLN 2000000UNIT/0.5ML Not Covered
160MG; 2100UNIT;
400UNIT; 1MG; 30MCG;
1250MCG; 75MG; 30MG;
20MG; 20MG; 4MG; 4MG;
ACTIVE FE TABS 40UNIT; 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 TABS 850MG; 15MG Not Covered

ACTOPLUS MET XR TB24 1000MG; 15MG Not Covered

ACTOPLUS MET XR TB24 1000MG; 30MG Not Covered


ACTOS TABS 15MG Not Covered
ACTOS TABS 30MG Not Covered
ACTOS TABS 45MG Not Covered
ACULAR SOLN 0.50% Not Covered
ACUVAIL SOLN 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
15.5MCG/0.5ML;
ADACEL SUSP 2LF/0.5ML; 5LF/0.5ML Covered QL AL
ADAGEN SOLN 250UNIT/ML Not Covered
ADAPALENE GEL 0.10% Covered AL
ADAPALENE LOTN 0.10% Not Covered AL

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 3 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


ADAPALENE GEL 0.30% Not Covered

ADAPALENE CREA 0.10% Covered ST


ADAZIN CREA 2%; 0.035%; 2%; 10% Not Covered
ADCIRCA TABS 20MG Covered PA QL
1.25MG; 1.25MG; 1.25MG;
ADDERALL XR CP24 1.25MG Not Covered
ADDERALL XR CP24 5MG; 5MG; 5MG; 5MG Not Covered
6.25MG; 6.25MG; 6.25MG;
ADDERALL XR CP24 6.25MG Not Covered
3.75MG; 3.75MG; 3.75MG;
ADDERALL XR CP24 3.75MG Not Covered
2.5MG; 2.5MG; 2.5MG;
ADDERALL XR CP24 2.5MG Not Covered
7.5MG; 7.5MG; 7.5MG;
ADDERALL XR CP24 7.5MG Not Covered
ADEFOVIR
DIPIVOXIL TABS 10MG Covered
ADEMPAS TABS 1.5MG Covered PA QL
ADEMPAS TABS 2MG Covered PA QL
ADEMPAS TABS 0.5MG Covered PA QL
ADEMPAS TABS 1MG Covered PA QL
ADEMPAS TABS 2.5MG 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;
ADVAIR DISKUS AEPB 50MCG/DOSE Not Covered
500MCG/DOSE;
ADVAIR DISKUS AEPB 50MCG/DOSE Not Covered
100MCG/DOSE;
ADVAIR DISKUS AEPB 50MCG/DOSE Not Covered

ADVAIR HFA AERO 45MCG/ACT; 21MCG/ACT Not Covered

ADVAIR HFA AERO 230MCG/ACT; 21MCG/ACT Not Covered

ADVAIR HFA AERO 115MCG/ACT; 21MCG/ACT Not Covered

0; 0; 0; 0; 0; 0; 0; 10MG;
ADVANCED AM/PM MISC 100MG; 650MG; 0; 50UNIT Covered
ADVATE SOLR 1000UNIT Not Covered
ADVICOR TB24 20MG; 500MG Not Covered
ADVICOR TB24 20MG; 1000MG Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 4 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


ADVICOR TB24 20MG; 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 2.5MG 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; 200MG Not Covered
AIMSCO
LUBRICATED MISC Covered QL
AKYNZEO CAPS 300MG; 0.5MG Not Covered
ALAVERT TABS 10MG Covered
ALAVERT
ALLERGY/SINUS TB12 5MG; 120MG Not Covered
ALAWAY SOLN 0.03% 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 0.08% 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


ALBUTEROL
SULFATE TABS 4MG Covered
ALBUTEROL
SULFATE NEBU 0.50% Covered
ALBUTEROL
SULFATE NEBU 0.63MG/3ML Covered QL
ALBUTEROL
SULFATE NEBU 1.25MG/3ML Covered QL
ALCALAK CHEW 420MG Covered
ALCLOMETASONE
DIPROPIONATE OINT 0.05% Not Covered
ALCLOMETASONE
DIPROPIONATE CREA 0.05% Not Covered
ALCOHOL PREP
PADS PADS 70% Covered
ALCORTIN A GEL 1%; 2%; 1% Not Covered
ALDARA CREA 5% Not Covered
ALDURAZYME SOLN 2.9MG/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
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; 120MG Not Covered
ALLEGRA-D 24
HOUR ALLERGY &
CONGESTION TB24 180MG; 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 12.5MG/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; 240MG Not Covered
ALLERGY-TIME TABS 4MG Covered
ALLOPURINOL TABS 100MG Covered QL
ALLOPURINOL TABS 300MG Covered QL

ALMACONE DOUBLE 400MG/5ML; 400MG/5ML;


STRENGTH SUSP 40MG/5ML Covered
ALMOTRIPTAN
MALATE TABS 6.25MG Covered QL
ALMOTRIPTAN
MALATE TABS 12.5MG Covered QL
ALOMIDE SOLN 0.10% Not Covered
ALORA PTTW 0.1MG/24HR Not Covered
ALORA PTTW 0.025MG/24HR Not Covered
ALORA PTTW 0.05MG/24HR Not Covered
ALORA PTTW 0.075MG/24HR Not Covered
ALOSETRON
HYDROCHLORIDE TABS 0.5MG 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


ALPHAGAN P SOLN 0.15% Not Covered
ALPHAGAN P SOLN 0.10% Not Covered
ALPHANATE/VON
WILLEBRAND
FACTOR
COMPLEX/HUMAN SOLR 500UNIT Not Covered
ALPHAQUIN HP CREA 5%; 4%; 7.5% Not Covered
ALPRAZOLAM TABS 1MG Not Covered
ALPRAZOLAM TABS 2MG Not Covered
ALPRAZOLAM TABS 0.25MG Not Covered
ALPRAZOLAM TABS 0.5MG Not Covered
ALPRAZOLAM ER TB24 1MG Not Covered
ALPRAZOLAM ER TB24 2MG Not Covered
ALPRAZOLAM ER TB24 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 0.5MG 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/0.5ML Not Covered
ALTABAX OINT 1% Not Covered
ALTAVERA TABS 0.03MG; 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; 1MG Covered
ALYACEN 7/7/7 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 6.25MG Not Covered
AMBIEN CR TBCR 12.5MG Not Covered
AMCINONIDE OINT 0.10% Not Covered
AMCINONIDE LOTN 0.10% Not Covered
AMCINONIDE CREA 0.10% Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 8 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


AMETHIA TABS 0; 0 Not Covered
AMETHIA LO TABS 0; 0 Not Covered
AMETHYST TABS 20MCG; 90MCG Not Covered
AMILORIDE HCL TABS 5MG Covered QL

AMILORIDE/HYDRO
CHLOROTHIAZIDE 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 2.5MG 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; 80MG Not Covered
AMLODIPINE
BESYLATE/ATORVA
STATIN CALCIUM TABS 10MG; 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


AMLODIPINE
BESYLATE/ATORVA
STATIN CALCIUM TABS 2.5MG; 10MG Not Covered
AMLODIPINE
BESYLATE/ATORVA
STATIN CALCIUM TABS 10MG; 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; 40MG Not Covered
AMLODIPINE
BESYLATE/ATORVA
STATIN CALCIUM TABS 2.5MG; 20MG Not Covered
AMLODIPINE
BESYLATE/ATORVA
STATIN CALCIUM TABS 2.5MG; 40MG Not Covered
AMLODIPINE
BESYLATE/ATORVA
STATIN CALCIUM TABS 10MG; 10MG Not Covered
AMLODIPINE
BESYLATE/BENAZE
PRIL
HYDROCHLORIDE CAPS 2.5MG; 10MG Covered QL
AMLODIPINE
BESYLATE/BENAZE
PRIL
HYDROCHLORIDE CAPS 5MG; 10MG Covered QL
AMLODIPINE
BESYLATE/BENAZE
PRIL
HYDROCHLORIDE CAPS 5MG; 20MG Covered QL
AMLODIPINE
BESYLATE/BENAZE
PRIL
HYDROCHLORIDE CAPS 5MG; 40MG Covered QL
AMLODIPINE
BESYLATE/BENAZE
PRIL
HYDROCHLORIDE CAPS 10MG; 20MG Covered QL

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 10 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


AMLODIPINE
BESYLATE/BENAZE
PRIL
HYDROCHLORIDE CAPS 10MG; 40MG Covered QL
AMLODIPINE
BESYLATE/VALSART
AN TABS 5MG; 160MG Not Covered
AMLODIPINE
BESYLATE/VALSART
AN TABS 10MG; 160MG Not Covered
AMLODIPINE
BESYLATE/VALSART
AN TABS 5MG; 320MG Not Covered
AMLODIPINE
BESYLATE/VALSART
AN TABS 10MG; 320MG Not Covered
AMLODIPINE/VALSA
RTAN/HCTZ TABS 10MG; 25MG; 320MG Not Covered
AMLODIPINE/VALSA
RTAN/HCTZ TABS 5MG; 25MG; 160MG Not Covered
AMLODIPINE/VALSA
RTAN/HCTZ TABS 10MG; 25MG; 160MG Not Covered
AMLODIPINE/VALSA
RTAN/HCTZ TABS 10MG; 12.5MG; 160MG Not Covered
AMLODIPINE/VALSA
RTAN/HCTZ TABS 5MG; 12.5MG; 160MG Not Covered
AMMONIUM
LACTATE CREA 12% Covered QL
AMMONIUM
LACTATE LOTN 12% Covered QL
AMMONUL SOLN 10%; 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


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 SUSR 200MG/5ML; 28.5MG/5ML Covered AL
AMOXICILLIN/CLAVU
LANATE
POTASSIUM SUSR 400MG/5ML; 57MG/5ML Covered AL
AMOXICILLIN/CLAVU
LANATE
POTASSIUM CHEW 200MG; 28.5MG Covered AL
AMOXICILLIN/CLAVU
LANATE
POTASSIUM CHEW 400MG; 57MG Covered AL
AMOXICILLIN/CLAVU
LANATE
POTASSIUM SUSR 600MG/5ML; 42.9MG/5ML Covered AL
AMOXICILLIN/CLAVU
LANATE
POTASSIUM SUSR 250MG/5ML; 62.5MG/5ML Covered AL
AMOXICILLIN/CLAVU
LANATE
POTASSIUM TABS 500MG; 125MG Covered
AMOXICILLIN/CLAVU
LANATE
POTASSIUM TABS 250MG; 125MG Covered
AMOXICILLIN/CLAVU
LANATE
POTASSIUM ER TB12 1000MG; 62.5MG Covered

AMPHETAMINE/DEX 2.5MG; 2.5MG; 2.5MG;


TROAMPHETAMINE TABS 2.5MG Not Covered

AMPHETAMINE/DEX 7.5MG; 7.5MG; 7.5MG;


TROAMPHETAMINE TABS 7.5MG Not Covered

AMPHETAMINE/DEX
TROAMPHETAMINE TABS 5MG; 5MG; 5MG; 5MG Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 12 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL

AMPHETAMINE/DEX 1.25MG; 1.25MG; 1.25MG;


TROAMPHETAMINE TABS 1.25MG Not Covered

AMPHETAMINE/DEX 3.75MG; 3.75MG; 3.75MG;


TROAMPHETAMINE TABS 3.75MG Not Covered

AMPHETAMINE/DEX 3.125MG; 3.125MG;


TROAMPHETAMINE TABS 3.125MG; 3.125MG Not Covered

AMPHETAMINE/DEX 2.5MG; 2.5MG; 2.5MG;


TROAMPHETAMINE CP24 2.5MG Not Covered

AMPHETAMINE/DEX
TROAMPHETAMINE CP24 5MG; 5MG; 5MG; 5MG Not Covered

AMPHETAMINE/DEX 7.5MG; 7.5MG; 7.5MG;


TROAMPHETAMINE CP24 7.5MG Not Covered

AMPHETAMINE/DEX 6.25MG; 6.25MG; 6.25MG;


TROAMPHETAMINE CP24 6.25MG Not Covered

AMPHETAMINE/DEX 1.25MG; 1.25MG; 1.25MG;


TROAMPHETAMINE CP24 1.25MG Not Covered

AMPHETAMINE/DEX 3.75MG; 3.75MG; 3.75MG;


TROAMPHETAMINE CP24 3.75MG Not Covered

AMPHETAMINE/DEX 1.875MG; 1.875MG;


TROAMPHETAMINE TABS 1.875MG; 1.875MG 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; 5MG; 12.5MG Covered QL
ANAGRELIDE
HYDROCHLORIDE CAPS 0.5MG Covered
ANAGRELIDE
HYDROCHLORIDE CAPS 1MG Covered
ANALPRAM-HC LOTN 2.5%; 1% Not Covered
ANALPRAM-HC CREA 1%; 1% Not Covered
ANALPRAM-HC CREA 2.5%; 1% Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 13 of 178
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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


ARANESP ALBUMIN
FREE SOSY 25MCG/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; 200MCG Not Covered
ARTHROTEC 75 TBEC 75MG; 200MCG Not Covered
ARTIFICIAL TEARS SOLN 1.40% Covered
ARTIFICIAL TEARS SOLN 0.5%; 0.6% Covered
ASACOL HD TBEC 800MG Covered QL
ASCRIPTIN TABS 0; 325MG; 0; 0; 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
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; 200MG Covered
ASPIRIN-CAFFEINE-
DIHYDROCODEINE CAPS 356.4MG; 30MG; 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 0.5MG Not Covered
ASTAGRAF XL CP24 5MG Not Covered
ASTEPRO SOLN 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; 12.5MG Not Covered
ATACAND HCT TABS 32MG; 12.5MG Not Covered
ATACAND HCT TABS 32MG; 25MG Not Covered
ATELVIA TBEC 35MG Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 18 of 178
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; 25MG Covered
ATENOLOL/CHLORT
HALIDONE TABS 100MG; 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; 100MG Not Covered
ATRALIN GEL 0.05% Not Covered
ATRIPLA TABS 600MG; 200MG; 300MG Not Covered

ATROPINE SULFATE SOLN 1% Covered

ATROPINE SULFATE OINT 1% Covered


ATROVENT SOLN 0.06% Covered
ATROVENT SOLN 0.03% Covered
ATROVENT HFA AERS 17MCG/ACT Covered
AUBAGIO TABS 14MG Not Covered
AUBAGIO TABS 7MG Not Covered
AUGMENTED
BETAMETHASONE
DIPROPIONATE OINT 0.05% Covered
AUGMENTED
BETAMETHASONE
DIPROPIONATE GEL 0.05% Covered
AUGMENTED
BETAMETHASONE
DIPROPIONATE CREA 0.05% Covered
AURYXIA TABS 210MG Covered
AUVI-Q SOAJ 0.15MG/0.15ML Not Covered
AUVI-Q SOAJ 0.3MG/0.3ML Not Covered
AVANDAMET TABS 1000MG; 2MG Not Covered
AVANDAMET TABS 500MG; 2MG Not Covered
AVANDAMET TABS 1000MG; 4MG Not Covered
AVANDAMET TABS 500MG; 4MG Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 19 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


AVANDARYL TABS 1MG; 4MG Covered
AVANDARYL TABS 2MG; 4MG Covered
AVANDARYL TABS 4MG; 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; 0.1MG Covered
AVODART CAPS 0.5MG Not Covered
AVONEX KIT 30MCG/VIAL Covered QL
AVONEX PSKT 30MCG/0.5ML Covered QL
AVONEX PEN AJKT 30MCG/0.5ML Covered QL
AVYCAZ SOLR 0.5GM; 2GM Not Covered
AXERT TABS 12.5MG Not Covered
AXERT TABS 6.25MG Not Covered
AXIRON SOLN 30MG/ACT Not Covered
AZASITE SOLN 1% Not Covered
AZATHIOPRINE TABS 50MG Covered QL
AZELASTINE HCL SOLN 0.10% Covered QL
AZELASTINE HCL SOLN 0.05% Covered
AZELASTINE HCL SOLN 0.15% 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; 20MG Not Covered
AZOR TABS 10MG; 40MG Not Covered
AZOR TABS 5MG; 40MG Not Covered
AZOR TABS 10MG; 20MG Not Covered
AZURETTE TABS 0; 0 Covered

5MG; 1MCG; 60MG; 20MG;


B COMPLEX CAPS 0.5MG; 3MG; 3MG; 60MG Covered
B
COMPLEX/VITAMIN 300MG; 10MG; 50MG;
C CAPS 5MG; 10.2MG; 15MG Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 20 of 178
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;
CIN/POLYMYXIN OINT 5000UNIT/GM Covered
BACITRACIN/POLYM 500UNIT/GM;
YXIN B OINT 10000UNIT/GM Covered
BACLOFEN TABS 10MG Covered AL
BACLOFEN TABS 20MG Covered AL

500MG; 150MCG; 25MG;


0.1MG; 3MG; 50MCG;
27MG; 1MG; 50MG; 50MG;
5MG; 100MG; 25MG;
20MG; 50MCG; 20MG;
BACMIN TABS 30UNIT; 5000UNIT; 22.5MG Covered
BACTROBAN CREA 2% Not Covered
BACTROBAN OINT 2% Not Covered

BACTROBAN NASAL OINT 2% Not Covered


0.3MG; 25MCG; 25MCG;
BALANCED B 25MG; 25MG; 25MG;
COMPLEX TABS 25MG; 25MG Covered
BALSALAZIDE
DISODIUM CAPS 750MG Covered
BALZIVA TABS 35MCG; 0.4MG Covered
BANOPHEN LIQD 12.5MG/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 0.05MG/ML Not Covered
BARACLUDE TABS 0.5MG 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
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; 140MG Covered
BAZA ANTIFUNGAL CREA 2% Covered
2%; 2MG/ML; 100MG/ML;
2MG/ML; 2MG/ML;
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-
100/0.5ML/28G X 1/2" MISC Covered

BD INSULIN
SYRINGE
MICROFINE/U-
100/0.3ML/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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


BD INTEGRA
SYRINGE/3ML/22G X
1.5" 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" 12.7MM 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; 12.5MG Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 23 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


BENAZEPRIL
HCL/HYDROCHLOR
OTHIAZIDE TABS 20MG; 12.5MG Not Covered
BENAZEPRIL
HCL/HYDROCHLOR
OTHIAZIDE TABS 5MG; 6.25MG Not Covered
BENAZEPRIL
HCL/HYDROCHLOR
OTHIAZIDE TABS 20MG; 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; 40MG Not Covered
BENICAR HCT TABS 12.5MG; 20MG Not Covered
BENICAR HCT TABS 12.5MG; 40MG Not Covered
BENZACLIN GEL 5%; 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 0.5MG Not Covered
BEPREVE SOLN 1.50% Not Covered
BERINERT KIT 500UNIT Not Covered
BESIVANCE SUSP 0.60% Not Covered
BETA HC LOTN 1% Covered
BETAMETHASONE
DIPROPIONATE LOTN 0.05% Not Covered
BETAMETHASONE
DIPROPIONATE CREA 0.05% Covered
BETAMETHASONE
VALERATE CREA 0.10% Covered
BETAMETHASONE
VALERATE OINT 0.10% Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 24 of 178
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
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; 50MG Covered QL AL
BUTALBITAL/ACETA
MINOPHEN/CAFFEIN
E TABS 325MG; 50MG; 40MG Covered QL AL
BUTALBITAL/ACETA
MINOPHEN/CAFFEIN
E TABS 500MG; 50MG; 40MG Covered
BUTALBITAL/ACETA
MINOPHEN/CAFFEIN
E CAPS 300MG; 50MG; 40MG Not Covered QL
BUTALBITAL/ACETA
MINOPHEN/CAFFEIN
E CAPS 325MG; 50MG; 40MG Covered QL AL
BUTALBITAL/ACETA
MINOPHEN/CAFFEIN 300MG; 50MG; 40MG;
E/CODEINE CAPS 30MG Not Covered
BUTALBITAL/ACETA
MINOPHEN/CAFFEIN 325MG; 50MG; 40MG;
E/CODEINE CAPS 30MG Covered QL
BUTALBITAL/ASPIRI
N/CAFFEINE CAPS 325MG; 50MG; 40MG Covered QL AL
BUTALBITAL/ASPIRI
N/CAFFEINE/CODEI 325MG; 50MG; 40MG;
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 7.5MCG/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
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/0.02ML Not Covered
BYETTA SOPN 10MCG/0.04ML Not Covered
BYSTOLIC TABS 2.5MG Not Covered
BYSTOLIC TABS 5MG Not Covered
BYSTOLIC TABS 10MG Not Covered
CABERGOLINE TABS 0.5MG Covered
CADUET TABS 2.5MG; 10MG Not Covered
CADUET TABS 10MG; 10MG Not Covered
CADUET TABS 5MG; 10MG Not Covered

