CONNECTICUT MEDICAID ACNE AGENTS, TOPICAL ‡ Angiotensin Modulators/CCB Comb., Cont Antidepressants, Other, Cont. AZELEX (TOPICAL) EXFORGE, EXFORGE HCT (ORAL) MIRTAZAPINE TABLET, ODT (ORAL) Preferred Drug List BENZACLIN GEL (TOPICAL) Antibiotics, GI PARNATE (ORAL) BENZACLIN GEL PUMP (TOPICAL) METRONIDAZOLE TABLET (ORAL) PHENELZINE (ORAL) • The Connecticut Medicaid Preferred Drug List (PDL) CLINDAMYCIN PHOSPHATE GEL, LOTION, SOLUTION (TOPICAL) NEOMYCIN (ORAL) PRISTIQ ER (ORAL) is a listing of prescription products selected by the CLINDAMYCIN / BENZOYL PEROXIDE 1.2-5% (TOPICAL) VANCOMYCIN HCL (ORAL) TRAZODONE (ORAL) Pharmaceutical and Therapeutics Committee as DIFFERIN CREAM, GEL, GEL PUMP, LOTION (TOPICAL) Antibiotics, Inhaled TRINTELLIX (BRINTELLIX) (ORAL) efficacious, safe and cost effective choices when EPIDUO GEL PUMP (TOPICAL) BETHKIS (INHALATION) VENLAFAXINE ER CASPULES (ORAL) prescribing for Medicaid patients ERYTHROMYCIN SOLUTION (TOPICAL) CAYSTON (INHALATION) VIIBRYD (ORAL) • Preferred or Non-preferred status only applies to RETIN-A CREAM (TOPICAL) KITABIS PAK (INHALATION) those medications that fall within the drug classes RETIN-A GEL (TOPICAL) TOBI PODHALER (INHALATION) Antidepressants, SSRI listed on this PDL Alzheimer's Agents Antibiotics, Topical CITALOPRAM TABLET, SOLUTION (ORAL) • HIV medications are excluded from the PDL and DONEPEZIL ODT, TABLET 5MG & 10MG (ORAL) BACTROBAN CREAM (TOPICAL) ESCITALOPRAM SOLUTION, TABLET (ORAL) do not require prior authorization EXELON PATCH (TRANSDERMAL) GENTAMICIN CREAM, OINTMENT (TOPICAL) FLUOXETINE CAPSULE, SOLUTION (ORAL) (not Tablet) • All strengths and dosage forms of preferred agents GALANTAMINE ER (ORAL) MUPIROCIN CREAM, OINTMENT (TOPICAL) FLUVOXAMINE (ORAL) are covered, unless otherwise stated MEMANTINE TABLET, TITRATION PACK (ORAL) PAROXETINE TABLET (ORAL) • The brand-name of a generically available MEMANTINE SOLUTION (ORAL)* Antibiotics, Vaginal SERTRALINE CONC, TABLET (ORAL) medication will not be covered without a PA, unless RIVASTIGMINE CAPSULES (ORAL) CLEOCIN OVULES (VAGINAL) Antiemetics/Antivertigo the brand is listed on the PDL Analgesics, Narcotic Long METRONIDAZOLE VAGINAL GEL (VAGINAL) EMEND, EMEND TRIFOLD PACK (ORAL) • Preferred brand-name medications with non- FENTANYL (12MG, 25MG, 50MG, 75MG, 100MG) (TRANSDERM) DICLEGIS (ORAL) preferred generic equivalents are listed in bold HYSINGLA ER (ORAL) Anticoagulants DRONABINOL (ORAL) ** New Therapeutic Class added to PDL effective METHADONE CONC, SOL TABLET, SOLUTION, TABLET (ORAL) ELIQUIS (ORAL) ONDANSETRON ODT, SOLUTION, TABLET (ORAL) 1/1/2017 MORPHINE ER TABLET(ORAL) FRAGMIN VIAL (SUBCUTANE.) Antifungals, Oral * New Drug added to the PDL effective 1/1/2017 TRAMADOL ER TABLET (ORAL) (generic ULTRAM ER) LOVENOX SYRINGE, VIAL (SUBCUTANE.) CLOTRIMAZOLE TROCHE (MUCOUS MEM) PA Requirements Analgesics, Narcotic Short PRADAXA (ORAL) FLUCONAZOLE SUSPENSION, TABLET (ORAL) APAP / CODEINE ELIXIR, TABLET (ORAL) WARFARIN (ORAL) GRIFULVIN V TABLET (ORAL) • Intolerance of the preferred agents BUTALBITAL / CAFFEINE / APAP W/CODEINE (ORAL) XARELTO, XARELTO DOSE PACK (ORAL) GRISEOFULVIN MICRO TAB, SUSPENSION (ORAL) • Adverse reaction to the preferred agents BUTALBITAL / CAFFEINE / ASA W/CODEINE (ORAL) Anticonvulsants GRISEOFULVIN ULTRAMICROSIZE TABLET (ORAL) • Inadequate response from the preferred agents BUTORPHANOL TARTRATE (NASAL) CARBAMAZEPINE SUSPENSION, TAB CHEW, TABLET (ORAL) NYSTATIN SUSPENSION, TABLET (ORAL) • Determined medically necessary and medically CODEINE (ORAL) CARBAMAZEPINE ER CAPSULE (ORAL) TERBINAFINE (ORAL) appropriate DIHYDROCODEINE / APAP / CAFFEINE (ORAL) CARBAMAZEPINE ER TABLET (ORAL)* Antifungals, Topical • Absence of appropriate formulation of the HYDROCODONE / APAP CAPSULE, SOLUTION, TABLET (ORAL) CELONTIN (ORAL) CLOTRIMAZOLE CREAM RX (TOPICAL) preferred agents HYDROCODONE / IBUPROFEN (ORAL) CLONAZEPAM (not ER) (ORAL) CLOTRIMAZOLE CREAM OTC (TOPICAL) Step Therapy PA Requirements HYDROMORPHONE TABLET (IR) (ORAL) DEPAKOTE (ORAL) CLOTRIMAZOLE-BETAMETHASONE CREAM (TOPICAL) MORPHINE CONC, SOLUTION (ORAL) DIASTAT, DIASTAT ACUDIAL (RECTAL) KETOCONAZOLE CREAM, SHAMPOO (TOPICAL) ‡ Agents from the following FIVE categories: MORPHINE IR TABLET (ORAL) DIVALPROEX ER (ORAL) NYSTATIN CREAM, OINT, POWDER (TOPICAL) ACNE AGENTS, TOPICAL, ANTIMIGRAINE AGENTS, OXYCODONE / APAP CAPSULE, TABLET (ORAL) DIVALPROEX SPRINKLE, TABLET (ORAL)* NYSTATIN-TRIAMCINOLONE CREAM, OINT (TOPICAL) CYTOKINE/CAM ANTAGONISTS, LIPOTROPICS, STATINS, OXYCODONE / ASA (ORAL) ETHOSUXIMIDE SOLUTION (ORAL) Antihistamines, Minimally Sedating PROTON PUMP INHIBITORS, OXYCODONE TABLET (ORAL) GABITRIL (ORAL) CETIRIZINE CAPSULE OTC, CETIRIZINE SOLUTION, Important Connecticut Medicaid OXYCODONE 5 MG/5 ML SOLUTION (ORAL) LAMOTRIGINE STARTER PACK, TABLET (IR), DISPERS TAB (ORAL) CETIRIZINE SOLUTION OTC, CETIRIZINE TABLET OTC (ORAL)* TRAMADOL TABLET (ORAL) LEVETIRACETAM SOLUTION, TABLET (ORAL) FEXOFENADINE-D 12-HOUR OTC (ORAL) Phone Numbers TRAMADOL / APAP (ORAL) OXCARBAZEPINE SUSPENSION, TABLET (ORAL) FEXOFENADINE SUSPENSION OTC (ORAL) Androgenic Agents HPE Pharmacy Prior Authorization Center PEGANONE (ORAL) LEVOCETIRIZINE TABLETS (ORAL)* ANDROGEL GEL PACKET, PUMP (TRANSDERM.) PHENOBARBITAL ELIXIR, TABLET (ORAL) LORATADINE ODT, SOLUTION, TABLET (ORAL) p. 1-866-409-8386 (toll-free) Angiotensin Modulators PHENYTOIN CHEW TABLET, SUSPENSION (ORAL) LORATADINE-D OTC (ORAL) f. 1-866-759-4110 (toll-free) DIOVAN (ORAL) PHENYTOIN SOD EXT CAPSULE (ORAL) ENALAPRIL, ENALAPRIL HCTZ (ORAL) PRIMIDONE (ORAL) Antihypertensives, Sympatholytics PA forms are only available on our website: ENTRESTO (ORAL) TOPIRAMATE SPRINKLE, TABLET (ORAL) CATAPRES-TTS PATCH (TRANSDERM) http://www.CTDSSMAP.com EPANED SOLUTION (ORAL) VALPROIC ACID CAPSULE, SOLUTION (ORAL) CLONIDINE TABLET (ORAL) Navigate to: Pharmacy Information LISINOPRIL, LISINOPRIL HCTZ (ORAL) VIMPAT SOLUTION, TABLET (ORAL) GUANFACINE (ORAL) or: information > publications > forms LOSARTAN, LOSARTAN HCTZ (ORAL) ZONISAMIDE (ORAL) METHYLDOPA (ORAL) QUINAPRIL, QUINIPRIL HCTZ (ORAL) METHYLDOPA HCTZ (ORAL) HPE Provider Assistance Center VALSARTAN HCTZ (ORAL) Antidepressants, Other Antihyperuricemics 1-800-842-8440 Angiotensin Modulators/CCB Comb. BUPROPION, BUPROPION SR, BUPROPION XL (ORAL) ALLOPURINOL (ORAL) Dept of Social Services Rx Consultant AMLODIPINE / BENAZEPRIL (ORAL) FETZIMA ER, FETZIMA STARTER PACK (ORAL) PROBENECID (ORAL) (860) 424-5150 AZOR (ORAL) MARPLAN (ORAL) PROBENECID-COLCHICINE (ORAL) Updated January 1, 2017 ANTIMIGRAINE AGENTS ‡ Antipsychotics, Cont. BPH Agents Contraceptives, Oral, Cont. RELPAX (ORAL) PERPHENAZINE / AMITRIPTYLINE (ORAL) ALFUZOSIN ER (ORAL) JUNEL FE 1/20, JUNEL FE 1.5/30 (ORAL) (not 24) RIZATRIPTAN ODT, RIZATRIPTAN TABLET (ORAL) QUETIAPINE TABLET (ORAL) DOXAZOSIN (ORAL) LARIN FE 1/20, LARIN FE 1.5/30 (ORAL) (not 24) SUMATRIPTAN NASAL SPRAY (NASAL) REXULTI (ORAL) FINASTERIDE (ORAL) LESSINA-28 (ORAL) SUMATRIPTAN TABLET (ORAL) RISPERDAL