CAFFEINE CITRATE SOLN 60MG/3ML Covered AL


CALAMINE LOTN 0 Not Covered
CALCIFEROL SOLN 8000UNIT/ML Covered
CALCIPOTRIENE SOLN 0.01% Covered
CALCIPOTRIENE CREA 0.01% Covered
CALCIPOTRIENE OINT 0.01% Covered
CALCITONIN-
SALMON SOLN 200UNIT/ACT Covered
CALCITRENE OINT 0.01% Not Covered
CALCITRIOL SOLN 1MCG/ML Covered AL
CALCITRIOL CAPS 0.25MCG Covered QL
CALCITRIOL OINT 3MCG/GM Not Covered
CALCITRIOL CAPS 0.5MCG 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 0.35MG Covered
CAMPRAL TBEC 333MG Not Covered
CAMRESE TABS 0; 0 Not Covered
CAMRESE LO TABS 0; 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
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; 25MG Not Covered
CANDESARTAN
CILEXETIL/HYDROC
HLOROTHIAZIDE TABS 16MG; 12.5MG Not Covered
CANDESARTAN
CILEXETIL/HYDROC
HLOROTHIAZIDE TABS 32MG; 12.5MG 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 0.03% Covered
CAPTOPRIL TABS 12.5MG Covered
CAPTOPRIL TABS 100MG Covered
CAPTOPRIL TABS 25MG Covered
CAPTOPRIL TABS 50MG Covered

CAPTOPRIL/HYDRO
CHLOROTHIAZIDE TABS 50MG; 15MG Not Covered

CAPTOPRIL/HYDRO
CHLOROTHIAZIDE TABS 25MG; 25MG Not Covered

CAPTOPRIL/HYDRO
CHLOROTHIAZIDE TABS 50MG; 25MG Not Covered

CAPTOPRIL/HYDRO
CHLOROTHIAZIDE TABS 25MG; 15MG Not Covered
CARAC CREA 0.50% 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
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; 100MG Covered
CARBIDOPA/LEVOD
OPA TABS 25MG; 250MG Covered
CARBIDOPA/LEVOD
OPA TABS 25MG; 100MG Covered
CARBIDOPA/LEVOD
OPA ER TBCR 25MG; 100MG Covered
CARBIDOPA/LEVOD
OPA ER TBCR 50MG; 200MG Covered
CARBIDOPA/LEVOD
OPA ODT TBDP 10MG; 100MG Covered
CARBIDOPA/LEVOD
OPA ODT TBDP 25MG; 100MG Covered QL
CARBIDOPA/LEVOD
OPA ODT TBDP 25MG; 250MG Covered

CARBIDOPA/LEVOD
OPA/ENTACAPONE TABS 12.5MG; 200MG; 50MG Not Covered

CARBIDOPA/LEVOD
OPA/ENTACAPONE TABS 18.75MG; 200MG; 75MG Not Covered

CARBIDOPA/LEVOD
OPA/ENTACAPONE TABS 25MG; 200MG; 100MG Not Covered

CARBIDOPA/LEVOD
OPA/ENTACAPONE TABS 50MG; 200MG; 200MG Not Covered

CARBIDOPA/LEVOD
OPA/ENTACAPONE TABS 31.25MG; 200MG; 125MG Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 31 of 178
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
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; 2.5MG Not Covered
CHLORDIAZEPOXID
E/AMITRIPTYLINE TABS 12.5MG; 5MG Not Covered
CHLORDIAZEPOXID
E/AMITRIPTYLINE TABS 25MG; 10MG Not Covered
CHLORHEXIDINE
GLUCONATE ORAL
RINSE SOLN 0.12% 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


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 0.77% 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 0.2%; 1% Not Covered
CIPRODEX SUSP 0.3%; 0.1% Covered AL
CIPROFLOXACIN SUSR 250MG/5ML Covered AL
CIPROFLOXACIN SUSR 500MG/5ML Covered AL

CIPROFLOXACIN ER TB24 1000MG; 0 Not Covered

CIPROFLOXACIN ER TB24 500MG; 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
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 0.30% 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; 159MG; 400UNIT;
2MG; 300MG; 50MG;
0.75MG; 0; 1MG; 90MG; 0;
20MG; 150MCG; 20MG;
3.4MG; 3MG; 30UNIT;
CITRANATAL 90 DHA MISC 25MG Not Covered
120MG; 124MG; 400UNIT;
2MG; 50MG; 0; 1MG;
27MG; 0; 20MG; 150MCG;
20MG; 3.4MG; 3MG;
CITRANATAL RX TABS 30UNIT; 25MG Not Covered

CITRUS BERGAMOT POWD 250MG/0.25GM 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%; 5% Not Covered
CLARIS CLARIFYING
WASH EMUL 10%; 4%; 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
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; 120MG Not Covered
CLARITIN-D 24
HOUR TB24 10MG; 240MG Not Covered
CLEAR-ATADINE D TB24 10MG; 240MG Not Covered
CLEMASTINE
FUMARATE TABS 2.68MG Covered
CLEMASTINE
FUMARATE SYRP 0.67MG/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%; 1% Not Covered
CLINDAMYCIN/BENZ
OYL PEROXIDE GEL 5%; 1.2% Not Covered
CLOBETASOL
PROPIONATE OINT 0.05% Covered PA QL
CLOBETASOL
PROPIONATE CREA 0.05% Covered PA QL
CLOBETASOL
PROPIONATE GEL 0.05% Not Covered
CLOBETASOL
PROPIONATE SOLN 0.05% Covered QL
CLOBETASOL
PROPIONATE SHAM 0.05% Not Covered
CLOBETASOL
PROPIONATE FOAM 0.05% Not Covered
CLOBETASOL
PROPIONATE LOTN 0.05% Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 38 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


CLOBETASOL
PROPIONATE E CREA 0.05% Not Covered
CLOBEX LOTN 0.05% Not Covered
CLOBEX SHAM 0.05% Not Covered
CLOBEX LIQD 0.05% Not Covered
CLOCORTOLONE
PIVALATE CREA 0.10% Not Covered QL
CLOCORTOLONE
PIVALATE PUMP CREA 0.10% Not Covered
CLODERM CREA 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 0.5MG Not Covered
CLONAZEPAM TABS 1MG Not Covered
CLONAZEPAM ODT TBDP 2MG Not Covered
CLONAZEPAM ODT TBDP 0.125MG Not Covered
CLONAZEPAM ODT TBDP 1MG Not Covered
CLONAZEPAM ODT TBDP 0.25MG Not Covered
CLONAZEPAM ODT TBDP 0.5MG Not Covered
CLONIDINE HCL TABS 0.1MG Covered
CLONIDINE HCL TABS 0.2MG Covered
CLONIDINE HCL TABS 0.3MG Covered
CLONIDINE HCL PTWK 0.3MG/24HR Not Covered
CLONIDINE HCL PTWK 0.1MG/24HR Not Covered
CLONIDINE HCL PTWK 0.2MG/24HR Not Covered

CLONIDINE HCL ER TB12 0.1MG Not Covered


CLOPIDOGREL TABS 75MG Covered QL
CLORAZEPATE
DIPOTASSIUM TABS 7.5MG Not Covered
CLORAZEPATE
DIPOTASSIUM TABS 15MG Not Covered
CLORAZEPATE
DIPOTASSIUM TABS 3.75MG Not Covered
CLORPRES TABS 15MG; 0.2MG Not Covered
CLORPRES TABS 15MG; 0.1MG Not Covered
CLORPRES TABS 15MG; 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


CLOTRIMAZOLE/BET
AMETHASONE
DIPROPIONATE CREA 0.05%; 1% Not Covered
CLOZAPINE TABS 25MG Not Covered
CLOZAPINE TABS 50MG Not Covered
CLOZAPINE TABS 100MG Not Covered
CLOZAPINE ODT TBDP 12.5MG 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 0.6MG Covered QL
COLCRYS TABS 0.6MG 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 227.1GM; 2.82GM; 6.36GM;
PACKS SOLR 5.53GM; 21.5GM Covered
COLYTE-FLAVOR 240GM; 2.98GM; 6.72GM;
PACKS SOLR 5.84GM; 22.72GM Covered

COMBIVENT AERO 103MCG/ACT; 18MCG/ACT Covered


COMBIVENT
RESPIMAT AERS 100MCG/ACT; 20MCG/ACT Covered QL
COMBIVIR TABS 150MG; 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


COMETRIQ KIT 20MG Not Covered
COMPLERA TABS 200MG; 25MG; 300MG Not Covered
120MG; 1000UNIT;
400UNIT; 12MCG; 29MG;
1MG; 20MG; 10MG; 3MG;
COMPLETENATE CHEW 2MG; 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; 8MG Not Covered
CONTROLRX CREA 1.10% 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 0.05% 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 7.5MG Not Covered
CORLOPAM SOLN 10MG/ML Covered
CORTANE-B 1MG/ML; 10MG/ML;
AQUEOUS SOLN 10MG/ML Not Covered
CORTROSYN SOLR 0.25MG Not Covered

375MG; 750UNIT; 75MCG;


315UNIT; 150MCG; 1MG;
70MCG; 125UNIT; 1.25MG;
13MG; 10MG; 7MG; 2.5MG;
35MG; 35MG; 5MG; 35MG;
3.4MG; 125MCG; 25MG;
CORVITA TABS 35MG Covered
120MG; 15MCG; 1.25MG;
CORVITA 150 TABS 150MG; 10MG; 25MG Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 41 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL

375MG; 750UNIT; 75MCG;


315UNIT; 150MCG; 1MG;
70MCG; 125UNIT; 1.25MG;
13MG; 10MG; 7MG; 2.5MG;
35MG; 35MG; 5MG; 35MG;
3.4MG; 125MCG; 25MG;
CORVITE TABS 35MG Covered
100MCG; 120MG; 5MG;
20MCG; 700MCG; 150MG;
300MCG; 10MG; 10MG;
CORVITE 150 TABS 25MG Covered

120MG; 5MG; 1000UNIT;


15MCG; 15MG; 25MG;
CORVITE FE TABS 1MG; 125MG; 10MG; 25MG Covered

10MG; 500MG; 75MCG;


400UNIT; 150MCG; 35MG;
1MG; 70MCG; 125UNIT;
1.25MG; 400MCG;
125MCG; 35MG; 35MG;
5MG; 35MG; 3.4MG;
CORVITE FREE TABS 125MCG; 25MG; 35MG Covered
CORZIDE TABS 5MG; 40MG Not Covered
CORZIDE TABS 5MG; 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 7.5MG Not Covered
COUMADIN TABS 6MG Not Covered
COUMADIN TABS 5MG Not Covered
COUMADIN TABS 2MG Not Covered
COUMADIN TABS 2.5MG Not Covered
COUMADIN TABS 3MG Not Covered
COVARYX HS TABS 0.625MG; 1.25MG Not Covered
30000UNIT; 6000UNIT;
CREON CPEP 19000UNIT Covered QL
15000UNIT; 3000UNIT;
CREON CPEP 9500UNIT Covered QL

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 42 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


180000UNIT; 36000UNIT;
CREON CPEP 114000UNIT Covered QL
60000UNIT; 12000UNIT;
CREON CPEP 38000UNIT Covered QL
120000UNIT; 24000UNIT;
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 5.2MG/ACT Covered
CROMOLYN
SODIUM SOLN 4% Covered
CROMOLYN
SODIUM NEBU 20MG/2ML Covered
CRYSELLE-28 TABS 30MCG; 0.3MG Covered
CUVPOSA SOLN 1MG/5ML Not Covered
CYCLAFEM 1/35 TABS 35MCG; 1MG Covered
CYCLAFEM 7/7/7 TABS 0; 0 Covered
CYCLOBENZAPRINE
HCL TABS 10MG Covered AL
CYCLOBENZAPRINE
HCL TABS 5MG Covered AL
CYCLOBENZAPRINE
HCL TABS 7.5MG 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


CYCLOSERINE CAPS 250MG Covered
CYCLOSET TABS 0.8MG 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 0.44% Not Covered QL

CYTRA K CRYSTALS PACK 1002MG; 3300MG Not Covered


CYTRA-2 SOLN 334MG/5ML; 500MG/5ML Not Covered
334MG/5ML; 550MG/5ML;
CYTRA-3 SYRP 500MG/5ML Not Covered

CYTRA-K SOLN 334MG/5ML; 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; 1MG Covered
DASETTA 7/7/7 TABS 0; 0 Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 44 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


DAYSEE 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 0.01% Not Covered
DDAVP SOLN 0.01% Not Covered
DEBLITANE TABS 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 1.10% Covered
DENTAGEL GEL 1.10% 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
DERMA-
SMOOTHE/FS
SCALP OIL 0.01% Not Covered
DERMATOP OINT 0.10% Not Covered
DERMATOP CREA 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 0.2MG Covered QL
DESMOPRESSIN
ACETATE SOLN 0.01% Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 45 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


DESMOPRESSIN
ACETATE TABS 0.1MG Covered QL
DESMOPRESSIN
ACETATE SOLN 0.01% Covered
DESMOPRESSIN
ACETATE SOLN 0.01% Covered

DESOGESTREL/ETH
INYL ESTRADIOL TABS 0.15MG; 30MCG Covered

DESOGESTREL/ETH
INYL ESTRADIOL TABS 0; 0 Covered
DESONIDE LOTN 0.05% Not Covered
DESONIDE OINT 0.05% Not Covered
DESONIDE CREA 0.05% Not Covered

DESOXIMETASONE CREA 0.25% Not Covered

DESOXIMETASONE GEL 0.05% Not Covered

DESOXIMETASONE OINT 0.25% Not Covered

DESOXIMETASONE CREA 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 1.5MG Covered
DEXAMETHASONE SOLN 0.5MG/5ML Covered
DEXAMETHASONE TABS 0.5MG Covered
DEXAMETHASONE TABS 6MG Covered
DEXAMETHASONE TABS 4MG Covered
DEXAMETHASONE TABS 0.75MG Covered
DEXAMETHASONE ELIX 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


DEXAMETHASONE
SODIUM
PHOSPHATE SOLN 0.10% 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 2.5MG 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; 0.3MG; 0.006MG;
1MG; 20MG; 10MG; 10MG;
DIALYVITE TABS 1.7MG; 1.5MG Covered
100MG; 300MCG; 10MG;
30UNIT; 3MG; 1MG; 20MG;
25MG; 1.7MG; 70MCG;
DIALYVITE 3000 TABS 1.5MG; 15MG Covered
100MG; 300MCG; 10MG;
30UNIT; 5MG; 2MG; 20MG;
50MG; 1.7MG; 70MCG;
DIALYVITE 5000 TABS 1.5MG; 25MG Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 47 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


60MG; 300MCG; 10MG;
29MG; 800MCG; 6MCG;
20MG; 10MG; 1.7MG;
DIALYVITE 800/IRON TABS 1.5MG Covered

100MG; 300MCG; 10MG;


2000UNIT; 30UNIT; 3MG;
DIALYVITE 1MG; 20MG; 25MG; 1.7MG;
SUPREME D TABS 70MCG; 1.5MG; 15MG Covered

100MG; 300MCG; 10MG;


6MCG; 1MG; 20MG; 10MG;
DIALYVITE/ZINC TABS 1.7MG; 1.5MG; 50MG Covered
DIAMOX CP12 500MG Not Covered
DIASTAT ACUDIAL GEL 20MG Not Covered
DIASTAT ACUDIAL GEL 10MG Not Covered

DIASTAT PEDIATRIC GEL 2.5MG 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 2.5MG Not Covered
DIAZEPAM GEL 20MG Not Covered
DIAZEPAM
INTENSOL CONC 5MG/ML Not Covered
DICLEGIS TBEC 10MG; 10MG Not Covered
DICLOFENAC
POTASSIUM TABS 50MG Not Covered
DICLOFENAC
SODIUM SOLN 0.10% Covered
DICLOFENAC
SODIUM SOLN 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


DICLOFENAC
SODIUM/MISOPROS
TOL TBEC 75MG; 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 0.30% Not Covered
DIFFERIN LOTN 0.10% Not Covered
DIFICID TABS 200MG Not Covered
DIFLORASONE
DIACETATE CREA 0.05% 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
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 12.5MG; 320MG Not Covered
DIOVAN HCT TABS 25MG; 320MG Not Covered
DIOVAN HCT TABS 12.5MG; 160MG Not Covered
DIOVAN HCT TABS 25MG; 160MG Not Covered
DIOVAN HCT TABS 12.5MG; 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


DIPHENHYDRAMINE
HCL ELIX 12.5MG/5ML Covered AL
DIPHENHYDRAMINE
HCL MAXIMUM
STRENGTH TABS 50MG Not Covered
DIPHENOXYLATE/AT
ROPINE LIQD 0.025MG/5ML; 2.5MG/5ML Covered
DIPHENOXYLATE/AT
ROPINE TABS 0.025MG; 2.5MG Covered
DIPROLENE LOTN 0.05% 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; 8.6MG 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;
0.1037MG/5ML;
16.2MG/5ML;
DONNATAL ELIX 0.0065MG/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
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;
DOUBLE ANTIBIOTIC OINT 10000UNIT/GM Covered
DOVONEX CREA 0.01% 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 0.5MCG Covered

DOXERCALCIFEROL CAPS 1MCG Covered

DOXERCALCIFEROL CAPS 2.5MCG 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
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; 2.5GM; 40MG;
POWDER PACK 190MG; 320MG; 1.2MG Not Covered
140MG; 80MEQ; 83MG;
DRIPDROP ORS PACK 390MG; 665MG; 3MG Not Covered
DRONABINOL CAPS 5MG Covered PA
DRONABINOL CAPS 2.5MG Covered PA
DRONABINOL CAPS 10MG Covered PA

DROSPIRENONE/ET
HINYL ESTRADIOL TABS 3MG; 0.03MG 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%; 1.2% Not Covered
DUAVEE TABS 20MG; 0.45MG Not Covered
DUETACT TABS 2MG; 30MG Not Covered
DUETACT TABS 4MG; 30MG Not Covered
DUEXIS TABS 26.6MG; 800MG Not Covered

DULERA AERO 5MCG/ACT; 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 4.63MG/ML; 20MG/ML Not Covered
DUREZOL EMUL 0.05% Not Covered
DUTASTERIDE CAPS 0.5MG Covered
DYLOJECT SOLN 37.5MG/ML Not Covered
E.E.S. 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL

EARWAX
TREATMENT DROPS SOLN 6.50% 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; 12.5MG Not Covered
EDARBYCLOR TABS 40MG; 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 0.625MG; 1.25MG Not Covered
EFFERVESCENT
POTASSIUM TBEF 2GM; 2.5GM Covered
EFFERVESCENT
POTASSIUM/CHLORI 0.55GM; 0.91GM; 0.5GM;
DE TBEF 1.5GM Covered
EFFEXOR XR CP24 150MG Not Covered
EFFEXOR XR CP24 37.5MG 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; 10MG; 400UNIT;


1MG; 70MG; 5MG; 25MG;
2MG; 5MG; 10MG;
ELDERCAPS CAPS 4000UNIT; 25UNIT; 110MG Covered
ELELYSO SOLR 200UNIT Not Covered
ELESTAT SOLN 0.05% Not Covered
ELIDEL CREA 1% Covered PA QL
ELIMITE CREA 5% Not Covered
ELINEST TABS 30MCG; 0.3MG Covered
ELIPHOS TABS 667MG Covered
ELIQUIS TABS 2.5MG 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


120MG; 2100UNIT;
315UNIT; 1MG; 15MCG;
20UNIT; 1.25MG; 50MG;
15MG; 10MG; 10MG;
ELITE-OB TABS 3.4MG; 2MG; 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 0.05% Not Covered
EMBEDA CPCR 20MG; 0.8MG Not Covered
EMBEDA CPCR 50MG; 2MG Not Covered
EMBEDA CPCR 30MG; 1.2MG Not Covered
EMBEDA CPCR 60MG; 2.4MG Not Covered
EMBEDA CPCR 80MG; 3.2MG Not Covered
EMBEDA CPCR 100MG; 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 0.15MG; 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 7.5MG Not Covered
ENALAPRIL
MALEATE TABS 5MG Covered QL
ENALAPRIL
MALEATE TABS 10MG Covered QL
ENALAPRIL
MALEATE TABS 2.5MG Covered QL
ENALAPRIL
MALEATE TABS 20MG Covered QL
ENALAPRIL
MALEATE/HYDROCH
LOROTHIAZIDE TABS 10MG; 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; 12.5MG Covered QL
ENBREL SOLR 25MG Not Covered
ENBREL SOSY 50MG/ML Covered PA
ENEMEEZ MINI ENEM 283MG Covered QL
ENEMEEZ PLUS ENEM 20MG; 283MG Covered QL
ENGERIX-B INJ 10MCG/0.5ML Covered QL AL
ENGERIX-B INJ 20MCG/ML Covered QL AL
21MG; 5MG; 25MCG;
25MCG; 1.5MG; 40MG;
25MCG; 2.5MG; 2.4MG;
3.83MG; 25MCG; 25MCG;
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/0.8ML Covered QL
ENOXAPARIN
SODIUM SOLN 30MG/0.3ML Covered QL
ENOXAPARIN
SODIUM SOLN 80MG/0.8ML Covered QL
ENOXAPARIN
SODIUM SOLN 150MG/ML Covered QL
ENOXAPARIN
SODIUM SOLN 60MG/0.6ML Covered QL
ENOXAPARIN
SODIUM SOLN 40MG/0.4ML Covered QL
ENOXAPARIN
SODIUM SOLN 100MG/ML Covered QL
ENPRESSE-28 TABS 0; 0 Covered
ENSKYCE TABS 0.15MG; 30MCG Covered
ENTACAPONE TABS 200MG Not Covered
ENTECAVIR TABS 0.5MG Covered QL

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 56 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


ENTECAVIR TABS 1MG Covered QL
ENTRESTO TABS 24MG; 26MG Not Covered
ENTRESTO TABS 49MG; 51MG Not Covered
ENTRESTO TABS 97MG; 103MG Not Covered
ENULOSE SOLN 10GM/15ML Not Covered
ENVARSUS XR TB24 1MG Not Covered
ENVARSUS XR TB24 4MG Not Covered
ENVARSUS XR TB24 0.75MG Not Covered
EPANED SOLR 1MG/ML Covered AL
EPIDUO GEL 0.1%; 2.5% Not Covered
EPIDUO FORTE GEL 0.3%; 2.5% Not Covered
EPIFOAM FOAM 1%; 1% Not Covered
EPINASTINE HCL SOLN 0.05% Not Covered
EPINEPHRINE SOAJ 0.3MG/0.3ML Covered QL
EPINEPHRINE SOAJ 0.15MG/0.15ML Covered QL
EPIPEN 2-PAK SOAJ 0.3MG/0.3ML Not Covered QL
EPIPEN-JR 2-PAK SOAJ 0.15MG/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; 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 0.35MG 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
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%; 3% Covered QL
ERYTHROMYCIN/SU
LFISOXAZOLE SUSR 200MG/5ML; 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; 50MG; 40MG Covered QL AL
ESGIC CAPS 325MG; 50MG; 40MG Covered QL AL
ESOMEPRAZOLE
STRONTIUM CPDR 49.3MG Not Covered
ESTARYLLA TABS 35MCG; 0.25MG Covered
ESTAZOLAM TABS 1MG Not Covered
ESTAZOLAM TABS 2MG Not Covered
ESTERIFIED
ESTROGENS/METH
YLTESTOSTERONE
DS TABS 1.25MG; 2.5MG Covered
ESTERIFIED
ESTROGENS/METH
YLTESTOSTERONE
HS TABS 0.625MG; 1.25MG Covered
ESTRACE CREA 0.1MG/GM Covered QL
ESTRADIOL TABS 2MG Covered AL
ESTRADIOL PTWK 0.1MG/24HR Covered QL
ESTRADIOL PTWK 0.075MG/24HR Covered QL
ESTRADIOL TABS 0.5MG Covered AL
ESTRADIOL TABS 1MG Covered AL
ESTRADIOL PTWK 0.025MG/24HR Covered QL
ESTRADIOL PTWK 0.05MG/24HR Covered QL
ESTRADIOL PTWK 37.5MCG/24HR Covered QL

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 58 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


ESTRADIOL PTTW 0.1MG/24HR Covered QL
ESTRADIOL PTTW 0.0375MG/24HR Covered QL
ESTRADIOL PTTW 0.05MG/24HR Covered QL
ESTRADIOL PTWK 0.06MG/24HR Covered QL
ESTRADIOL PTTW 0.075MG/24HR Covered QL
ESTRADIOL PTTW 0.025MG/24HR Covered QL
ESTRADIOL/NORET
HINDRONE
ACETATE TABS 0.5MG; 0.1MG Covered
ESTRADIOL/NORET
HINDRONE
ACETATE TABS 1MG; 0.5MG Covered
ESTRASORB EMUL 4.35MG/1.74GM Covered
ESTRING RING 2MG Not Covered
ESTROPIPATE TABS 0.75MG Covered AL
ESTROPIPATE TABS 1.5MG 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; 150MG Not Covered
EVZIO SOAJ 0.4MG/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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


EXALGO T24A 32MG Not Covered
EXELON CAPS 4.5MG Not Covered
EXELON CAPS 3MG Not Covered
EXELON PT24 4.6MG/24HR Not Covered QL AL
EXELON PT24 13.3MG/24HR Not Covered QL AL
EXELON CAPS 1.5MG Not Covered
EXELON CAPS 6MG Not Covered
EXELON PT24 9.5MG/24HR Not Covered QL AL
EXFORGE TABS 10MG; 160MG Not Covered
EXFORGE TABS 5MG; 320MG Not Covered
EXFORGE TABS 5MG; 160MG Not Covered
EXFORGE TABS 10MG; 320MG Not Covered
EXFORGE HCT TABS 10MG; 25MG; 160MG Not Covered
EXFORGE HCT TABS 10MG; 12.5MG; 160MG Not Covered
EXFORGE HCT TABS 5MG; 12.5MG; 160MG Not Covered
EXFORGE HCT TABS 5MG; 25MG; 160MG Not Covered
EXFORGE HCT TABS 10MG; 25MG; 320MG Not Covered
EXTAVIA KIT 0.3MG Not Covered
EXTINA FOAM 2% Not Covered
FABB TABS 1MG; 2.2MG; 25MG Covered
FABIOR FOAM 0.10% Not Covered
FABRAZYME SOLR 35MG Not Covered
FALMINA TABS 20MCG; 0.1MG 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 12.5MG Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 60 of 178
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; 12MCG; 50MG; 0;
FE 90 PLUS TABS 1MG; 90MG; 0 Covered
250MG; 25MCG; 1MG;
FE C PLUS TABS 100MG Covered
250MG; 25MCG; 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 2.5MG Covered QL
FELODIPINE ER TB24 5MG Covered QL
FEMARA TABS 2.5MG Not Covered
FEMCON FE CHEW 35MCG; 0; 0.4MG Covered PA

FEMHRT LOW DOSE TABS 2.5MCG; 0.5MG Not Covered


FEMRING RING 0.1MG/24HR Not Covered
FEMRING RING 0.05MG/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
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 37.5MCG/HR Not Covered
FENTANYL PT72 62.5MCG/HR Not Covered
FENTANYL PT72 50MCG/HR Covered QL
FENTANYL PT72 87.5MCG/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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL

152MG; 300MCG; 12MCG;


FERIVA CAPS 25MG; 0; 1MG; 75MG; 0 Covered
600MCG; 175MG; 12MCG;
50MG; 75MG; 400MCG;
FERIVA 21/7 TABS 150MG; 10MG Covered
175MG; 300MCG; 1.5MG;
12MCG; 50MG; 0; 1MG;
FERIVAFA CAPS 110MG; 0; 0 Covered
75MG; 15MCG; 110MG;
FEROCON CAPS 0.5MG; 240MG Covered
FEROSUL ELIX 220MG/5ML Covered AL
120MG; 12MCG; 50MG;
FERRALET 90 TABS 1MG; 90MG Covered
120MG; 12MCG; 50MG;
FERRAPLUS 90 TABS 1MG; 90MG Covered
FERREX 150 CAPS 150MG Covered

FERREX 150 FORTE CAPS 25MCG; 1MG; 150MG Covered

FERREX 150 FORTE 60MG; 0.8MG; 25MCG;


PLUS CAPS 50MG; 1MG; 100MG; 50MG Covered
50MG; 0; 150MG; 0; 50MG;
FERREX 150 PLUS CAPS 0 Covered
140MG; 60MG; 0.8MG;
10MCG; 70MG; 81MG;
FERREX 28 TABS 1MG; 150MG Covered
FERRIPROX TABS 500MG Not Covered
FERRLECIT SOLN 12.5MG/ML Covered
10MG; 0.8MG; 15MCG;
324MG; 1MG; 6.9MG;
1.3MG; 30MG; 5MG; 6MG;
FERROCITE PLUS TABS 200MG; 10MG; 18.2MG Covered
60MG; 10MCG; 460MG;
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
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; 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; 50MG; 40MG Not Covered
300MG; 50MG; 40MG;
FIORICET/CODEINE CAPS 30MG Not Covered
FIRAZYR SOLN 30MG/3ML Not Covered
FIRST-
LANSOPRAZOLE SUSP 3MG/ML Covered
3.15GM/237ML;
0.2GM/237ML;
1.6GM/237ML;
FIRST-MOUTHWASH 3.15GM/237ML;
BLM SUSP 0.315GM/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 0.10% 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


FLECAINIDE
ACETATE TABS 50MG Covered
FLECTOR PTCH 1.30% Not Covered

FLEET PEDIATRIC ENEM 3.5GM/59ML; 9.5GM/59ML Covered


FLEXBUMIN SOLN 25% Not Covered
FLOMAX CAPS 0.4MG Not Covered
FLORIVA LIQD 0.25MG/ML; 400UNIT/ML Not Covered
75MG; 40MCG; 600UNIT;
1MG; 6MCG; 100MCG;
162MCG; 15MG; 1.8MG;
1.5MG; 0.5MG; 1.3MG;
FLORIVA CHEW 20UNIT; 2000UNIT; 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; 2.5MG/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 0.1MG Covered
FLULAVAL
QUADRIVALENT
2015-2016 SUSP 0 Covered AL
FLUMIST
QUADRIVALENT SUSP 0 Covered AL
FLUNISOLIDE SOLN 0.03% Covered
FLUOCINOLONE
ACETONIDE CREA 0.01% Not Covered
FLUOCINOLONE
ACETONIDE OINT 0.03% Not Covered
FLUOCINOLONE
ACETONIDE CREA 0.03% Not Covered
FLUOCINOLONE
ACETONIDE SOLN 0.01% Not Covered
FLUOCINOLONE
ACETONIDE OIL 0.01% Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 65 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


FLUOCINOLONE
ACETONIDE BODY OIL 0.01% Not Covered

FLUOCINOLONE
ACETONIDE SCALP OIL 0.01% Not Covered
FLUOCINONIDE GEL 0.05% Not Covered
FLUOCINONIDE OINT 0.05% Covered QL
FLUOCINONIDE CREA 0.10% Not Covered
FLUOCINONIDE CREA 0.05% Covered QL
FLUOCINONIDE SOLN 0.05% Covered
FLUOCINONIDE-E CREA 0.05% Covered QL
FLUORIDE CHEW 2.2MG Covered QL AL
FLUORIDE CHEW 1.1MG Covered QL AL
FLUORIDEX DAILY
DEFENSE
ENHANCED
WHITENING GEL 1.10% Covered AL
FLUOROMETHOLON
E SUSP 0.10% Covered QL
FLUOROURACIL SOLN 2% Not Covered
FLUOROURACIL SOLN 5% Not Covered
FLUOROURACIL 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 2.5MG 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 0.03% Covered
FLUTICASONE
PROPIONATE SUSP 50MCG/ACT Covered
FLUTICASONE
PROPIONATE OINT 0.01% Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 66 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


FLUTICASONE
PROPIONATE CREA 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 0.10% Covered
FML FORTE SUSP 0.25% Covered QL
120MG; 12MCG; 50MG; 0;
FOCALGIN DSS TABS 1MG; 90MG; 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
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; 2.5MG; 25MG Covered
60MG; 300MCG; 10MG;
1MG; 5MG; 20MG; 50MG;
FOLBEE PLUS TABS 1.5MG; 1.5MG Covered
60MG; 300MCG; 10MG;
1.5MG; 2MG; 5MG; 20MG;
50MG; 1.5MG; 1.5MG;
FOLBEE PLUS CZ TABS 25MG Covered
FOLBIC TABS 2MG; 2.5MG; 25MG Covered
FOLBIC RF TABS 2MG; 1.13MG; 25MG Covered
120MG; 0; 400UNIT;
12MCG; 350MG; 50MG; 0;
38MG; 0; 1MG; 30MG;
20MG; 40MG; 3.4MG;
65MCG; 3MG; 2700UNIT;
FOLET DHA THPK 18UNIT; 10MG Not Covered
0; 18MG; 250UNIT; 15MCG;
225MG; 25MG; 0; 38MG; 0;
1MG; 15MG; 30MG;
FOLET ONE CAPS 15UNIT; 20MG Not Covered
500MG; 300UNIT; 250MCG;
1.1MG; 100MG; 12.5MG;
FOLGARD OS TABS 1.5MG Covered
FOLGARD RX TABS 1MG; 2.2MG; 25MG Covered
FOLIC ACID TABS 1MG Covered QL
40MG; 62.5MG; 1MG; 3MG;
FOLIVANE-F CAPS 62.5MG Covered
210MG; 300MCG; 7MG;
10MCG; 62.5MG; 1MG;
20MG; 62.5MG; 25MG;
FOLIVANE-PLUS CAPS 5MG; 5MG Covered
FOLPLEX 2.2 TABS 0.5MG; 2.2MG; 25MG Covered
FOLTANX TABS 3MG; 2MG; 35MG Covered
FOLTX TABS 2MG; 1.13MG; 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL

150MG; 0; 15MG; 25MCG;


1.5MG; 100MG; 25MG;
50MG; 25MG; 2MCG;
50MCG; 1MG; 25MCG;
1MG; 7.5MG; 200MCG;
67.5MG; 25MCG; 75MCG;
40MG; 25MG; 5MG; 25MG;
5MCG; 25MG; 15MG;
25MG; 25MG; 1MG; 0;
2.5MG; 5MG; 13MCG;
25MG; 5000UNIT; 200UNIT;
FORTAVIT CAPS 150UNIT; 8MG Covered
FORTEO SOLN 600MCG/2.4ML 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; 12.5MG Not Covered
FOSINOPRIL
SODIUM/HYDROCHL
OROTHIAZIDE TABS 20MG; 12.5MG 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 2.5MG Not Covered QL

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 69 of 178
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; 300MCG; 12MCG;
65MG; 1250MCG; 30MG;
10MG; 6MG; 65MG; 10MG;
FUSION PLUS CAPS 3MG; 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/0.3ML Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 70 of 178
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; 2.98GM; 6.72GM;
GAVILYTE-C SOLR 5.84GM; 22.72GM Covered
236GM; 2.97GM; 6.74GM;
GAVILYTE-G SOLR 5.86GM; 22.74GM Covered
5MG; 210GM; 0.74GM;
GAVILYTE-H KIT 2.86GM; 5.6GM Covered
GAVILYTE- 420GM; 1.48GM; 5.72GM;
N/FLAVOR PACK SOLR 11.2GM Covered
GEMFIBROZIL TABS 600MG Covered QL
GENAC TABS 60MG; 2.5MG Not Covered
GENERESS FE CHEW 25MCG; 75MG; 0.8MG 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 0.30% Covered
GENTAMICIN
SULFATE OINT 0.10% Covered
GENTAMICIN
SULFATE CREA 0.10% Covered
GENTAMICIN
SULFATE OINT 0.30% 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; 0.02MG Covered
GIAZO TABS 1.1GM Not Covered
GILDAGIA TABS 35MCG; 0.4MG Covered
GILDESS 1.5/30 TABS 30MCG; 1.5MG Covered
GILDESS 1/20 TABS 20MCG; 1MG Covered
GILDESS 24 FE TABS 20MCG; 75MG; 1MG Covered
GILDESS FE 1.5/30 TABS 30MCG; 75MG; 1.5MG Covered
GILDESS FE 1/20 TABS 20MCG; 75MG; 1MG Covered
GILENYA CAPS 0.5MG Covered
GILOTRIF TABS 40MG Not Covered
GILOTRIF TABS 20MG Not Covered
GILOTRIF TABS 30MG Not Covered
25MG; 50MG; 10MG;
GINSENG EDGE CAPS 125MG Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 71 of 178
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 Covered QL
GLIPIZIDE ER TB24 10MG Covered QL
GLIPIZIDE XL TB24 10MG Covered QL
GLIPIZIDE XL TB24 2.5MG Covered QL
GLIPIZIDE XL TB24 5MG Covered QL
GLIPIZIDE/METFOR
MIN HCL TABS 2.5MG; 250MG Covered
GLIPIZIDE/METFOR
MIN HCL TABS 2.5MG; 500MG Covered
GLIPIZIDE/METFOR
MIN HCL TABS 5MG; 500MG Covered
GLUCAGEN
HYPOKIT SOLR 1MG Covered
GLUCAGON
EMERGENCY KIT KIT 1MG Covered
GLUCAGON HCL
DIAGNOSTIC SOLR 1MG Not Covered
GLUCOVANCE TABS 1.25MG; 250MG Not Covered
GLUCOVANCE TABS 5MG; 500MG Not Covered
GLUCOVANCE TABS 2.5MG; 500MG Not Covered
GLUMETZA TB24 500MG Not Covered
GLYBURIDE TABS 5MG Covered QL
GLYBURIDE TABS 2.5MG Covered QL
GLYBURIDE TABS 1.25MG Covered QL
GLYBURIDE
MICRONIZED TABS 6MG Covered QL
GLYBURIDE
MICRONIZED TABS 3MG Covered QL
GLYBURIDE
MICRONIZED TABS 1.5MG Covered QL
GLYBURIDE/METFO
RMIN HCL TABS 2.5MG; 500MG Covered QL
GLYBURIDE/METFO
RMIN HCL TABS 1.25MG; 250MG Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 72 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


GLYBURIDE/METFO
RMIN HCL TABS 5MG; 500MG Covered QL
GLYCOPHOS SOLN 1MMOLE/ML Covered

GLYCOPYRROLATE TABS 2MG Covered

GLYCOPYRROLATE TABS 1MG Covered


GLYXAMBI TABS 10MG; 5MG Not Covered QL
GLYXAMBI TABS 25MG; 5MG Not Covered QL
236GM; 2.97GM; 6.74GM;
GOLYTELY SOLR 5.86GM; 22.74GM Covered
227.1GM; 2.82GM; 6.36GM;
GOLYTELY SOLR 5.53GM; 21.5GM 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/0.8ML Not Covered
GRANIX SOSY 300MCG/0.5ML Not Covered
788MG/GM; 87MG/GM;
GRANULEX AERS 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.P. ACTHAR GEL 80UNIT/ML Not Covered
HALAVEN SOLN 1MG/2ML Not Covered
HALOBETASOL
PROPIONATE OINT 0.05% Covered
HALOBETASOL
PROPIONATE CREA 0.05% Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 73 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


HALOG CREA 0.10% Not Covered
HALOG OINT 0.10% Not Covered
HALOPERIDOL TABS 0.5MG Not Covered
HALOPERIDOL TABS 2MG Not Covered
HALOPERIDOL TABS 5MG Not Covered
HALOPERIDOL TABS 1MG Not Covered
HARVONI TABS 90MG; 400MG Not Covered
HAVRIX SUSP 1440ELU/ML Covered QL AL
HAVRIX SUSP 720ELU/0.5ML Covered QL AL
HEATHER TABS 0.35MG Covered
HECTOROL CAPS 0.5MCG Covered
HECTOROL CAPS 2.5MCG Covered
HECTOROL SOLN 2MCG/ML Covered
HECTOROL SOLN 4MCG/2ML Covered
HECTOROL CAPS 1MCG Covered
HELIXATE FS KIT 2000UNIT Not Covered
HEMANGEOL SOLN 4.28MG/ML Covered AL
10MG; 0.8MG; 15MCG;
HEMATINIC PLUS 106MG; 1MG; 6.9MG;
VITAMINS/MINERAL 1.3MG; 30MG; 5MG; 6MG;
S TABS 200MG; 10MG; 18.2MG Covered
250MG; 10MCG; 200MG;
HEMATOGEN CAPS 100MG Covered
250MG; 10MCG; 200MG;
HEMATOGEN FA CAPS 1MG Covered
HEMATOGEN 60MG; 10MCG; 460MG;
FORTE CAPS 1MG Covered
25MCG/5ML; 5MG/5ML;
0.8MG/5ML; 10MG/5ML;
10MG/5ML; 100MG/5ML;
2MG/5ML; 2MG/5ML;
HEMATRON LIQD 10MG/5ML; 2.3MG/5ML Covered
500MG; 150MCG; 3MG;
60MCG; 50MG; 1MG;
HEMATRON-AF TABS 150MG; 30UNIT Covered
500MG; 150MCG; 3MG;
60MCG; 50MG; 1MG;
HEMAX TABS 150MG; 30UNIT Covered

HEMETAB TABS 25MCG; 1MG; 6MG; 22MG Covered


10MG; 0.8MG; 15MCG;
324MG; 1MG; 6.9MG;
1.3MG; 30MG; 5MG; 6MG;
HEMOCYTE PLUS CAPS 200MG; 10MG; 18.2MG Covered
HEMOCYTE-F TABS 324MG; 1MG Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 74 of 178
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; 10MG/5ML;
HISTEX-AC SYRP 2.5MG/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; 50UNIT/ML Covered


HUMALOG MIX 50/50
KWIKPEN SUPN 50UNIT/ML; 50UNIT/ML Covered

HUMALOG MIX 75/25 SUSP 25UNIT/ML; 75UNIT/ML Covered


HUMALOG MIX 75/25
KWIKPEN SUPN 25UNIT/ML; 75UNIT/ML Covered QL
HUMATE-P SOLR 250UNIT; 600UNIT Not Covered
HUMIRA PSKT 40MG/0.8ML Covered PA
HUMIRA PEN PNKT 40MG/0.8ML Covered PA
HUMIRA PEN-
CROHNS
DISEASESTARTER PNKT 40MG/0.8ML Covered PA
HUMULIN 70/30 SUSP 30UNIT/ML; 70UNIT/ML Covered

HUMULIN 70/30 PEN SUPN 30UNIT/ML; 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 0.25MG Covered QL
HYCAMTIN CAPS 1MG Covered QL

HYCET SOLN 325MG/15ML; 7.5MG/15ML Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 75 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


200MG/5ML; 2.5MG/5ML;
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 12.5MG Covered QL
HYDROCHLOROTHI
AZIDE TABS 25MG Covered QL
HYDROCHLOROTHI
AZIDE TABS 50MG Covered QL
HYDROCHLOROTHI
AZIDE TABS 12.5MG Covered
HYDROCODONE
BITARTRATE/ACETA
MINOPHEN TABS 300MG; 5MG Not Covered
HYDROCODONE
BITARTRATE/ACETA
MINOPHEN TABS 300MG; 10MG Not Covered
HYDROCODONE
BITARTRATE/ACETA
MINOPHEN SOLN 325MG/15ML; 7.5MG/15ML Covered QL
HYDROCODONE
BITARTRATE/ACETA
MINOPHEN TABS 300MG; 7.5MG Not Covered
HYDROCODONE
BITARTRATE/ACETA
MINOPHEN SOLN 217MG/10ML; 5MG/10ML Covered QL
HYDROCODONE
BITARTRATE/ACETA
MINOPHEN SOLN 108MG/5ML; 2.5MG/5ML Covered QL
HYDROCODONE
BITARTRATE/ACETA
MINOPHEN TABS 750MG; 10MG Covered
HYDROCODONE
BITARTRATE/CHLOR
PHENIRAMINE 4MG/5ML; 5MG/5ML;
MALEATE/PSE SOLN 60MG/5ML Not Covered
HYDROCODONE
POLISTIREX/CHLOR
PHENIRAMINE
POLISTIREX SUER 8MG/5ML; 10MG/5ML Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 76 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


HYDROCODONE/AC
ETAMINOPHEN TABS 750MG; 7.5MG Covered
HYDROCODONE/AC
ETAMINOPHEN TABS 325MG; 10MG Covered QL
HYDROCODONE/AC
ETAMINOPHEN TABS 500MG; 7.5MG Covered
HYDROCODONE/AC
ETAMINOPHEN TABS 325MG; 5MG Covered QL
HYDROCODONE/AC
ETAMINOPHEN TABS 500MG; 10MG Covered
HYDROCODONE/AC
ETAMINOPHEN TABS 500MG; 5MG Covered
HYDROCODONE/AC
ETAMINOPHEN TABS 325MG; 7.5MG Covered QL
HYDROCODONE/AC
ETAMINOPHEN TABS 650MG; 7.5MG Covered
HYDROCODONE/AC
ETAMINOPHEN TABS 650MG; 10MG Covered
HYDROCODONE/AC
ETAMINOPHEN SOLN 500MG/15ML; 7.5MG/15ML Covered QL
HYDROCODONE/IBU
PROFEN TABS 7.5MG; 200MG Not Covered

HYDROCORTISONE TABS 20MG Covered

HYDROCORTISONE OINT 2.50% Covered

HYDROCORTISONE CREA 1% Covered

HYDROCORTISONE CREA 2.50% Covered

HYDROCORTISONE TABS 10MG Covered

HYDROCORTISONE OINT 1% Covered

HYDROCORTISONE LOTN 2.50% 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL

HYDROCORTISONE
ACETATE/PRAMOXI
NE CREA 2.5%; 1% Not Covered

HYDROCORTISONE
ACETATE/PRAMOXI
NE CREA 1%; 1% Not Covered
HYDROCORTISONE
BUTYRATE CREA 0.10% Not Covered
HYDROCORTISONE
BUTYRATE SOLN 0.10% Not Covered
HYDROCORTISONE
BUTYRATE OINT 0.10% Not Covered
HYDROCORTISONE
VALERATE CREA 0.20% Covered
HYDROCORTISONE
VALERATE OINT 0.20% Not Covered
HYDROCORTISONE/
ACETIC ACID SOLN 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
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/5ML Covered AL
HYOSCYAMINE
SULFATE SUBL 0.125MG Covered AL
HYOSCYAMINE
SULFATE SOLN 0.125MG/ML Covered AL
HYOSCYAMINE
SULFATE TABS 0.125MG Covered AL
HYOSCYAMINE
SULFATE TBDP 0.125MG Covered AL
HYOSCYAMINE
SULFATE ER TB12 0.375MG Covered AL
HYPERCARE SOLN 20% Not Covered
HYPER-SAL NEBU 7% Not Covered
HYPOLANCE AST
LANCING KIT KIT Covered
HYPOTEARS SOLN 1%; 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
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; 25MCG; 1MG;
ICAR-C PLUS TABS 100MG Covered
ICLUSIG TABS 15MG Not Covered
ICLUSIG TABS 45MG Not Covered

IFEREX 150 FORTE CAPS 25MCG; 1MG; 150MG Covered


ILARIS SOLR 180MG Not Covered
ILEVRO SUSP 0.30% Not Covered
ILUVIEN IMPL 0.19MG 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/0.5ML Not Covered
IMITREX TABS 100MG Not Covered
IMITREX TABS 50MG Not Covered
IMITREX STATDOSE
REFILL SOCT 4MG/0.5ML Not Covered
IMITREX STATDOSE
REFILL SOCT 6MG/0.5ML Not Covered

IMITREX STATDOSE
SYSTEM SOAJ 4MG/0.5ML Not Covered

IMITREX STATDOSE
SYSTEM SOAJ 6MG/0.5ML Not Covered
IMOVAX RABIES
(H.D.C.V.) INJ 2.5UNIT/ML Covered AL

120MG; 2700UNIT; 200MG;


400UNIT; 2MG; 12MCG;
50MG; 1MG; 90MG; 30MG;
20MG; 20MG; 3.4MG; 3MG;
INATAL ADVANCE TABS 30UNIT; 25MG Covered QL AL

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 80 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL

120MG; 0; 30MCG; 200MG;


6MG; 400UNIT; 2MG;
12MCG; 50MG; 1MG;
90MG; 30MG; 20MG;
20MG; 3.4MG; 3MG;
INATAL GT TABS 10UNIT; 2700UNIT; 15MG Covered QL AL
120MG; 0; 200MG; 2MG;
12MCG; 50MG; 1MG;
90MG; 20MG; 150MCG;
20MG; 3.4MG; 3MG;
2700UNIT; 400UNIT;
INATAL ULTRA TABS 30UNIT; 25MG Covered QL AL
INCIVEK TABS 375MG Not Covered
INCRUSE ELLIPTA AEPB 62.5MCG/INH Covered AL
INDAPAMIDE TABS 2.5MG Covered QL
INDAPAMIDE TABS 1.25MG Covered QL
INDOMETHACIN CAPS 50MG Covered AL
INDOMETHACIN CAPS 25MG Covered AL
INDOMETHACIN ER CPCR 75MG Covered AL
104MG; 400UNIT; 265MG;
50MG; 1MG; 29MG; 25MG;
INFANATE BALANCE CAPS 30UNIT Not Covered
INFED SOLN 50MG/ML Covered

200MG/5ML; 60MCG/5ML;
200UNIT/5ML; 5MCG/5ML;
15MG/5ML; 600MCG/5ML;
40MG/5ML; 150MCG/5ML;
6MG/5ML; 3.6MG/5ML;
6MG/5ML; 10UNIT/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; 62.5MG; 1000MCG;
INTEGRA F CAPS 3MG; 62.5MG Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 81 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL

210MG; 300MCG; 7MG;


10MCG; 62.5MG;
1000MCG; 20MG; 62.5MG;
INTEGRA PLUS CAPS 25MG; 5MG; 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 0.03MG; 0.15MG 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/0.5ML Not Covered
INVEGA SUSTENNA SUSP 117MG/0.75ML Not Covered
INVEGA SUSTENNA SUSP 39MG/0.25ML Not Covered
INVEGA SUSTENNA SUSP 156MG/ML Not Covered
INVEGA SUSTENNA SUSP 234MG/1.5ML Not Covered
INVEGA TRINZA SUSP 546MG/1.75ML Not Covered
INVEGA TRINZA SUSP 819MG/2.625ML Not Covered
INVEGA TRINZA SUSP 273MG/0.875ML Not Covered
INVEGA TRINZA SUSP 410MG/1.315ML Not Covered
INVIRASE TABS 500MG Not Covered
INVIRASE CAPS 200MG Not Covered
INVOKAMET TABS 50MG; 1000MG Covered PA QL
INVOKAMET TABS 150MG; 500MG Covered PA QL
INVOKAMET TABS 50MG; 500MG 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
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 0.02% Covered
IPRATROPIUM
BROMIDE SOLN 0.03% Covered QL
IPRATROPIUM
BROMIDE SOLN 0.06% Covered QL
IPRATROPIUM
BROMIDE/ALBUTER
OL SULFATE SOLN 2.5MG/3ML; 0.5MG/3ML Covered QL
IRBESARTAN TABS 75MG Covered QL
IRBESARTAN TABS 300MG Covered QL
IRBESARTAN TABS 150MG Covered QL

IRBESARTAN/HYDR
OCHLOROTHIAZIDE TABS 12.5MG; 150MG Covered QL

IRBESARTAN/HYDR
OCHLOROTHIAZIDE TABS 12.5MG; 300MG Covered QL
IRENKA CPEP 40MG Not Covered
IRESSA TABS 250MG Not Covered
250MG; 25MCG; 1MG;
IRON 100 PLUS TABS 100MG Covered AL

IRON SUPPLEMENT
CHILDRENS SOLN 15MG/ML Covered AL
300MCG; 100MG; 155MG;
7MG; 10MCG; 65MG;
1000MCG; 25MG; 65MG;
30MG; 5MG; 100MG;
IROSPAN 24/6 MISC 150MG; 5MG Covered
ISENTRESS TABS 400MG Not Covered
ISOMETHEPTENE/C
AFFEINE/ACETAMIN
OPHEN TABS 500MG; 20MG; 130MG Not Covered
ISOMETHEPTENE/DI
CHLORALPHENAZO
NE/ACETAMINOPHE
N CAPS 325MG; 100MG; 0; 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


ISOPTO
HOMATROPINE SOLN 2% Covered

ISOPTO HYOSCINE SOLN 0.25% 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 2.5MG 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


JANTOVEN TABS 6MG Not Covered
JANTOVEN TABS 7.5MG Not Covered
JANTOVEN TABS 2MG Not Covered
JANTOVEN TABS 4MG Not Covered
JANTOVEN TABS 10MG Not Covered
JANUMET TABS 500MG; 50MG Covered PA QL
JANUMET TABS 1000MG; 50MG Covered PA QL
JANUMET XR TB24 1000MG; 50MG Covered PA QL
JANUMET XR TB24 1000MG; 100MG Covered PA QL
JANUMET XR TB24 500MG; 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 0.35MG Covered
JENTADUETO TABS 2.5MG; 850MG Covered PA
JENTADUETO TABS 2.5MG; 1000MG Covered PA
JENTADUETO TABS 2.5MG; 500MG Covered PA
JINTELI TABS 5MCG; 1MG Not Covered
JOLESSA TABS 0.03MG; 0.15MG Covered
JOLIVETTE TABS 0.35MG Covered
JUBLIA SOLN 10% Not Covered
JUNEL 1.5/30 TABS 30MCG; 1.5MG Covered
JUNEL 1/20 TABS 20MCG; 1MG Covered
JUNEL FE 1.5/30 TABS 30MCG; 75MG; 1.5MG Covered
JUNEL FE 1/20 TABS 20MCG; 75MG; 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; 50MG Not Covered
KALYDECO TABS 150MG Not Covered
KALYDECO PACK 50MG Not Covered
KALYDECO PACK 75MG Not Covered
KAPVAY TB12 0.1MG Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 85 of 178
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; 0 Covered
KAYEXALATE POWD 0 Covered
KAZANO TABS 12.5MG; 1000MG Not Covered
KAZANO TABS 12.5MG; 500MG Not Covered
K-EFFERVESCENT TBEF 25MEQ Covered
KEFLEX CAPS 750MG Not Covered
KELNOR 1/35 TABS 35MCG; 1MG Covered
KENALOG AERS 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 0.50% 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/0.67ML 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
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; 2.5MG Not Covered
KOMBIGLYZE XR TB24 1000MG; 5MG Not Covered
KORLYM TABS 300MG Not Covered
K-PHOS TABS 500MG Covered
K-PHOS NO 2 TABS 305MG; 700MG Covered
KRISTALOSE PACK 10GM Covered
KRISTALOSE PACK 20GM Covered
K-TAB TBCR 10MEQ Not Covered
KURVELO TABS 0.03MG; 0.15MG 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%; 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
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; 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 187.5MCG Not Covered
LANOXIN TABS 62.5MCG Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 88 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; 500MG; 30MG Not Covered
LANTUS SOLN 100UNIT/ML Covered

LANTUS SOLOSTAR SOPN 100UNIT/ML Covered QL


LARIN 1.5/30 TABS 30MCG; 1.5MG Covered
LARIN 1/20 TABS 20MCG; 1MG Covered
LARIN FE 1.5/30 TABS 30MCG; 75MG; 1.5MG Covered
LARIN FE 1/20 TABS 20MCG; 75MG; 1MG Covered
LATANOPROST SOLN 0.01% 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/1.2ML 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; 0.1MG Covered
LETAIRIS TABS 5MG Covered PA QL
LETAIRIS TABS 10MG Covered PA QL
LETROZOLE TABS 2.5MG 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


LEUCOVORIN
CALCIUM TABS 15MG Covered
LEUKERAN TABS 2MG Covered
LEVALBUTEROL NEBU 1.25MG/0.5ML Not Covered
LEVALBUTEROL
HCL NEBU 0.31MG/3ML Not Covered
LEVALBUTEROL
HCL NEBU 1.25MG/3ML Not Covered
LEVALBUTEROL
HCL NEBU 0.63MG/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 2.5MG Not Covered
LEVITRA TABS 5MG Not Covered

LEVOBUNOLOL HCL SOLN 0.25% Covered

LEVOBUNOLOL HCL SOLN 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 0.50% Covered
LEVOMEFOLATE
CALCIUM/ACETYLC
YSTEINE/MECOBAL
AMIN/ALGAL 600MG; 6MG; 2MG;
POWDER TABS 90.314MG Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 90 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


LEVOMEFOLATE
CALCIUM/PYRIDOXA
L-5
PHOSPHATE/MECO 3MG; 2MG; 35MG;
BALAMIN/ALGAL CAPS 90.314MG Covered
LEVONEST TABS 0; 0 Covered

LEVONORGESTREL TABS 0.75MG Covered

LEVONORGESTREL TABS 1.5MG Covered


LEVONORGESTREL
AND ETHINYL
ESTRADIOL TABS 20MCG; 90MCG Covered
LEVONORGESTREL/
ETHINYL
ESTRADIOL TABS 0.03MG; 0.15MG Covered
LEVONORGESTREL/
ETHINYL
ESTRADIOL TABS 20MCG; 0.1MG Covered
LEVORA 0.15/30-28 TABS 30MCG; 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
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 1.2GM Not Covered
LICIDE SHAM 4%; 0.33% 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 2.5%; 2.5% Covered QL
LIDODERM PTCH 5% Not Covered
LIDOPIN CREA 3% Not Covered
LILETTA IUD 18.6MCG/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
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; 10MG Not Covered
LIPTRUZET TABS 10MG; 10MG Not Covered
LIPTRUZET TABS 20MG; 10MG Not Covered
LIPTRUZET TABS 40MG; 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 Covered QL
LISINOPRIL TABS 40MG Covered QL

LISINOPRIL/HYDRO
CHLOROTHIAZIDE TABS 25MG; 20MG Covered QL

LISINOPRIL/HYDRO
CHLOROTHIAZIDE TABS 12.5MG; 10MG Covered QL

LISINOPRIL/HYDRO
CHLOROTHIAZIDE TABS 12.5MG; 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 2.5%; 2.5% Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 93 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


L-METHYL-B6-B12 TABS 3MG; 2MG; 35MG Covered
L-METHYLFOLATE 600MG; 6MG; 2MG;
CA ME-CBL NAC TABS 90.314MG Covered
L-METHYL-MC NAC TABS 600MG; 6MG; 2MG Covered

LMTHF/PYRIDOXINE
HCL/CYANOCOBALA
MIN TABS 2MG; 1.13MG; 25MG Covered
LO LOESTRIN FE TABS 10MCG; 75MG; 1MG Covered
LODOSYN TABS 25MG Not Covered
LOESTRIN 1/20-21 TABS 20MCG; 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; 75MG; 1MG Covered
LOMUSTINE CAPS 100MG Covered
LOMUSTINE CAPS 10MG Covered
LOMUSTINE CAPS 40MG Covered
LONSURF TABS 6.14MG; 15MG Not Covered
LONSURF TABS 8.19MG; 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; 120MG Not Covered
LORATADINE-D
24HR TB24 10MG; 240MG Not Covered
LORAZEPAM TABS 2MG Not Covered
LORAZEPAM TABS 0.5MG Not Covered
LORAZEPAM TABS 1MG Not Covered
LORAZEPAM
INTENSOL CONC 2MG/ML Not Covered
LORYNA TABS 3MG; 0.02MG 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL

LOSARTAN
POTASSIUM/HYDRO
CHLOROTHIAZIDE TABS 12.5MG; 100MG Covered QL

LOSARTAN
POTASSIUM/HYDRO
CHLOROTHIAZIDE TABS 25MG; 100MG Covered QL

LOSARTAN
POTASSIUM/HYDRO
CHLOROTHIAZIDE TABS 12.5MG; 50MG Covered QL
LOSEASONIQUE TABS 0; 0 Not Covered
LOTEMAX OINT 0.50% Not Covered
LOTEMAX GEL 0.50% Not Covered
LOTEMAX SUSP 0.50% Not Covered
LOTREL CAPS 5MG; 40MG Not Covered
LOTREL CAPS 10MG; 40MG Not Covered
LOTRONEX TABS 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; 465MG; 1GM Not Covered
LOVENOX SOLN 40MG/0.4ML Not Covered
LOVENOX SOLN 80MG/0.8ML Not Covered
LOVENOX SOLN 100MG/ML Not Covered
LOVENOX SOLN 30MG/0.3ML Not Covered
LOVENOX SOLN 60MG/0.6ML Not Covered
LOVENOX SOLN 120MG/0.8ML Not Covered
LOVENOX SOLN 150MG/ML Not Covered
LOW-OGESTREL TABS 30MCG; 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 0.01% 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
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 3.75MG; 5MG Not Covered
LUPANETA PACK KIT 11.25MG; 5MG Not Covered
LUPRON DEPOT KIT 7.5MG Not Covered
LUPRON DEPOT KIT 3.75MG Not Covered
LUPRON DEPOT KIT 30MG Not Covered
LUPRON DEPOT KIT 22.5MG Not Covered
LUPRON DEPOT KIT 11.25MG Not Covered
LUPRON DEPOT KIT 45MG Not Covered
LUPRON DEPOT-
PED KIT 11.25MG Not Covered
LUPRON DEPOT-
PED KIT 7.5MG Not Covered
LUPRON DEPOT-
PED KIT 15MG Not Covered
LURIDE SOLN 0.5MG/ML Covered AL
LUSTRA-AF CREA 0; 4%; 0 Not Covered
LUSTRA-ULTRA CREA 4% Not Covered
LUTERA TABS 20MCG; 0.1MG 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;
60MCG/10ML;
5MCG/10ML; 15MG/10ML;
5MCG/10ML;
600MCG/10ML;
40MG/10ML;
150MCG/10ML; 6MG/10ML;
3.6MG/10ML; 6MG/10ML;
M.V.I. ADULT INJ 10MG/10ML; 1MG/10ML Covered
MACA CAPS 500MG Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 96 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


MACRODANTIN CAPS 25MG Not Covered QL
250MG; 1MG; 1MG; 5MG;
MACUVEX CAPS 200UNIT; 1MG; 40MG Not Covered
MAGNEBIND 200 TABS 450MG; 200MG Not Covered
MAGNEBIND 400 TABS 200MG; 1MG; 400MG Covered
MAGNESIUM
CHLORIDE SOLN 200MG/ML Covered
MAGNESIUM OXIDE TABS 400MG Covered
MAGNESIUM
SULFATE SOLN 50% Covered
MAGNESIUM
SULFATE IN D5W SOLN 5%; 10MG/ML Covered
MAKENA OIL 250MG/ML Not Covered
MALARONE TABS 250MG; 100MG Not Covered
MALATHION LOTN 0.50% Covered QL
MAPROTILINE HCL TABS 25MG Not Covered
MAPROTILINE HCL TABS 50MG Not Covered
MAPROTILINE HCL TABS 75MG Not Covered
MARGESIC CAPS 325MG; 50MG; 40MG Covered QL AL
MARLISSA TABS 0.03MG; 0.15MG Covered
MARPLAN TABS 10MG Not Covered
MARQIBO SUSP 5MG/31ML Not Covered
MARTEN-TAB TABS 325MG; 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; 70MG; 80MG;
MAXARON FORTE TABS 1.13MG; 250MCG Covered
100MG; 150MCG; 60MCG;
50MG; 0; 160MG; 0; 1MG;
MAXFE TABS 6.5MG; 0; 12MG Covered
0.1%; 3.5MG/ML;
MAXITROL SUSP 10000UNIT/ML Not Covered
MAXX LUBRICATED MISC Covered QL
MCT OIL OIL 0 Covered
MECLIZINE HCL TABS 12.5MG Covered
MECLIZINE HCL TABS 25MG Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 97 of 178
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 2.5MG 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 0.5MG Not Covered
MELOXICAM TABS 7.5MG Covered QL
MELOXICAM TABS 15MG Covered QL
MELOXICAM SUSP 7.5MG/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 0.625MG Covered QL
MENEST TABS 0.3MG Covered QL
MENEST TABS 1.25MG Covered QL
MENEST TABS 2.5MG Covered QL

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 98 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; 6MG; 2MG Covered
METAFOLBIC PLUS 600MG; 6MG; 2MG;
RF TABS 90.314MG Covered
METAMUCIL POWD 28.30% 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


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 0.5GM Covered
METHIMAZOLE TABS 5MG Covered
METHIMAZOLE TABS 10MG Covered
METHOCARBAMOL TABS 750MG Covered AL
METHOCARBAMOL TABS 500MG Covered AL
METHOTREXATE TABS 2.5MG Covered
METHOTREXATE
SODIUM SOLR 1GM Not Covered
METHOTREXATE
SODIUM SOLN 200MG/8ML Covered
METHOXSALEN CAPS 10MG Not Covered
METHSCOPOLAMIN
E BROMIDE TABS 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; 250MG Covered

METHYLDOPA/HYDR
OCHLOROTHIAZIDE TABS 15MG; 250MG Covered
METHYLERGONOVI
NE MALEATE TABS 0.2MG Covered AL
METHYLIN CHEW 10MG Not Covered
METHYLIN CHEW 2.5MG 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
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 1.25MG; 2.5MG Not Covered
METHYLTESTOSTE
RONE/ESTERIFIED
ESTROGENS HS TABS 0.625MG; 1.25MG 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


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
METOPROLOL/HYD
ROCHLOROTHIAZID
E TABS 25MG; 50MG Not Covered
METOPROLOL/HYD
ROCHLOROTHIAZID
E TABS 50MG; 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 0.75% Not Covered
METRONIDAZOLE GEL 1% Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 102 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


METRONIDAZOLE GEL 0.75% Not Covered
METRONIDAZOLE CAPS 375MG Not Covered
METRONIDAZOLE
VAGINAL GEL 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
1.5/30 TABS 30MCG; 1.5MG Covered
MICROGESTIN 1/20 TABS 20MCG; 1MG Covered
MICROGESTIN FE TABS 20MCG; 75MG; 1MG Covered
MICROGESTIN FE
1.5/30 TABS 30MCG; 75MG; 1.5MG Covered
MICROZIDE CAPS 12.5MG Not Covered
MIDODRINE HCL TABS 5MG Covered QL
MIDODRINE HCL TABS 2.5MG Covered QL
MIDODRINE HCL TABS 10MG Covered QL
MIGERGOT SUPP 100MG; 2MG Not Covered
MIGRAINE
FORMULA TABS 250MG; 250MG; 65MG Covered
MIGRANAL SOLN 4MG/ML Not Covered
MINASTRIN 24 FE CHEW 20MCG; 75MG; 1MG Covered PA
MINERAL OIL OIL 0 Covered
0; 0; 0; 0; 0; 0; 0; 0; 0; 0; 0;
MINERIN LOTN 0; 0 Not Covered
MINI WRIGHT PEAK
FLOW METER DEVI Covered QL
MINITRAN PT24 0.2MG/HR Not Covered
MINITRAN PT24 0.6MG/HR Not Covered
MINITRAN PT24 0.1MG/HR Not Covered
MINITRAN PT24 0.4MG/HR Not Covered
MINIVELLE PTTW 0.075MG/24HR Not Covered
MINIVELLE PTTW 0.0375MG/24HR Not Covered
MINIVELLE PTTW 0.1MG/24HR Not Covered
MINIVELLE PTTW 0.05MG/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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


MINOXIDIL TABS 2.5MG Covered
MIRALAX POWD 0 Covered
MIRAPEX TABS 0.125MG Not Covered
MIRAPEX TABS 0.5MG Not Covered
MIRAPEX TABS 0.75MG Not Covered
MIRAPEX TABS 1MG Not Covered
MIRAPEX TABS 0.25MG Not Covered
MIRAPEX TABS 1.5MG Not Covered
MIRAPEX ER TB24 1.5MG Not Covered
MIRAPEX ER TB24 0.75MG Not Covered
MIRAPEX ER TB24 3MG Not Covered
MIRAPEX ER TB24 0.375MG Not Covered
MIRAPEX ER TB24 4.5MG Not Covered
MIRCERA SOSY 75MCG/0.3ML Not Covered
MIRCERA SOSY 100MCG/0.3ML Not Covered
MIRCERA SOSY 50MCG/0.3ML Not Covered
MIRCERA SOSY 200MCG/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 0.33% Not Covered
MISOPROSTOL TABS 100MCG Covered QL
MISOPROSTOL TABS 200MCG Covered QL
MITIGARE CAPS 0.6MG Not Covered
M-M-R II INJ 0; 0; 0 Covered QL AL
MODAFINIL TABS 100MG Not Covered
MODAFINIL TABS 200MG Not Covered
MODICON TABS 35MCG; 0.5MG Covered
MOEXIPRIL HCL TABS 15MG Not Covered
MOEXIPRIL HCL TABS 7.5MG Not Covered
MOEXIPRIL/HYDRO
CHLOROTHIAZIDE TABS 25MG; 15MG Not Covered
MOEXIPRIL/HYDRO
CHLOROTHIAZIDE TABS 12.5MG; 7.5MG Not Covered
MOEXIPRIL/HYDRO
CHLOROTHIAZIDE TABS 12.5MG; 15MG Not Covered
MOMETASONE
FUROATE CREA 0.10% Covered
MOMETASONE
FUROATE SOLN 0.10% Covered
MOMETASONE
FUROATE OINT 0.10% Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 104 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


MONISTAT 1-DAY OINT 6.50% Covered
MONONESSA TABS 35MCG; 0.25MG 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
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 12.5MG Not Covered
4.7GM; 100GM; 1.015GM;
MOVIPREP SOLR 5.9GM; 2.691GM; 7.5GM Covered
MOXATAG TB24 775MG Not Covered
MOXEZA SOLN 0.50% Not Covered

MOXIFLOXACIN HCL TABS 400MG Not Covered

MOXIFLOXACIN HCL SOLN 400MG/250ML Not Covered


MULTAQ TABS 400MG Not Covered
150MG; 2MG; 10MCG;
MULTIGEN TABS 50MG; 70MG; 75MG Covered
150MG; 2MG; 10MCG;
MULTIGEN FOLIC TABS 70MG; 1MG; 75MG Covered

60MG; 0.8MG; 10MCG;


MULTIGEN PLUS TABS 50MG; 101MG; 1MG; 50MG Covered
35MG/ML; 400UNIT/ML;
2MCG/ML; 8MG/ML;
0.4MG/ML; 0.6MG/ML;
MULTI- 0.5MG/ML; 0.5MG/ML;
VIT/FLUORIDE SOLN 5UNIT/ML; 1500UNIT/ML Not Covered AL

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 106 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


35MG/ML; 400UNIT/ML;
2MCG/ML; 8MG/ML;
0.4MG/ML; 0.6MG/ML;
MULTI- 0.25MG/ML; 0.5MG/ML;
VIT/FLUORIDE SOLN 5UNIT/ML; 1500UNIT/ML Not Covered AL
35MG/ML; 400UNIT/ML;
10MG/ML; 8MG/ML;
0.4MG/ML; 0.6MG/ML;
MULTI- 0.25MG/ML; 0.5MG/ML;
VIT/IRON/FLUORIDE SOLN 5UNIT/ML; 1500UNIT/ML Not Covered AL
60MG; 4.5MCG; 0.3MG;
13.5MG; 1.05MG; 1.2MG;
MULTIVITAMIN WITH 1MG; 1.05MG; 2500UNIT;
FLUORIDE CHEW 400UNIT; 15UNIT Covered
60MG; 400UNIT; 4.5MCG;
0.3MG; 13.5MG; 1.05MG;
MULTIVITAMINS/FLU 1.2MG; 0.5MG; 1.05MG;
ORIDE CHEW 15UNIT; 2500UNIT Covered
60MG; 400UNIT; 4.5MCG;
0.3MG; 13.5MG; 1.05MG;
MULTIVITAMINS/FLU 1.2MG; 1MG; 1.05MG;
ORIDE CHEW 15UNIT; 2500UNIT Covered
60MG; 400UNIT; 4.5MCG;
0.3MG; 13.5MG; 1.05MG;
MULTIVITAMINS/FLU 1.2MG; 0.25MG; 1.05MG;
ORIDE CHEW 15UNIT; 2500UNIT Not Covered AL
MUPIROCIN CREA 2% Not Covered
MUPIROCIN OINT 2% Covered QL
MUSE PLLT 125MCG Not Covered

500MG; 150MCG; 25MG;


0.1MG; 3MG; 50MCG;
27MG; 1MG; 50MG; 50MG;
5MG; 100MG; 25MG;
20MG; 50MCG; 20MG;
M-VIT TABS 30UNIT; 5000UNIT; 22.5MG Covered QL AL
MYALEPT SOLR 11.3MG 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
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; 1MG; 150MG Covered
MYFORTIC TBEC 180MG Not Covered
MYFORTIC TBEC 360MG Not Covered
MYLERAN TABS 2MG Covered

120MG; 0; 200MG;
400UNIT; 2MG; 12MCG;
50MG; 1MG; 90MG; 30MG;
20MG; 20MG; 3.4MG; 3MG;
MYNATAL ADVANCE TABS 30UNIT; 2700UNIT; 25MG Covered QL AL
120MG; 200MG; 400UNIT;
2MG; 12MCG; 1MG; 65MG;
20MG; 10MG; 3MG;
1.84MG; 4000UNIT; 11MG;
MYNATAL PLUS TABS 25MG Covered QL AL
120MG; 0; 200MG;
400UNIT; 2MG; 12MCG;
50MG; 1MG; 90MG; 20MG;
150MCG; 20MG; 3.4MG;
MYNATAL 3MG; 30UNIT; 2700UNIT;
ULTRACAPLET TABS 25MG Covered QL AL
70MG; 200MG; 2.2MCG;
65MG; 1MG; 100MG;
17MG; 175MCG; 2.2MG;
1.6MG; 65MCG; 1.5MG;
4000UNIT; 400UNIT;
MYNATAL-Z TABS 10UNIT; 15MG Covered QL AL
120MG; 250MG; 2MG;
12MCG; 50MG; 400UNIT;
90MG; 1MG; 20MG;
0.15MG; 20MG; 3.4MG;
3MG; 4000UNIT; 30UNIT;
MYNATE 90 PLUS TBCR 25MG Covered QL AL
100MG; 150MCG; 5MG;
6MCG; 1MG; 20MG; 10MG;
MYNEPHROCAPS CAPS 1.7MG; 1.5MG 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


MYZILRA TABS 0; 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; 40MG Not Covered
NADOLOL/BENDROF
LUMETHIAZIDE TABS 5MG; 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; 14MG Not Covered
NAMZARIC CP24 10MG; 28MG Not Covered
NAPHAZOLINE HCL SOLN 0.10% 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
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 2.5MG 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; 0 Not Covered
NATEGLINIDE TABS 60MG Covered QL
NATEGLINIDE TABS 120MG Covered QL
NATESTO GEL 5.5MG/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 0.90% Not Covered AL
NATURAL FIBER
THERAPY POWD 48.57% Covered
NATURAL FIBER
THERAPY POWD 30.90% Covered
NATURE-THROID TABS 195MG Covered AL
NATURE-THROID TABS 97.5MG Covered AL
NATURE-THROID TABS 260MG Covered AL
NATURE-THROID TABS 325MG Covered AL
NATURE-THROID TABS 146.25MG Covered AL
NATURE-THROID TABS 48.75MG Covered AL
NATURE-THROID TABS 81.25MG Covered AL
NATURE-THROID TABS 130MG Covered AL
NATURE-THROID TABS 16.25MG Covered AL
NATURE-THROID TABS 113.75MG Covered AL
NATURE-THROID TABS 32.5MG Covered AL
NATURE-THROID TABS 65MG Covered AL
NATURE-THROID NT-
2.5 TABS 162.5MG Covered AL
NAVA-SC CREA 4%; 7.5%; 5% Not Covered
NEBUPENT SOLR 300MG Not Covered
NECON 0.5/35-28 TABS 35MCG; 0.5MG Covered
NECON 1/35 TABS 35MCG; 1MG Covered
NECON 1/50-28 TABS 50MCG; 1MG Covered
NECON 10/11-28 TABS 35MCG; 0 Covered
NECON 7/7/7 TABS 0; 0 Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 110 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


0; 85MG; 110MG; 5MCG;
27MG; 1.13MG; 60MG;
1MG; 18MG; 220MCG;
25MG; 1.4MG; 60MCG; 0;
NEEVO DHA CAPS 1.4MG; 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; 5MG/GM;
CIN/POLYMYXIN OINT 10000UNIT/GM Covered

NEOMYCIN/POLYMY
XIN/BACITRACIN/HY 400UNIT/GM; 1%; 0.5%;
DROCORTISONE OINT 10000UNIT/GM Not Covered
NEOMYCIN/POLYMY
XIN/DEXAMETHASO 0.1%; 3.5MG/ML;
NE SUSP 10000UNIT/ML Covered
NEOMYCIN/POLYMY
XIN/DEXAMETHASO 0.1%; 3.5MG/GM;
NE OINT 10000UNIT/GM Covered
NEOMYCIN/POLYMY 0.025MG/ML; 1.75MG/ML;
XIN/GRAMICIDIN SOLN 10000UNIT/ML Not Covered
NEOMYCIN/POLYMY 1%; 3.5MG/ML;
XIN/HC SOLN 10000UNIT/ML Covered
NEOMYCIN/POLYMY
XIN/HYDROCORTIS 1%; 3.5MG/ML;
ONE SUSP 10000UNIT/ML Covered
NEOMYCIN/POLYMY
XIN/HYDROCORTIS 1%; 3.5MG/ML;
ONE SUSP 10000UNIT/ML Covered
NEORAL CAPS 100MG Not Covered
NEORAL SOLN 100MG/ML Not Covered
NEORAL CAPS 25MG Not Covered

60MG; 300MCG; 6MG;


1MG; 20MG; 10MG; 10MG;
NEPHPLEX RX TABS 1.7MG; 1.5MG; 12.5MG Covered
100MG; 150MCG; 5MG;
6MCG; 1MG; 20MG; 10MG;
NEPHROCAPS CAPS 1.7MG; 1.5MG Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 111 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


100MG; 150MCG;
1750UNIT; 6MCG; 1MG;
20MG; 5MG; 10MG; 1.7MG;
NEPHROCAPS QT TBDP 1.5MG Covered
40MG; 300MCG; 6MCG;
75MG; 200MG; 1MG;
20MG; 10MG; 10MG;
NEPHRON FA TABS 1.7MG; 1.5MG Covered
60MG; 300MCG; 6MCG;
1MG; 20MG; 10MG; 10MG;
NEPHRO-VITE RX TABS 1.7MG; 1.5MG Covered
NESINA TABS 25MG Not Covered
NESINA TABS 6.25MG Not Covered
NESINA TABS 12.5MG Not Covered
200MG; 450UNIT; 55MG;
10MCG; 120MG; 180MG;
1MG; 20MG; 32MG;
100MCG; 50MG; 3MG;
120MG; 3MG; 30UNIT;
NESTABS ABC MISC 10MG Not Covered
NEUAC GEL 5%; 1.2% Not Covered
NEUAC KIT KIT 5%; 1.2% Not Covered
NEULASTA SOSY 6MG/0.6ML Not Covered
NEUMEGA SOLR 5MG Not Covered
NEUPOGEN SOLN 480MCG/1.6ML Not Covered
NEUPOGEN SOSY 300MCG/0.5ML Covered PA
NEUPOGEN SOSY 480MCG/0.8ML 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 0.10% 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


NEXT CHOICE ONE
DOSE TABS 1.5MG 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; 2MG; 500MCG; 0; 8MG;
OX/COPPER TABS 0; 0; 12MG Covered
NIACOR TABS 500MG Not Covered
NIASPAN TBCR 1000MG Not Covered
NIASPAN TBCR 750MG Not Covered
NIASPAN TBCR 500MG Not Covered
50MG; 100MG; 2MG;
500MCG; 5MG; 800MG;
NICADAN TABS 10MG; 20MG Covered
NICARDIPINE HCL CAPS 20MG Covered QL
NICARDIPINE HCL CAPS 30MG Covered QL
5MG; 1.5MG; 500MCG;
NICAZEL TABS 600MG; 5MG; 10MG Covered
0; 2MG; 0; 500MCG; 0;
NICAZEL FORTE TABS 8MG; 0; 12MG Covered
1.5MG; 500MCG; 750MG;
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; 0.02MG Covered
NIMODIPINE CAPS 30MG Covered QL
NIRAVAM TBDP 0.25MG Not Covered
NIRAVAM TBDP 2MG Not Covered
NIRAVAM TBDP 1MG Not Covered
NIRAVAM TBDP 0.5MG Not Covered
NISOLDIPINE TB24 40MG Not Covered
NISOLDIPINE TB24 8.5MG 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
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 6.5MG Not Covered

NITROGLYCERIN ER CPCR 2.5MG Not Covered


NITROGLYCERIN
TRANSDERMAL PT24 0.1MG/HR Covered QL

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 114 of 178
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 0.2MG/HR Covered QL
NITROGLYCERIN
TRANSDERMAL PT24 0.4MG/HR Covered QL
NITROLINGUAL
PUMPSPRAY SOLN 0.4MG/SPRAY Not Covered
NITROSTAT SUBL 0.3MG Covered
NITROSTAT SUBL 0.4MG Covered
NITROSTAT SUBL 0.6MG Covered
NITRO-TIME CPCR 9MG Not Covered
NITRO-TIME CPCR 2.5MG Not Covered
NITRO-TIME CPCR 6.5MG Not Covered
NIVA-FOL TABS 2MG; 2.5MG; 25MG Covered
NIZATIDINE SOLN 15MG/ML Not Covered
NODOLOR CAPS 325MG; 100MG; 0; 65MG Not Covered
NORA-BE TABS 0.35MG Covered
NORDITROPIN
FLEXPRO SOLN 15MG/1.5ML Covered PA
NORDITROPIN
FLEXPRO SOLN 10MG/1.5ML Covered PA
NORDITROPIN
FLEXPRO SOLN 5MG/1.5ML Covered PA
NORDITROPIN
NORDIFLEX PEN SOLN 30MG/3ML Covered PA
NORETHINDRONE &
ETHINYL
ESTRADIOL
FERROUS
FUMARATE CHEW 25MCG; 75MG; 0.8MG Covered
NORETHINDRONE
ACETATE TABS 5MG Covered QL
NORETHINDRONE
ACETATE/ETHINYL
ESTRADIOL TABS 2.5MCG; 0.5MG Covered QL
NORETHINDRONE
ACETATE/ETHINYL
ESTRADIOL TABS 5MCG; 1MG Covered
NORETHINDRONE
ACETATE/ETHINYL
ESTRADIOL TABS 20MCG; 1MG Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 115 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


NORETHINDRONE
ACETATE/ETHINYL
ESTRADIOL/FERRO
US FUMARATE TABS 20MCG; 75MG; 1MG Covered
NORETHINDRONE
ACETATE/ETHINYL
ESTRADIOL/FERRO
US FUMARATE TABS 20MCG; 75MG; 1MG Covered

NORGESTIMATE/ET
HINYL ESTRADIOL TABS 0; 0 Covered

NORGESTIMATE/ET
HINYL ESTRADIOL TABS 0; 0 Covered

NORGESTIMATE/ET
HINYL ESTRADIOL TABS 35MCG; 0.25MG Covered
NORTHERA CAPS 300MG Not Covered
NORTHERA CAPS 100MG Not Covered
NORTHERA CAPS 200MG Not Covered

NORTREL 0.5/35 (28) TABS 35MCG; 0.5MG Covered


NORTREL 1/35 TABS 35MCG; 1MG Covered
NORTREL 7/7/7 TABS 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%; 2%; 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; 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
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; 70UNIT/ML Covered


NOVOLOG MIX 70/30
PREFILLED
FLEXPEN SUPN 30UNIT/ML; 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; 10MG Not Covered
NULEV TBDP 0.125MG Not Covered
NULYTELY/FLAVOR 420GM; 1.48GM; 5.72GM;
PACKS SOLR 11.2GM Covered
NUQUIN HP CREA 3%; 4%; 2%; 8% Not Covered

150MG; 6000UNIT; 80MCG;


10MG; 5MG; 25MCG; 2MG;
25MCG; 18MG; 1MG;
50MG; 2MG; 25MCG;
20MG; 150MCG; 10MG;
17MG; 25MCG; 15MG;
200UNIT; 400UNIT;
NUTRICAP TABS 33.5MCG; 18MG Covered
NUTROPIN AQ
NUSPIN 10 SOLN 10MG/2ML Not Covered
NUTROPIN AQ PEN SOLN 10MG/2ML Not Covered
0.015MG/24HR;
NUVARING RING 0.12MG/24HR Covered QL
NUVESSA GEL 1.30% 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
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; 2100UNIT;
315UNIT; 1MG; 15MCG;
20UNIT; 1.25MG; 50MG;
15MG; 10MG; 10MG;
OB COMPLETE TABS 3.4MG; 2MG; 10MG Covered

150MG; 25MG; 170UNIT;


260MG; 40MG; 7MG; 1MG;
20MG; 30MG; 30MG;
OB-NATAL ONE CAPS 330MG; 25MG; 30UNIT Covered
OBREDON SOLN 200MG/5ML; 2.5MG/5ML Not Covered

120MG; 2700UNIT;
400UNIT; 12MCG; 50MG;
1MG; 29MG; 30MG; 20MG;
40MG; 3.4MG; 65MCG;
OBSTETRIX EC TABS 3MG; 18UNIT; 25MG Covered QL AL

90MG; 200MG; 400UNIT;


2MG; 12MCG; 27MG; 1MG;
100MG; 20MG; 150MCG;
4MG; 3MG; 0.5MG; 3MG;
O-CAL FA TABS 2500UNIT; 30UNIT; 15MG Covered QL AL
OCELLA TABS 3MG; 0.03MG 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL

250MG; 1MG; 0.5MG; 5MG;


OCUVEL CAPS 200UNIT; 1MG; 40MG Not Covered
ODOMZO CAPS 200MG Not Covered
OFEV CAPS 100MG Not Covered
OFEV CAPS 150MG Not Covered
OFLOXACIN TABS 300MG Covered
OFLOXACIN SOLN 0.30% Covered
OFLOXACIN TABS 400MG Covered
OGESTREL TABS 50MCG; 0.5MG Covered
OLANZAPINE TABS 7.5MG Not Covered
OLANZAPINE TABS 5MG Not Covered
OLANZAPINE TABS 10MG Not Covered
OLANZAPINE SOLR 10MG Not Covered
OLANZAPINE TABS 20MG Not Covered
OLANZAPINE TABS 2.5MG 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; 3MG Not Covered
OLANZAPINE/FLUOX
ETINE CAPS 25MG; 12MG Not Covered
OLANZAPINE/FLUOX
ETINE CAPS 25MG; 6MG Not Covered
OLANZAPINE/FLUOX
ETINE CAPS 50MG; 6MG Not Covered

OLOPATADINE HCL SOLN 0.60% Not Covered


OLYSIO CAPS 150MG Not Covered
OMEGA-3-ACID
ETHYL ESTERS CAPS 375MG; 465MG; 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; 1100MG Not Covered
OMNARIS SUSP 50MCG/ACT Not Covered
OMNITROPE SOLN 5MG/1.5ML Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 119 of 178
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%; 1.2% Not Covered
ONFI SUSP 2.5MG/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
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 0.05% Covered
OPTIVAR SOLN 0.05% Not Covered
ORALAIR SUBL 0; 0; 0; 0; 0 Not Covered
ORAP TABS 1MG Not Covered
ORAP TABS 2MG Not Covered
ORENITRAM TBCR 0.125MG Not Covered
ORENITRAM TBCR 0.25MG Not Covered
ORENITRAM TBCR 1MG Not Covered
ORENITRAM TBCR 2.5MG Not Covered
ORFADIN CAPS 2MG Not Covered
ORFADIN CAPS 10MG Not Covered
ORFADIN CAPS 5MG Not Covered
ORKAMBI TABS 125MG; 200MG Not Covered
ORPHENADRINE
CITRATE ER TB12 100MG Covered QL AL
ORPHENADRINE/AS
A/CAFFEINE TABS 385MG; 30MG; 25MG Covered
ORSYTHIA TABS 20MCG; 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
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;
ORTHO EVRA PTWK 150MCG/24HR Not Covered

ORTHO MICRONOR TABS 0.35MG Covered

ORTHO TRI-CYCLEN TABS 0; 0 Covered


ORTHO TRI-CYCLEN
LO TABS 0; 0 Covered

ORTHO-NOVUM 1/35 TABS 35MCG; 1MG Covered


OSCIMIN SR TB12 0.375MG Not Covered
OSENI TABS 25MG; 15MG Not Covered
OSENI TABS 25MG; 30MG Not Covered
OSENI TABS 25MG; 45MG Not Covered
OSENI TABS 12.5MG; 15MG Not Covered
OSENI TABS 12.5MG; 45MG Not Covered
OSENI TABS 12.5MG; 30MG Not Covered
OSMOPREP TABS 0.398GM; 1.102GM Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 122 of 178
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/0.4ML Not Covered
OTREXUP SOAJ 15MG/0.4ML Not Covered
OTREXUP SOAJ 10MG/0.4ML Not Covered
OTREXUP SOAJ 25MG/0.4ML Not Covered

OVACE PLUS WASH LIQD 10% Not Covered


OVACE WASH LIQD 10% Not Covered
OVCON-35 TABS 35MCG; 0.4MG 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
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; 7.5MG Covered
OXYCODONE/ACET
AMINOPHEN TABS 325MG; 7.5MG Covered QL
OXYCODONE/ACET
AMINOPHEN TABS 325MG; 10MG Covered QL
OXYCODONE/ACET
AMINOPHEN TABS 325MG; 5MG Covered QL
OXYCODONE/ACET
AMINOPHEN TABS 325MG; 2.5MG Not Covered
OXYCODONE/ACET
AMINOPHEN TABS 650MG; 10MG Covered
OXYCODONE/ACET
AMINOPHEN CAPS 500MG; 5MG Covered
OXYCODONE/ASPIR
IN TABS 325MG; 4.835MG 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 7.5MG 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
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; 500MG Covered

OYSTER SHELL
CALCIUM/VITAMIN D TABS 250MG; 125UNIT; 0 Covered
OYSTER
SHELL/VITAMIN D TABS 600MG; 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 1.5MG Not Covered
PALIPERIDONE ER TB24 9MG Not Covered
PALIPERIDONE ER TB24 3MG Not Covered
PALIPERIDONE ER TB24 6MG Not Covered
70000UNIT; 16800UNIT;
PANCREAZE CPEP 40000UNIT Covered
61000UNIT; 21000UNIT;
PANCREAZE CPEP 37000UNIT Covered
17500UNIT; 4200UNIT;
PANCREAZE CPEP 10000UNIT Covered
43750UNIT; 10500UNIT;
PANCREAZE CPEP 25000UNIT Covered
27000UNIT; 5000UNIT;
PANCRELIPASE CPEP 17000UNIT Covered
PANHEMATIN SOLR 313MG Not Covered
PANTOPRAZOLE
SODIUM TBEC 20MG Covered QL
PANTOPRAZOLE
SODIUM TBEC 40MG Covered QL
PARCOPA TBDP 25MG; 250MG Not Covered
PARCOPA TBDP 25MG; 100MG Not Covered
PARCOPA TBDP 10MG; 100MG Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 125 of 178
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 12.5MG Not Covered
PAROXETINE HCL
ER TB24 37.5MG Not Covered
PATANASE SOLN 0.60% Not Covered
PATANOL SOLN 0.10% 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 12.5MG Not Covered
PAXIL CR TB24 37.5MG Not Covered
PAZEO SOLN 0.70% Not Covered

PEAK FLOW METER DEVI Covered QL


35MEQ/L; 30MEQ/L;
PEDIATRIC 25GM/L; 20MEQ/L;
ELECTROLYTE SOLN 45MEQ/L Covered
PEDIPAK THPK 8%; 20% Not Covered
PEG 3350 POWD 0 Covered
PEG
3350/ELECTROLYTE 240GM; 2.98GM; 6.72GM;
S SOLR 5.84GM; 22.72GM Covered
PEG-
3350/ELECTROLYTE 236GM; 2.97GM; 6.74GM;
S SOLR 5.86GM; 22.74GM Covered
PEGANONE TABS 250MG Not Covered
PEGASYS KIT 180MCG/0.5ML Not Covered
PEGASYS SOLN 180MCG/ML Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 126 of 178
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/0.5ML Not Covered
PEG-INTRON KIT 150MCG/0.5ML Not Covered
PEG-INTRON KIT 80MCG/0.5ML Not Covered
PEG-INTRON KIT 50MCG/0.5ML Not Covered
PEG-INTRON KIT 120MCG/0.5ML Not Covered
5MG; 210GM; 0.74GM;
PEG-PREP KIT 2.86GM; 5.6GM 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 1.50% Not Covered
PENNSAID SOLN 2% Not Covered

PENTASA CPCR 250MG Covered ST QL

PENTASA CPCR 500MG Covered ST QL


PENTAZOCINE/ACE
TAMINOPHEN TABS 650MG; 25MG Covered
PENTAZOCINE/NAL
OXONE HCL TABS 0.5MG; 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


PERPHENAZINE/AMI
TRIPTYLINE TABS 10MG; 2MG Not Covered
PERPHENAZINE/AMI
TRIPTYLINE TABS 25MG; 4MG Not Covered
PERPHENAZINE/AMI
TRIPTYLINE TABS 50MG; 4MG Not Covered
PERPHENAZINE/AMI
TRIPTYLINE TABS 10MG; 4MG Not Covered
PERPHENAZINE/AMI
TRIPTYLINE TABS 25MG; 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 64.8MG Not Covered
PHENOBARBITAL TABS 97.2MG 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

PHENTERMINE HCL CAPS 15MG Not Covered

PHENTERMINE HCL CAPS 30MG Not Covered

PHENTERMINE HCL TABS 37.5MG Not Covered


PHENYLEPHRINE
HCL SOLN 2.50% 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
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; 0.4MG Covered
PHOSLO CAPS 667MG Covered
PHOSLYRA SOLN 667MG/5ML Covered
PHOSPHOLINE
IODIDE SOLR 0.13% Covered
PICATO GEL 0.02% Not Covered
PICATO GEL 0.05% Not Covered
PILOCARPINE HCL SOLN 1% Covered
PILOCARPINE HCL SOLN 4% Covered
PILOCARPINE HCL SOLN 2% Covered
PILOCARPINE HCL TABS 7.5MG Not Covered
PILOCARPINE
HYDROCHLORIDE TABS 5MG Covered
PIMOZIDE TABS 2MG Not Covered
PIMOZIDE TABS 1MG Not Covered
PIMTREA TABS 0; 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/METFORMIN
HCL TABS 850MG; 15MG Not Covered
PIOGLITAZONE HCL-
GLIMEPIRIDE TABS 4MG; 30MG Not Covered
PIOGLITAZONE HCL-
GLIMEPIRIDE TABS 2MG; 30MG Not Covered
PIRMELLA 1/35 TABS 35MCG; 1MG Covered
PIRMELLA 7/7/7 TABS 0; 0 Covered
PIROXICAM CAPS 20MG Not Covered
PIROXICAM CAPS 10MG Not Covered
PLAN B ONE-STEP TABS 1.5MG 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


PLEGRIDY SOPN 125MCG/0.5ML Not Covered
PLEGRIDY STARTER
PACK SOPN 0 Not Covered
PNEUMOVAX 23 INJ 25MCG/0.5ML Covered QL AL
120MG; 0; 200MG;
400UNIT; 2MG; 12MCG;
27MG; 1MG; 20MG; 10MG;
PNV PRENATAL 3MG; 1.84MG; 22MG;
PLUS MULTIVITAMIN TABS 4000UNIT; 25MG Covered QL AL
30MG; 1100UNIT;
1000UNIT; 2MG; 12MCG;
200MG; 1MG; 20MG;
15MG; 29MG; 150MCG;
2.5MG; 1.8MG; 1.6MG;
PNV-FIRST CAPS 20UNIT; 25MG Covered
PODIAPN CAPS 300MG; 5MG; 2MG; 35MG Covered
PODOFILOX SOLN 0.50% Covered
POLYETHYLENE
GLYCOL 3350 POWD 0 Covered
POLY-IRON 150
FORTE CAPS 25MCG; 1MG; 150MG Covered
POLYTRIM SOLN 10000UNIT/ML; 0.1% 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 0.03MG; 0.15MG 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
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; 1100MG/5ML Covered
POTASSIUM
CITRATE-CITRIC
ACID CRYSTALS PACK 1002MG; 3300MG Covered
POTASSIUM
PHOSPHATE SOLN 236MG/ML; 224MG/ML Covered
POTASSIUM
PHOSPHATE SOLN 236MG/ML; 224MG/ML Covered
POTASSIUM
PHOSPHATE SOLN 236MG/ML; 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 7.50% 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 1.5MG Covered QL

PRAMIPEXOLE
DIHYDROCHLORIDE TABS 0.75MG Covered QL

PRAMIPEXOLE
DIHYDROCHLORIDE TABS 0.25MG Covered QL

PRAMIPEXOLE
DIHYDROCHLORIDE TABS 1MG Covered QL

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 131 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL

PRAMIPEXOLE
DIHYDROCHLORIDE TABS 0.5MG Covered QL
PRAMIPEXOLE
DIHYDROCHLORIDE
ER TB24 1.5MG Not Covered
PRAMIPEXOLE
DIHYDROCHLORIDE
ER TB24 0.75MG Not Covered
PRAMIPEXOLE
DIHYDROCHLORIDE
ER TB24 4.5MG Covered
PRAMIPEXOLE
DIHYDROCHLORIDE
ER TB24 3MG Covered
PRAMIPEXOLE
DIHYDROCHLORIDE
ER TB24 0.375MG Not Covered
PRAMOSONE CREA 2.5%; 1% Not Covered
PRAMOSONE LOTN 2.5%; 1% Not Covered
PRAMOSONE OINT 1%; 1% Not Covered
PRAMOSONE CREA 1%; 1% Not Covered
PRAMOSONE OINT 2.5%; 1% Not Covered
PRAMOSONE LOTN 1%; 1% Not Covered
PRANDIMET TABS 500MG; 2MG Not Covered
PRANDIMET TABS 500MG; 1MG Not Covered
PRANDIN TABS 2MG Not Covered
PRANDIN TABS 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 0.12% Covered
PRED-G SUSP 0.3%; 1% Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 132 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


PRED-G S.O.P. OINT 0.3%; 0.6% Not Covered
PREDNICARBATE CREA 0.10% Not Covered
PREDNICARBATE 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 2.5MG Covered
25MG; 30MCG; 10MG;
400UNIT; 12MCG; 200MG;
1MG; 6MG; 17MG; 22MG;
175MCG; 50MG; 10UNIT;
PREFERAOB ONE CAPS 15MG Not Covered
PREMARIN TABS 0.9MG Covered QL AL
PREMARIN TABS 0.625MG Covered QL AL
PREMARIN TABS 0.45MG Covered QL AL
PREMARIN CREA 0.625MG/GM Covered AL
PREMARIN TABS 0.3MG Covered QL AL
PREMARIN TABS 1.25MG Covered QL AL
PREMIUM
CONDOMS
LUBRICATED MISC Covered QL
PREMPHASE TABS 0.625MG; 5MG Covered QL
PREMPRO TABS 0.45MG; 1.5MG Covered QL
PREMPRO TABS 0.625MG; 2.5MG Covered QL
PREMPRO TABS 0.3MG; 1.5MG Covered QL
PREMPRO TABS 0.625MG; 5MG Covered QL

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 133 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


120MG; 0; 200MG;
400UNIT; 8MCG; 17MG;
1MG; 20MG; 150MCG;
3MG; 3MG; 3MG; 30UNIT;
PRENAFIRST TABS 4000UNIT; 15MG Covered
120MG; 0; 200MG; 8MCG;
29MG; 1MG; 20MG;
150MCG; 3MG; 3MG; 3MG;
30UNIT; 4000UNIT;
PRENATABS FA TABS 400UNIT; 15MG Covered

120MG; 4000UNIT; 30MCG;


200MG; 7MG; 400UNIT;
3MG; 8MCG; 1MG; 29MG;
100MG; 20MG; 150MCG;
3MG; 3MG; 0; 3MG;
PRENATABS RX TABS 30UNIT; 15MG Covered
120MG; 4000UNIT; 200MG;
400UNIT; 8MCG; 28MG;
800MCG; 20MG; 2.6MG;
1.7MG; 1.8MG; 30UNIT;
PRENATAL TABS 25MG Covered QL AL
100MG; 1000UNIT; 200MG;
7MG; 400UNIT; 12MCG;
25MG; 29MG; 1MG; 15MG;
20MG; 3MG; 3MG; 30UNIT;
PRENATAL 19 TABS 20MG Not Covered

100MG; 1000UNIT; 200MG;


7MG; 400UNIT; 12MCG;
29MG; 1MG; 15MG; 20MG;
PRENATAL 19 CHEW 3MG; 3MG; 30UNIT; 20MG Covered QL AL

120MG; 0; 200MG;
400UNIT; 2MG; 12MCG;
50MG; 1MG; 90MG; 30MG;
20MG; 20MG; 3.4MG; 3MG;
PRENATAL AD TABS 30UNIT; 2700UNIT; 25MG Covered QL AL
120MG; 0; 200MG;
400UNIT; 2MG; 12MCG;
27MG; 1MG; 20MG; 10MG;
PRENATAL LOW 3MG; 1.84MG; 22UNIT;
IRON TABS 4000UNIT; 25MG Covered QL AL

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 134 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


100MG; 0; 150MG;
400UNIT; 4MCG; 200MG;
28MG; 27MG; 800MCG;
18MG; 228MG; 2.6MG;
PRENATAL MULTI 1.7MG; 1.5MG; 11UNIT;
+DHA CAPS 4000UNIT; 25MG Covered QL AL
120MG; 0; 200MG;
400UNIT; 2MG; 12MCG;
27MG; 1MG; 20MG; 10MG;
3MG; 1.84MG; 22MG;
PRENATAL PLUS TABS 4000UNIT; 25MG Covered QL AL
120MG; 0; 200MG;
400UNIT; 2MG; 12MCG;
1MG; 29MG; 20MG; 10MG;
PRENATAL PLUS 3MG; 1.84MG; 22UNIT;
IRON TABS 4000UNIT; 25MG Covered AL
120MG; 4000UNIT; 200MG;
400UNIT; 8MCG; 28MG;
800MCG; 20MG; 2.6MG;
PRENATAL 1.7MG; 1.8MG; 30UNIT;
VITAMINS TABS 25MG Covered QL AL
100MG; 200MG; 4MCG;
400UNIT; 60MG; 0.8MG;
18MG; 2.6MG; 1.7MG;
PRENATAL 1.5MG; 11MG; 4000UNIT;
VITAMINS TABS 25MG Covered
120MG; 0; 0; 200MG;
400UNIT; 2MG; 12MCG;
PRENATAL 27MG; 1MG; 20MG; 10MG;
VITAMINS PLUS 3MG; 1.84MG; 22MG;
LOW IRON TABS 4000UNIT; 25MG Covered QL AL
10MG; 0.8MG; 15MCG;
106.5MG; 1MG; 1.3MG;
30MG; 5MG; 6MG; 200MG;
PRENATAL-U CAPS 10MG Covered QL AL
200MG; 12MCG; 400MCG;
600MCG; 75MG; 25MG;
PRENATE AM TABS 500MG Covered AL
PREPOPIK PACK 12GM; 3.5GM; 10MG Covered
PRESTALIA TABS 2.5MG; 3.5MG Not Covered
PRESTALIA TABS 5MG; 7MG Not Covered
PRESTALIA TABS 10MG; 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
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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


300MCG; 60MG; 6MG;
400UNIT; 1MG; 12MCG;
20MG; 1.25MG; 30MG;
20MG; 10MG; 20MG;
25MG; 3.5MG; 2.5MG;
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; 0.8MG; 15MCG;
162MG; 1MG; 1.3MG;
30MG; 115.2MG; 5MG;
PUREVIT DUALFE 6MG; 200MG; 10MG;
PLUS CAPS 18.2MG Covered
PURIXAN SUSP 2000MG/100ML Not Covered
PYLERA CAPS 140MG; 125MG; 125MG Not Covered
PYRAZINAMIDE TABS 500MG Covered
PYRIDOSTIGMINE
BROMIDE TABS 60MG Not Covered
PYRIL D SUSP 5MG/5ML; 16MG/5ML Not Covered
PYRILAMINE-
PHENYLEPHRINE SUSP 5MG/5ML; 16MG/5ML Covered
QNASL AERS 80MCG/ACT Not Covered

QNASL CHILDRENS AERS 40MCG/ACT Not Covered


Q-PAP INFANTS SOLN 80MG/0.8ML Covered
QSYMIA CP24 15MG; 92MG Not Covered
QSYMIA CP24 11.25MG; 69MG Not Covered
QSYMIA CP24 7.5MG; 46MG Not Covered
QSYMIA CP24 3.75MG; 23MG Not Covered
QUALAQUIN CAPS 324MG Not Covered
QUARTETTE TABS 0; 0 Not Covered
QUASENSE TABS 0.03MG; 0.15MG 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
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 12.5MG; 10MG Not Covered
QUINAPRIL/HYDROC
HLOROTHIAZIDE TABS 12.5MG; 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 2.5MG Covered QL
RAMIPRIL CAPS 1.25MG Covered QL
RAMIPRIL CAPS 5MG Covered QL

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 140 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 0.5MG Not Covered
RAPIVAB SOLN 200MG/20ML Not Covered
RASUVO SOAJ 7.5MG/0.15ML Not Covered
RASUVO SOAJ 20MG/0.4ML Not Covered
RASUVO SOAJ 22.5MG/0.45ML Not Covered
RASUVO SOAJ 12.5MG/0.25ML Not Covered
RASUVO SOAJ 15MG/0.3ML Not Covered
RASUVO SOAJ 27.5MG/0.55ML Not Covered
RASUVO SOAJ 30MG/0.6ML Not Covered
RASUVO SOAJ 10MG/0.2ML Not Covered
RASUVO SOAJ 17.5MG/0.35ML Not Covered
RASUVO SOAJ 25MG/0.5ML Not Covered
RAVICTI LIQD 1.1GM/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/0.5ML Not Covered QL
REBIF REBIDOSE SOAJ 22MCG/0.5ML Not Covered
REBIF REBIDOSE SOAJ 44MCG/0.5ML Not Covered
REBIF REBIDOSE
TITRATION PACK SOAJ 0 Not Covered
REBIF TITRATION
PACK SOSY 0 Not Covered QL
RECLIPSEN TABS 0.15MG; 30MCG Covered
RECOMBINATE SOLR 401-800 UNIT Not Covered
RECOMBIVAX HB SUSP 40MCG/ML Covered QL AL
RECOMBIVAX HB SUSP 5MCG/0.5ML Covered QL AL
RECOMBIVAX HB SUSP 10MCG/ML Covered QL AL
RECTIV OINT 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


REFISSA CREA 0.05% Not Covered
REGLAN TABS 10MG Covered
REGRANEX GEL 0.01% Not Covered
RELENZA
DISKHALER AEPB 5MG/BLISTER Covered AL
RELISTOR KIT 12MG/0.6ML Not Covered
RELISTOR SOLN 12MG/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; 150MCG; 6MCG;
1MG; 20MG; 5MG; 10MG;
RENAL CAPS 1.7MG; 1.5MG Covered
60MG; 300MCG; 10MG;
6MCG; 1MG; 20MG; 10MG;
RENA-VITE RX TABS 1.7MG; 1.5MG Covered
RENVELA TABS 800MG Covered PA QL
REPAGLINIDE TABS 1MG Covered QL
REPAGLINIDE TABS 2MG Covered QL
REPAGLINIDE TABS 0.5MG Covered QL
REQUIP TABS 1MG Not Covered
REQUIP TABS 2MG Not Covered
REQUIP TABS 4MG Not Covered
REQUIP TABS 0.25MG Not Covered
REQUIP TABS 3MG Not Covered
REQUIP TABS 0.5MG 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 0.25MG Not Covered
RESERPINE TABS 0.1MG Not Covered
RESTASIS EMUL 0.05% Not Covered
RESTORIL CAPS 7.5MG Not Covered
RESTORIL CAPS 22.5MG Not Covered
RETIN-A MICRO
PUMP GEL 0.08% Not Covered
RETROVIR CAPS 100MG Not Covered
REVATIO TABS 20MG Not Covered
REVATIO SUSR 10MG/ML Not Covered
REVESTA CAPS 5750UNIT; 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


REVLIMID CAPS 25MG Covered QL
REVLIMID CAPS 2.5MG 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 0.5MG Not Covered
REXULTI TABS 0.25MG 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; 60MG/5ML Not Covered
RHINOCORT AQUA SUSP 32MCG/ACT Not Covered
RIASTAP SOLR 0 Not Covered
RIAX FOAM 5.50% Not Covered
RIAX FOAM 9.50% 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 0.25MG Not Covered
RISPERDAL TABS 0.5MG Not Covered
RISPERDAL TABS 4MG Not Covered
RISPERDAL TABS 1MG Not Covered
RISPERDAL TABS 2MG Not Covered
RISPERDAL
CONSTA SUSR 37.5MG Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 143 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 12.5MG Not Covered
RISPERDAL M-TAB TBDP 1MG Not Covered
RISPERDAL M-TAB TBDP 3MG Not Covered
RISPERDAL M-TAB TBDP 0.5MG Not Covered
RISPERDAL M-TAB TBDP 2MG Not Covered
RISPERDAL M-TAB TBDP 4MG Not Covered
RISPERIDONE TABS 0.25MG Not Covered
RISPERIDONE TABS 4MG Not Covered
RISPERIDONE TABS 0.5MG 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 0.5MG 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 Covered AL
RIVASTIGMINE
TARTRATE CAPS 3MG Covered AL
RIVASTIGMINE
TARTRATE CAPS 1.5MG Covered AL
RIVASTIGMINE
TARTRATE CAPS 6MG Covered AL
RIVASTIGMINE
TRANSDERMAL
SYSTEM PT24 13.3MG/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


RIVASTIGMINE
TRANSDERMAL
SYSTEM PT24 4.6MG/24HR Covered QL
RIVASTIGMINE
TRANSDERMAL
SYSTEM PT24 9.5MG/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 0.25MG Covered QL
ROPINIROLE HCL TABS 0.5MG 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; 5MG Covered QL
ROZEREM TABS 8MG Not Covered
RUCONEST SOLR 2100UNIT Not Covered
RYTARY CPCR 61.25MG; 245MG Not Covered
RYTARY CPCR 48.75MG; 195MG Not Covered
RYTARY CPCR 36.25MG; 145MG Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 145 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


RYTARY CPCR 23.75MG; 95MG Not Covered
SABRIL PACK 500MG Not Covered
SABRIL TABS 500MG Not Covered
SAFYRAL TABS 3MG; 0.03MG; 0.451MG 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 2.5MG 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 2.50% Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 146 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL

SELENIUM SULFIDE SHAM 0; 2.25%; 0 Covered


SELRX SHAM 0; 2.3%; 0 Not Covered
SELZENTRY TABS 150MG Not Covered
SELZENTRY TABS 300MG Not Covered
SENNA TABS 8.6MG Covered
SENNA LAXATIVE TABS 8.6MG Covered
SENNA PLUS TABS 50MG; 8.6MG 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; 0.8MG; 15MCG;
162MG; 1MG; 1.3MG;
30MG; 115.2MG; 5MG;
6MG; 200MG; 10MG;
SE-TAN PLUS CAPS 18.2MG Covered
SEVELAMER
CARBONATE TABS 800MG Covered QL
SF GEL 1.10% Covered AL
SF 5000 PLUS CREA 1.10% Covered
SHAROBEL TABS 0.35MG Covered
SIGNIFOR SOLN 0.6MG/ML Not Covered
SIGNIFOR SOLN 0.3MG/ML Not Covered
SIGNIFOR SOLN 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
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 0.038%; 1%; 5% Not Covered
SIMBRINZA SUSP 0.2%; 1% Not Covered
SIMCOR TB24 500MG; 20MG Not Covered
SIMCOR TB24 1000MG; 20MG Not Covered
SIMCOR TB24 750MG; 20MG Not Covered
SIMETHICONE CHEW 80MG Covered
SIMPLE SYRUP SYRP 0 Covered
SIMPLY SLEEP TABS 25MG Not Covered
SIMPONI SOSY 50MG/0.5ML 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 0.5MG 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%; 75MG/GM; 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 0.90% Covered


SODIUM CITRATE GRAN 0 Covered
SODIUM
CITRATE/CITRIC
ACID SOLN 334MG/5ML; 500MG/5ML Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 148 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


SODIUM FERRIC
GLUCONATE
COMPLEX/SUCROS
E SOLN 12.5MG/ML Covered

SODIUM FLUORIDE CHEW 0.25MG Covered AL

SODIUM FLUORIDE CHEW 0.5MG Covered QL AL

SODIUM FLUORIDE CHEW 1MG Covered QL AL

SODIUM FLUORIDE SOLN 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/0.2ML Not Covered
SOMATULINE
DEPOT SOLN 90MG/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
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 17.5MG 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 0.90% Not Covered
SPIRIVA
HANDIHALER CAPS 18MCG Covered QL
SPIRIVA RESPIMAT AERS 2.5MCG/ACT Covered QL AL

SPIRONOLACTONE TABS 100MG Covered QL

SPIRONOLACTONE TABS 25MG Covered QL

SPIRONOLACTONE TABS 50MG Covered QL


SPIRONOLACTONE/
HYDROCHLOROTHI
AZIDE TABS 25MG; 25MG Covered QL
SPRINTEC 28 TABS 35MCG; 0.25MG 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; 0.1MG Covered
SSD CREA 1% Not Covered
SSKI SOLN 1GM/ML Not Covered
STALEVO 100 TABS 25MG; 200MG; 100MG Not Covered
STALEVO 125 TABS 31.25MG; 200MG; 125MG Not Covered
STALEVO 150 TABS 37.5MG; 200MG; 150MG Not Covered
STALEVO 200 TABS 50MG; 200MG; 200MG Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 150 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


STALEVO 50 TABS 12.5MG; 200MG; 50MG Not Covered
STALEVO 75 TABS 18.75MG; 200MG; 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/0.5ML 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 1.5MG/ML Covered QL
STIMULANT
LAXATIVE TBEC 5MG Covered

STIOLTO RESPIMAT AERS 2.5MCG/ACT; 2.5MCG/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; 200MG;
STRIBILD TABS 300MG Not Covered
STRIVERDI
RESPIMAT AERS 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


500MG; 1000UNIT;
0.15MG; 25MG; 0.1MG;
3MG; 50MCG; 10MG;
0.8MG; 50MG; 25MCG;
100MG; 25MG; 20MG;
50MCG; 20MG; 60UNIT;
STROVITE FORTE TABS 3000UNIT; 15MG Covered

15MG; 300MG; 100MCG;


15MG; 3000UNIT;
1000UNIT; 50MCG; 1.5MG;
50MCG; 1MG; 5MG; 50MG;
1.5MG; 25MG; 25MG; 5MG;
100MCG; 20MG; 100UNIT;
STROVITE ONE TABS 25MG Covered
SUBOXONE FILM 2MG; 0.5MG Not Covered
SUBOXONE FILM 8MG; 2MG Not Covered
SUBOXONE FILM 12MG; 3MG Not Covered
SUBOXONE FILM 4MG; 1MG Not Covered
1.6GM/180ML; 210GM;
0.74GM; 3.13GM/180ML;
2.86GM; 5.6GM;
SUCLEAR KIT 17.5GM/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 0.23%; 10% Covered

SULFAMETHOXAZO
LE/TRIMETHOPRIM SUSP 200MG/5ML; 40MG/5ML Not Covered

SULFAMETHOXAZO
LE/TRIMETHOPRIM TABS 400MG; 80MG Covered

SULFAMETHOXAZO
LE/TRIMETHOPRIM SUSP 200MG/5ML; 40MG/5ML Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 152 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


SULFAMETHOXAZO
LE/TRIMETHOPRIM
DS TABS 800MG; 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/0.5ML Covered QL
SUMATRIPTAN
SUCCINATE SOLN 6MG/0.5ML Covered QL

SUMATRIPTAN
SUCCINATE REFILL SOCT 6MG/0.5ML Covered QL

SUMATRIPTAN
SUCCINATE REFILL SOCT 4MG/0.5ML Covered QL
SUMAVEL
DOSEPRO SOTJ 4MG/0.5ML Not Covered
SUMAVEL
DOSEPRO SOTJ 6MG/0.5ML Not Covered

25MCG/15ML; 20MG/15ML;
1MG/15ML; 1000MG/15ML;
100MG/15ML; 2MG/15ML;
10MG/15ML; 10MG/15ML;
SUPERVITE LIQD 75MG/15ML Covered
400MG; 2700UNIT; 20MG;
400UNIT; 6MCG; 1MG;
100MG; 6MG; 5MG; 10MG;
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
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;
SUPREP BOWEL 3.13GM/180ML;
PREP SOLN 17.5GM/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 37.5MG Not Covered
SUTENT CAPS 12.5MG Not Covered
SUTENT CAPS 25MG Not Covered
SYEDA TABS 3MG; 0.03MG Covered
SYLATRON KIT 200MCG Not Covered
SYLATRON KIT 600MCG Not Covered
SYLATRON KIT 300MCG Not Covered
SYMAX DUOTAB TBCR 0.375MG Not Covered

SYMBICORT AERO 80MCG/ACT; 4.5MCG/ACT Covered


160MCG/ACT;
SYMBICORT AERO 4.5MCG/ACT Covered
SYMBYAX CAPS 50MG; 12MG Not Covered
SYMBYAX CAPS 25MG; 12MG Not Covered
SYMBYAX CAPS 25MG; 3MG Not Covered
SYMBYAX CAPS 25MG; 6MG Not Covered
SYMBYAX CAPS 50MG; 6MG Not Covered
SYMLINPEN 120 SOPN 2700MCG/2.7ML Not Covered
SYMLINPEN 60 SOPN 1500MCG/1.5ML Not Covered
SYNALGOS-DC CAPS 356.4MG; 30MG; 16MG Not Covered
SYNAREL SOLN 2MG/ML Not Covered
SYNJARDY TABS 12.5MG; 1000MG Not Covered
SYNJARDY TABS 5MG; 1000MG Not Covered
SYNJARDY TABS 12.5MG; 500MG Not Covered
SYNJARDY TABS 5MG; 500MG Not Covered
SYNRIBO SOLR 3.5MG Not Covered
TABLOID TABS 40MG Covered
TACLONEX SUSP 0.064%; 0.005% Not Covered
TACROLIMUS CAPS 1MG Covered
TACROLIMUS OINT 0.03% Covered
TACROLIMUS CAPS 0.5MG Covered
TACROLIMUS OINT 0.10% Covered
TACROLIMUS CAPS 5MG Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 154 of 178
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 0.4MG Covered QL
10MG; 0.8MG; 15MCG;
162MG; 1MG; 1.3MG;
30MG; 115.2MG; 5MG;
6MG; 200MG; 10MG;
TANDEM PLUS CAPS 18.2MG 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; 180MG Not Covered
TARKA TBCR 1MG; 240MG Not Covered
TARKA TBCR 2MG; 240MG Not Covered
TARKA TBCR 4MG; 240MG Not Covered
60MG; 0; 0; 25MCG; 80MG;
TARON FORTE CAPS 1MG; 70MG Covered
25MG; 300MCG; 5MG;
2MG; 12.5MCG; 156MG;
39MG; 53.5MG; 310MG;
1MG; 5MG; 1.8MG; 200MG;
38MG; 25MG; 3MG; 2MG;
TARON-C DHA CAPS 10MG Not Covered
TASIGNA CAPS 200MG Not Covered
TASIGNA CAPS 150MG Not Covered
TASMAR TABS 100MG Not Covered
650MG/0.82ML;
72.5MG/0.82ML;
TBC AERS 0.1MG/0.82ML 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


TECHNIVIE TABS 12.5MG; 75MG; 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; 5MG Not Covered
TEKAMLO TABS 300MG; 10MG Not Covered
TEKAMLO TABS 150MG; 10MG Not Covered
TEKAMLO TABS 150MG; 5MG Not Covered
TEKTURNA TABS 150MG Covered PA QL
TEKTURNA TABS 300MG Covered PA QL
TEKTURNA HCT TABS 300MG; 25MG Covered PA QL
TEKTURNA HCT TABS 300MG; 12.5MG Covered PA QL
TEKTURNA HCT TABS 150MG; 12.5MG Covered PA QL
TEKTURNA HCT TABS 150MG; 25MG Covered PA QL
TEMAZEPAM CAPS 15MG Not Covered
TEMAZEPAM CAPS 30MG Not Covered
TEMAZEPAM CAPS 22.5MG 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; 50MG Covered QL AL
TENIVAC INJ 2LFU; 5LFU Covered AL
TERAZOL 3 CREA 0.80% 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 2.5MG Covered
TERCONAZOLE SUPP 80MG Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 156 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


TERCONAZOLE CREA 0.80% Covered
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/2.5GM 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/0.5ML; 2LF/0.5ML Covered AL
TETRABENAZINE TABS 25MG Covered QL
TETRABENAZINE TABS 12.5MG 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; 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
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; 75MG; 1MG Covered
TIMOLOL MALEATE TABS 10MG Covered
TIMOLOL MALEATE SOLN 0.25% Not Covered
TIMOLOL MALEATE SOLN 0.50% Not Covered
TIMOLOL MALEATE TABS 5MG Covered
TIMOLOL MALEATE TABS 20MG Covered
TIMOLOL MALEATE
OPHTHALMIC GEL
FORMING SOLG 0.50% Not Covered
TIMOLOL MALEATE
OPHTHALMIC GEL
FORMING SOLG 0.25% 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; 2.2MG; 25MG Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 158 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


1.5MG; 500MG; 300UNIT;
250MCG; 1.1MG; 100MG;
TL G-FOL OS TABS 12.5MG Covered
75MG; 15MCG; 110MG;
TL ICON CAPS 0.5MG; 240MG Covered
60MG; 300MCG; 800UNIT;
2MG; 100MCG; 215MG;
25MG; 45MG; 27MG;
500MG; 1MG; 20MG;
25MG; 3.4MG; 3MG;
TL-CARE DHA CAPS 30UNIT; 10MG Covered
500MG; 150MCG; 3MG;
60MCG; 50MG; 1MG;
TL-HEM 150 TABS 150MG; 30UNIT Covered
TOBI NEBU 300MG/5ML Not Covered
TOBI PODHALER CAPS 28MG Covered PA
TOBRADEX SUSP 0.1%; 0.3% Not Covered
TOBRADEX OINT 0.1%; 0.3% Covered
TOBRAMYCIN NEBU 300MG/5ML Not Covered
TOBRAMYCIN
SULFATE SOLN 0.30% Not Covered
TOBRAMYCIN/DEXA
METHASONE SUSP 0.1%; 0.3% Not Covered
TOBREX OINT 0.30% 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
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; 50MG; 10MG;
TOTAL B/C TABS 5MG; 10MG; 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 62.5MG 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; 37.5MG 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
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; 240MG Not Covered
TRANDOLAPRIL/VER
APAMIL HCL ER TBCR 1MG; 240MG Not Covered
TRANDOLAPRIL/VER
APAMIL HCL ER TBCR 2MG; 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 0.00% Not Covered
TRAVOPROST SOLN 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 0.10% Covered AL
TRETINOIN CREA 0.05% Covered AL
TRETINOIN GEL 0.03% Covered AL
TRETINOIN CAPS 10MG Covered PA
TRETINOIN CREA 0.03% Covered AL
TRETINOIN GEL 0.01% Covered AL
TRETINOIN
EMOLLIENT CREA 0.05% Not Covered
TRETINOIN
MICROSPHERE GEL 0.04% Not Covered
TRETINOIN
MICROSPHERE GEL 0.10% Not Covered
TRETINOIN
MICROSPHERE
PUMP GEL 0.10% Not Covered
TRETINOIN
MICROSPHERE
PUMP GEL 0.04% Not Covered
TRETIN-X KIT 0; 0; 0; 0; 0; 0.05% Not Covered
TRETIN-X KIT 0; 0; 0; 0; 0; 0.1% Not Covered
TRETTEN SOLR 2000-3125 UNIT Not Covered
TREXIMET TABS 500MG; 85MG Not Covered
TREZIX CAPS 320.5MG; 30MG; 16MG Not Covered QL
TREZIX CAPS 356.4MG; 30MG; 16MG Covered QL

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 161 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


TRIAMCINOLONE
ACETONIDE CREA 0.10% Not Covered
TRIAMCINOLONE
ACETONIDE LOTN 0.03% Covered
TRIAMCINOLONE
ACETONIDE LOTN 0.10% Covered
TRIAMCINOLONE
ACETONIDE CREA 0.03% Covered
TRIAMCINOLONE
ACETONIDE OINT 0.10% Covered
TRIAMCINOLONE
ACETONIDE CREA 0.50% Covered
TRIAMCINOLONE
ACETONIDE OINT 0.03% Covered
TRIAMCINOLONE
ACETONIDE OINT 0.50% Covered
TRIAMCINOLONE
ACETONIDE AERS 0.147MG/GM Not Covered
TRIAMCINOLONE
ACETONIDE AERO 55MCG/ACT Covered
TRIAMCINOLONE IN
ORABASE PSTE 0.10% Covered
TRIAMTERENE/HYD
ROCHLOROTHIAZID
E TABS 25MG; 37.5MG Covered
TRIAMTERENE/HYD
ROCHLOROTHIAZID
E TABS 50MG; 75MG Covered
TRIAMTERENE/HYD
ROCHLOROTHIAZID
E CAPS 25MG; 37.5MG Covered
TRIAMTERENE/HYD
ROCHLOROTHIAZID
E CAPS 25MG; 50MG Covered
TRIAZOLAM TABS 0.125MG Not Covered
TRIAZOLAM TABS 0.25MG Not Covered
TRIBENZOR TABS 10MG; 12.5MG; 40MG Not Covered
TRIBENZOR TABS 5MG; 12.5MG; 20MG Not Covered
TRIBENZOR TABS 5MG; 12.5MG; 40MG Not Covered
TRIBENZOR TABS 10MG; 25MG; 40MG Not Covered
TRIBENZOR TABS 5MG; 25MG; 40MG Not Covered
TRI-BUFFERED
ASPIRIN TABS 325MG; 0; 0; 0 Covered AL

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 162 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


100MG; 200MG; 2MG;
12MCG; 27MG; 1MG;
20MG; 3.1MG; 1.6MG;
1.6MG; 10MCG; 30UNIT;
TRICARE TABS 10MG Covered
100MG; 200MG; 400UNIT;
2MG; 12MCG; 135MG;
33.8MG; 27MG; 0; 1MG;
20MG; 71.2MG; 3.1MG;
TRICARE PRENATAL 1.6MG; 1.6MG; 30UNIT;
COMPLEAT MISC 10MG Not Covered
60MG; 300MCG; 800UNIT;
2MG; 100MCG; 215MG;
25MG; 45MG; 27MG;
500MG; 1MG; 20MG;
TRICARE PRENATAL 25MG; 3.4MG; 3MG;
DHA ONE CAPS 30UNIT; 10MG Not Covered
334MG/5ML; 550MG/5ML;
TRICITRATES SOLN 500MG/5ML Not Covered
75MG; 15MCG; 110MG;
TRICON CAPS 0.5MG; 240MG Covered
TRICOR TABS 48MG Not Covered
TRICOR TABS 145MG Not Covered
TRI-ESTARYLLA TABS 0; 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; 10MCG; 151MG;
TRIGELS-F FORTE CAPS 1MG Covered
TRIHEXYPHENIDYL
HCL TABS 5MG Not Covered
TRIHEXYPHENIDYL
HCL TABS 2MG Not Covered
TRIHEXYPHENIDYL
HCL ELIX 0.4MG/ML Not Covered
TRI-LEGEST FE TABS 0; 75MG; 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
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; 0 Covered


TRI-LO-SPRINTEC TABS 0; 0 Covered
420GM; 1.48GM; 5.72GM;
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; 0 Covered
TRINESSA LO TABS 0; 0 Covered
100MG; 150MCG; 5MG;
6MCG; 1MG; 20MG; 10MG;
TRIPHROCAPS CAPS 1.7MG; 1.5MG Covered
TRI-PREVIFEM TABS 0; 0 Covered
TRI-SPRINTEC TABS 0; 0 Covered
TRIUMEQ TABS 600MG; 50MG; 300MG Not Covered
35MG/ML; 400UNIT/ML;
TRI-VIT/FLUORIDE SOLN 0.5MG/ML; 1500UNIT/ML Not Covered AL
35MG/ML; 400UNIT/ML;
TRI-VIT/FLUORIDE SOLN 0.25MG/ML; 1500UNIT/ML Not Covered AL
TRIVORA-28 TABS 0; 0 Covered
TRIZIVIR TABS 300MG; 150MG; 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 0.50% Covered
TROSPIUM
CHLORIDE TABS 20MG Covered QL
TROSPIUM
CHLORIDE ER CP24 60MG Not Covered
TRUETRACK TEST STRP 0 Not Covered
TRULICITY SOPN 0.75MG/0.5ML Not Covered
TRULICITY SOPN 1.5MG/0.5ML 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
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; 300MG Not Covered
TUDORZA
PRESSAIR AEPB 400MCG/ACT Covered
TUSSIN SYRP 100MG/5ML Not Covered
TUSSIONEX
PENNKINETIC
EXTENDED
RELEASE SUER 8MG/5ML; 10MG/5ML Not Covered
TUZISTRA XR SUER 2.8MG/5ML; 14.7MG/5ML Not Covered
TWINRIX SUSP 720ELU/ML; 20MCG/ML Covered QL AL
TWYNSTA TABS 5MG; 40MG Not Covered
TWYNSTA TABS 5MG; 80MG Not Covered
TWYNSTA TABS 10MG; 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 0.6MG/ML Not Covered
TYZEKA TABS 600MG Not Covered
UCERIS TB24 9MG Not Covered
UCERIS FOAM 2MG/ACT Not Covered QL
250MCG; 0; 0; 1000MCG;
2.5MG; 12.5MG; 100MCG;
320MG; 0; 17MG; 75UNIT;
UDAMIN SP TABS 7.5MG Covered
ULESFIA LOTN 5% Not Covered
ULORIC TABS 40MG Covered PA QL
ULORIC TABS 80MG Covered PA
120MG; 0; 200MG; 2MG;
12MCG; 50MG; 1MG;
90MCG; 20MG; 150MCG;
20MG; 3.4MG; 3MG;
2700UNIT; 400UNIT;
ULTRA TABS TABS 30UNIT; 25MG Not Covered
ULTRACET TABS 325MG; 37.5MG 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; 13800UNIT;
ULTRESA CPEP 27600UNIT Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 165 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


41400UNIT; 20700UNIT;
ULTRESA CPEP 41400UNIT Not Covered
46000UNIT; 23000UNIT;
ULTRESA CPEP 46000UNIT Not Covered
UNITHROID TABS 50MCG Covered
UNITUXIN SOLN 17.5MG/5ML Not Covered
UREA LOTN 40% Not Covered
UREA CREA 40% Not Covered
UREA GEL 40% Not Covered
URELIEF PLUS TABS 15MG; 0.3MG; 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 0.02% 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; 320MG Not Covered

VALSARTAN/HYDRO
CHLOROTHIAZIDE TABS 12.5MG; 320MG Not Covered

VALSARTAN/HYDRO
CHLOROTHIAZIDE TABS 25MG; 160MG Covered

VALSARTAN/HYDRO
CHLOROTHIAZIDE TABS 12.5MG; 160MG Covered

VALSARTAN/HYDRO
CHLOROTHIAZIDE TABS 12.5MG; 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
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 0.75% Not Covered
VANOS CREA 0.10% Not Covered
VAQTA SUSP 50UNIT/ML Covered QL AL
VAQTA SUSP 25UNIT/0.5ML Covered QL AL
VARIZIG SOLR 125UNIT Not Covered
VASCEPA CAPS 1GM Not Covered
788MG/GM; 87MG/GM;
VASOLEX OINT 90UNIT/GM Not Covered
150MG; 10MG; 10MCG;
1MG; 70MG; 4MG; 25MG;
2MG; 5MG; 10MG;
V-C FORTE CAPS 8000UNIT; 50UNIT; 80MG Covered
VCF VAGINAL
CONTRACEPTIVE
FOAM FOAM 12.50% Not Covered
VECAMYL TABS 2.5MG Not Covered
VECTICAL OINT 3MCG/GM Not Covered
VELCADE SOLR 3.5MG Not Covered
VELIVET TABS 0; 0 Covered
VELPHORO CHEW 500MG Covered
VENLAFAXINE HCL TABS 100MG Not Covered
VENLAFAXINE HCL TABS 75MG Not Covered
VENLAFAXINE HCL TABS 37.5MG 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 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
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 37.5MG Not Covered
VENOFER SOLN 20MG/ML Covered
VENTAVIS SOLN 10MCG/ML Not Covered
VENTOLIN HFA AERS 108MCG/ACT Covered
VERAMYST SUSP 27.5MCG/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 0.05% 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; 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
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; 10MG; 10MCG;
1MG; 70MG; 4MG; 25MG;
2MG; 5MG; 10MG;
VIC-FORTE CAPS 8000UNIT; 50UNIT; 80MG Covered
VICODIN TABS 300MG; 5MG Not Covered
VICODIN ES TABS 300MG; 7.5MG Not Covered
VICODIN HP TABS 300MG; 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; 12.5MG; 75MG;
VIEKIRA PAK TBPK 50MG Not Covered
VIGAMOX SOLN 0.50% 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; 375MG Not Covered
VIMOVO TBEC 20MG; 500MG Not Covered
VIMPAT TABS 50MG Not Covered
VIMPAT TABS 150MG Not Covered
VIMPAT TABS 200MG Not Covered
VIMPAT TABS 100MG Not Covered
120MG; 3000UNIT; 30MCG;
150MG; 8MG; 400UNIT;
2.5MG; 12MCG; 27MG;
1MG; 75MG; 20MG; 30MG;
3.5MG; 3MG; 30UNIT;
VINATE AZ TABS 15MG Covered
0; 85MG; 110MG; 5MCG;
27MG; 1.13MG; 60MG;
1MG; 18MG; 220MCG;
25MG; 1.4MG; 60MCG; 0;
VINATE DHA RF CAPS 1.4MG; 15MG Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 169 of 178
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL

120MG; 0; 30MCG; 200MG;


6MG; 400UNIT; 2MG;
12MCG; 50MG; 1MG;
90MG; 30MG; 20MG;
20MG; 3.4MG; 3MG;
VINATE GT TABS 10UNIT; 2700UNIT; 15MG Covered QL AL
10MG; 0.8MG; 15MCG;
162MG; 1MG; 6.9MG;
1.3MG; 30MG; 115.2MG;
5MG; 6MG; 200MG; 10MG;
VINATE IC CAPS 18.2MG Covered
120MG; 30MCG; 200MG;
10MG; 400UNIT; 25MCG;
2MG; 12MCG; 27MG; 1MG;
25MG; 5MG; 20MG;
150MCG; 10MG; 3.4MG;
25MCG; 20MCG; 3MG;
VINATE M TABS 30UNIT; 5000UNIT; 25MG Covered QL AL
80MG; 0; 0.03MG; 200MG;
400UNIT; 3MG; 2.5MCG;
60MG; 1MG; 100MG;
17MG; 7MG; 4MG; 1.6MG;
1.5MG; 15UNIT; 4000UNIT;
VINATE ONE TABS 25MG Covered
120MG; 0; 200MG; 2MG;
12MCG; 50MG; 1MG;
150MCG; 90MG; 20MG;
20MG; 3.4MG; 3MG;
2700UNIT; 400UNIT;
VINATE ULTRA TABS 30UNIT; 25MG Covered QL AL
78300UNIT; 20880UNIT;
VIOKACE TABS 78300UNIT Not Covered
39150UNIT; 10440UNIT;
VIOKACE TABS 39150UNIT Not Covered
VIORELE TABS 0; 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


25MG; 300MCG; 5MG;
2MG; 12.5MCG; 156MG;
39MG; 53.5MG; 310MG;
1MG; 5MG; 1.8MG; 200MG;
38MG; 25MG; 3MG; 2MG;
VIRT-C DHA CAPS 10MG Not Covered
100MG; 150MCG; 5MG;
6MCG; 1MG; 20MG; 10MG;
VIRT-CAPS CAPS 1.7MG; 1.5MG Covered
VIRT-VITE TABS 1MG; 2.5MG; 25MG Covered
VIRT-VITE FORTE TABS 2MG; 2.5MG; 25MG Covered
60MG; 300MCG; 1MG;
5MG; 20MG; 10MG; 50MG;
VIRT-VITE PLUS TABS 1.5MG; 1.5MG Covered

60MG; 125MG; 5MCG;


65MG; 1MG; 15MG; 2.5MG;
1.8MG; 1.1MG; 6000UNIT;
VITAFOL TABS 400UNIT; 30UNIT Covered
1000UNIT; 12MCG; 18MG;
0.4MG; 0.6MG; 150MCG;
VITAFOL-NANO TABS 2.5MG Not Covered
70MG; 2700UNIT; 100MG;
400UNIT; 2MG; 12MCG;
65MG; 1MG; 25MG; 18MG;
2.5MG; 1.8MG; 1.6MG;
VITAFOL-OB TABS 30UNIT; 25MG Not Covered
30MG; 0; 1100UNIT;
1000UNIT; 2MG; 12MCG;
200MG; 1MG; 20MG;
15MG; 29MG; 150MCG;
2.5MG; 1.8MG; 1.6MG;
VITAFOL-ONE CAPS 20UNIT; 25MG Not Covered
60MG; 125MG; 400UNIT;
5MCG; 65MG; 1MG; 25MG;
15MG; 2.5MG; 1.8MG;
65MCG; 1.6MG; 30UNIT;
VITAFOL-PN TABS 4000UNIT; 15MG Not Covered
60MG; 300MCG; 1750UNIT;
6MG; 1MG; 20MG; 10MG;
10MG; 1.7MG; 1.5MG;
VITAL-D RX TABS 12.5MG 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
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; 400UNIT/ML;
A/C/D/FLUORIDE SOLN 0.25MG/ML; 1500UNIT/ML Covered QL
30MG; 300MCG; 10MG;
400UNIT; 8MCG; 200MG; 0;
1.4MG; 30MG; 20MG;
150MCG; 25MG; 2MG; 0;
VITAPEARL CPCR 1.7MG; 30UNIT; 7.5MG Not Covered
VITA-RESPA TABS 1.3MG; 2.2MG; 25MG Covered
VITEKTA TABS 150MG Not Covered
VITEKTA TABS 85MG Not Covered
VITUZ SOLN 4MG/5ML; 5MG/5ML Not Covered
VIVACTIL TABS 10MG Not Covered
VIVACTIL TABS 5MG Not Covered
VIVELLE-DOT PTTW 0.075MG/24HR Not Covered
VIVELLE-DOT PTTW 0.1MG/24HR Not Covered
VIVELLE-DOT PTTW 0.0375MG/24HR Not Covered
VIVELLE-DOT PTTW 0.025MG/24HR Not Covered
VIVELLE-DOT PTTW 0.05MG/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; 300MCG; 10MG;
6MCG; 1MG; 20MG; 10MG;
VOL-CARE RX TABS 1.7MG; 1.5MG Covered

120MG; 3000UNIT; 200MG;


400UNIT; 2MG; 12MCG;
28MG; 1MG; 25MG; 20MG;
25MG; 4MG; 1.8MG; 22MG;
VOL-NATE TABS 25MG Covered

120MG; 4000UNIT; 30MCG;


200MG; 7MG; 400UNIT;
3MG; 8MCG; 1MG; 29MG;
100MG; 20MG; 150MCG;
3MG; 3MG; 3MG; 30UNIT;
VOL-TAB RX TABS 15MG Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 172 of 178
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; 30MCG; 10MG;
400UNIT; 12MCG; 200MG;
1MG; 6MG; 17MG; 22MG;
175MCG; 50MG; 10UNIT;
VP-HEME ONE CAPS 15MG Not Covered
VPRIV SOLR 400UNIT Not Covered
5MG; 1.5MG; 500MCG;
VP-ZEL TABS 600MG; 5MG; 10MG Covered
VUSION OINT 0.25%; 81.35%; 15% Not Covered
VYFEMLA TABS 35MCG; 0.4MG Covered
VYTONE CREA 0; 1.9%; 1% Not Covered
VYTORIN TABS 10MG; 40MG Not Covered
VYTORIN TABS 10MG; 10MG Not Covered
VYTORIN TABS 10MG; 20MG Not Covered
VYTORIN TABS 10MG; 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 7.5MG 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
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 Covered
WESTHROID TABS 130MG Not Covered
WESTHROID TABS 32.5MG Not Covered
XALATAN SOLN 0.01% 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; 7.5MG Not Covered
XELJANZ TABS 5MG Not Covered
XELODA TABS 500MG Not Covered
XELODA TABS 150MG Not Covered
XENAZINE TABS 12.5MG Not Covered
XENAZINE TABS 25MG Not Covered
XENICAL CAPS 120MG Not Covered
XERAC AC SOLN 6.25% Not Covered
XERESE CREA 5%; 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; 500MG Not Covered
XIGDUO XR TB24 5MG; 1000MG Not Covered
XIGDUO XR TB24 10MG; 500MG Not Covered
XIGDUO XR TB24 10MG; 1000MG Not Covered
XOFIGO SOLN 30MCCI/ML Not Covered
XOLAIR SOLR 150MG Not Covered
XOPENEX NEBU 1.25MG/3ML Not Covered
XOPENEX NEBU 0.63MG/3ML Not Covered
XOPENEX NEBU 0.31MG/3ML Not Covered
XOPENEX
CONCENTRATE NEBU 1.25MG/0.5ML Not Covered
XOPENEX HFA AERO 45MCG/ACT Not Covered
XTANDI CAPS 40MG Covered PA QL
35MCG/24HR;
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; 0.03MG Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 174 of 178
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; 0.03MG Covered
ZARXIO SOSY 300MCG/0.5ML Covered
ZARXIO SOSY 480MCG/0.8ML Covered
ZAVESCA CAPS 100MG Not Covered
ZEBUTAL CAPS 325MG; 50MG; 40MG Covered QL AL
ZECUITY PTCH 6.5MG/4HR Not Covered
ZEGERID PACK 20MG; 1680MG Not Covered
ZEGERID CAPS 20MG; 1100MG Not Covered
ZEGERID CAPS 40MG; 1100MG Not Covered
ZEGERID PACK 40MG; 1680MG Not Covered
ZEGERID OTC CAPS 20MG; 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; 0.4MG Covered
55000UNIT; 10000UNIT;
ZENPEP CPEP 34000UNIT Covered
82000UNIT; 15000UNIT;
ZENPEP CPEP 51000UNIT Covered
16000UNIT; 3000UNIT;
ZENPEP CPEP 10000UNIT Covered
109000UNIT; 20000UNIT;
ZENPEP CPEP 68000UNIT Covered
27000UNIT; 5000UNIT;
ZENPEP CPEP 17000UNIT Covered
136000UNIT; 25000UNIT;
ZENPEP CPEP 85000UNIT Covered
ZENZEDI TABS 2.5MG Not Covered
ZENZEDI TABS 10MG Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 175 of 178
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 7.5MG Not Covered
ZENZEDI TABS 20MG Not Covered
ZENZEDI TABS 30MG Not Covered
ZERBAXA SOLR 1GM; 0.5GM 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
ZEVALIN Y-90 KIT 3.2MG/2ML Not Covered
ZIAGEN TABS 300MG Not Covered
ZIANA GEL 1.2%; 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 1.20% 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 2.5MG Covered QL
ZOLMITRIPTAN TABS 5MG Covered QL

ZOLMITRIPTAN ODT TBDP 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
Medication Coverage Level Restrictions

Label Name Dose Form Strength Coverage Level PA ST QL AL


ZOLPIDEM
TARTRATE ER TBCR 12.5MG Not Covered
ZOLPIDEM
TARTRATE ER TBCR 6.25MG Not Covered
ZOLPIMIST SOLN 5MG/ACT Not Covered
ZOMIG TABS 5MG Not Covered
ZOMIG TABS 2.5MG Not Covered
ZOMIG NASAL
SPRAY SOLN 5MG Not Covered
ZOMIG ZMT TBDP 5MG Not Covered
ZOMIG ZMT TBDP 2.5MG Not Covered
ZONISAMIDE CAPS 25MG Not Covered
ZONISAMIDE CAPS 100MG Not Covered
ZONISAMIDE CAPS 50MG Not Covered
ZONTIVITY TABS 2.08MG Not Covered
ZORTRESS TABS 0.75MG Not Covered QL
ZORTRESS TABS 0.5MG Not Covered QL
ZORTRESS TABS 0.25MG Not Covered QL
ZORVOLEX CAPS 18MG Not Covered
ZORVOLEX CAPS 35MG Not Covered
ZOSTAVAX SOLR 19400UNT/0.65ML Covered QL AL
ZOVIA 1/35E TABS 35MCG; 1MG Covered
ZOVIA 1/50E TABS 50MCG; 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 5.7MG; 1.4MG Not Covered
ZUBSOLV SUBL 1.4MG; 0.36MG Not Covered
ZUBSOLV SUBL 8.6MG; 2.1MG Not Covered
ZUPLENZ FILM 4MG Not Covered
ZUPLENZ FILM 8MG Not Covered
4MG/5ML; 5MG/5ML;
ZUTRIPRO SOLN 60MG/5ML Not Covered
ZYCLARA CREA 3.75% 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 0.5%; 0.3% Not Covered
ZYMAXID SOLN 0.50% Not Covered
ZYPREXA TABS 2.5MG Not Covered
ZYPREXA TABS 20MG Not Covered

PA-Prior Authorization QL-Quantity Limit


ST-Step Therapy AL-Age Limit Page 177 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 7.5MG 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
© 2015 Priority Health   9013R 12/15