CONSTA (INTRAMUSC.) TAMSULOSIN (ORAL) LEVONEST-28 (ORAL) SUMATRIPTAN CARTRIDGE, PEN, SYRINGE, VIAL (SUBCUTANE.) RISPERIDONE ODT, SOLUTION, TABLET (ORAL) TERAZOSIN (ORAL) LEVONOR-ETH ESTRADIOL-28 0.1/20 (ORAL) (not 91) SAPHRIS (SUBLINGUAL) Bronchodilators, Beta-Agonists LEVONOR-ETH ESTRADIOL-28 0.15/30 (ORAL) (not 91) Antiparasitics, Topical SEROQUEL XR (ORAL) ALBUTEROL NEB SOLN 100 MG/20 ML (INHALATION) LEVORA-28 (ORAL) PERMETHRIN CREAM, LOTION, SHAMPOO(TOPICAL) SYMBYAX (ORAL) ALBUTEROL NEB SOLN 0.63, 1.25, 2.5 MG/3 ML (INHALATION) LOESTRIN 21 1/20, LOESTRIN 21 1.5/30 (ORAL) PIPERONYL BUTOXIDE/PYRETHRINS SHAMPOO OTC (TOPICAL) THIORIDAZINE (ORAL) ALBUTEROL NEB SOLN 2.5 MG/0.5 ML (INHALATION) LOESTRIN FE 1/20, LOESTRIN FE 1/5.30 (ORAL) NATROBA (TOPICAL) THIOTHIXENE (ORAL) ALBUTEROL SOLUTION, SYRUP (ORAL) LORYNA 3/20 (ORAL) SKLICE (TOPICAL) TRIFLUOPERAZINE (ORAL) FORADIL (INHALATION) LOSEASONIQUE (ORAL) Antiparkinson's Agents VRAYLAR (ORAL) PROAIR HFA (INHALATION) LOW-OGESTREL-28 (ORAL) AMANTADINE CAPSULE, SOLUTION (ORAL) ZIPRASIDONE CAPSULE (ORAL) PROVENTIL HFA (INHALATION) LUTERA-28 (ORAL) BENZTROPINE (ORAL) ZYPREXA VIAL (INTRAMUSC) SEREVENT (INHALATION) MICROGESTIN FE 1/20, MICROGESTIN FE 1.5/30 (ORAL) BROMOCRIPTINE (ORAL) ZYPREXA RELPREVV (INTRAMUSC) TERBUTALINE (ORAL) MIRCETTE-28 (ORAL) CARBIDOPA / LEVODOPA TABLET, ODT (ORAL) Antivirals, Oral & Inhaled MYZILRA-28 (ORAL) CARBIDOPA / LEVODOPA ER TABLET (ORAL) ACYCLOVIR CAPSULE, TABLET (ORAL) Calcium Channel Blockers NECON 0.5/35, NECON 1/35, NECON 1/50 (ORAL) CARBIDOPA / LEVODOPA / ENTACAPONE (ORAL) FAMCICLOVIR (ORAL) AMLODIPINE (ORAL) NORGEST-ETH ESTRADIOL 0.18-0.215-0.25/25 (ORAL) PRAMIPEXOLE (IR) (ORAL) RELENZA (INHALATION) DILTIAZEM TABLET, DILTIAZEM CAPSULE ER (ORAL) NORGEST-ETH ESTRADIOL 0.18-0.215-0.25/35 (ORAL) ROPINIROLE (IR) (ORAL) RIMANTADINE (ORAL) NIFEDIPINE ER, NIFEDIPINE IR (ORAL) NORINYL 1+35, NORINYL 1+50 (ORAL) SELEGILINE CAPSULE, TABLET (ORAL) TAMIFLU CAPSULE, SUSPENSION (ORAL) VERAPAMIL ER PM (ORAL) NOR-Q-D (ORAL) TRIHEXYPHENIDYL ELIXIR, TABLET (ORAL) VALACYCLOVIR (ORAL) VERAPAMIL TABLET, VERAPAMIL TABLET ER (ORAL) NORTREL 0.5/35, NORTREL 1/35, NORTREL 7/7/7 (ORAL) Antipsoriatics, Oral ZOVIRAX SUSPENSION (ORAL) ORSYTHIA-28 (ORAL) ACITRETIN (ORAL)* Cephalosporins & Related Agents ORTHO TRI-CYCLEN LO (ORAL) METHOXSALEN (ORAL) Antivirals, Topical AMOXICILLIN/CLAV CHEW TAB, SUSPENSION, TABLET (ORAL) ORTHO-NOVUM 1/35 (ORAL) DENAVIR CREAM (TOPICAL) CEFACLOR CAPSULE, SUSPENSION (ORAL) OVCON-35 (ORAL) Antipsoriatics, Topical ZOVIRAX CREAM (TOPICAL) CEFADROXIL CAPSULE, SUSPENSION, TABLET (ORAL) PHILITH 0.4/35 (ORAL) CALCIPOTRIENE CREAM, OINTMENT, SOLUTION (TOPICAL) Anxiolytics CEFDINIR CAPSULE, SUSPENSION (ORAL) PORTIA-28 (ORAL) CALCITRIOL OINTMENT (TOPICAL) ALPRAZOLAM TABLET (IR) (ORAL) CEFPODOXIME SUSPENSION, TABLET (ORAL) SEASONIQUE (ORAL) DOVONEX CREAM (TOPICAL) BUSPIRONE (ORAL) CEFPROZIL SUSPENSION, TABLET (ORAL) SRONYX 0.1/20 (ORAL) Antipsychotics CHLORDIAZEPOXIDE (ORAL) CEFTIN SUSPENSION (ORAL) SYEDA-28 (ORAL) ABILIFY DISCMELT, SOLUTION, TABLET (ORAL) DIAZEPAM 5 MG/5 ML SOLUTION (ORAL) CEFUROXIME TABLET (ORAL) TRI-LINYAH (ORAL) ABILIFY MAINTENA ER (INTRAMUSC.) DIAZEPAM TABLET (ORAL) CEPHALEXIN CAPSULE, SUSPENSION, TABLET (ORAL) TRI-NORINYL-28 (ORAL) ADASUVE (INHALATION) LORAZEPAM INTENSOL, TABLET (ORAL) SUPRAX CAPSULE, CHEW TAB (ORAL) TRI-PREVIFEM (ORAL) ARIPIPRAZOLE ODT, SOLUTION, TABLET (ORAL) SUPRAX SUSPENSION (ORAL) TRI-SPRINTEC (ORAL) CHLORPROMAZINE (ORAL) Beta Blockers Colony Stimulating Factors TRIVORA-28 (ORAL) CLOZAPINE (ORAL) ATENOLOL, ATENOLOL / CHLORTHALIDONE (ORAL) GRANIX (INJECTION) VESTURA 3/20 (ORAL) CLOZAPINE ODT (ORAL) CARVEDILOL (ORAL) NEULASTA SYRINGE, KIT (INJECTION) WERA 0.5/35 (ORAL) FANAPT (ORAL) LABETALOL (ORAL) NEUPOGEN DISP SYRINGE, VIAL (INJECTION) YASMIN-28 (ORAL) FAZACLO ODT (ORAL) METOPROLOL TARTRATE (ORAL) YAZ-28 (ORAL) FLUPHENAZINE DECANOATE (INJECTION) METOPROLOL SUCCINATE ER (ORAL) Contraceptives, Oral ZARAH (ORAL) FLUPHENAZINE ELIXIR/SOLN, TABLET (ORAL) PROPRANOLOL SOLUTION, TABLET (ORAL) APRI-28 (ORAL) ZENCHENT FE CHEWABLE (ORAL) GEODON VIAL (INTRAMUSC) PROPRANOLOL ER (ORAL) ALYACEN 1/35, ALCACEN 7/7/7 (ORAL) HALOPERIDOL (ORAL) Bile Salts, Oral AVIANE-28 (ORAL) COPD Agents HALOPERIDOL DECANOATE, LACTATE (INJECTION) URSODIOL TABLET (ORAL) (not CAPSULE) BREVICON-28 (ORAL) ALBUTEROL SULF/IPRATROPIUM NEB SOLUTION (INHALATION) HALOPERIDOL LACTATE CONC (ORAL) CHATEAL-28 (ORAL) ANORO ELLIPTA (INHALATION)* INVEGA ER (ORAL) Bladder Relaxants CRYSELLE-28 (ORAL) ATROVENT HFA (INHALATION) INVEGA SUSTENNA (INTRAMUSC) OXYBUTYNIN SYRUP, TABLET, OXYBUTYNIN ER (ORAL) CYCLAFEM 1/35 (ORAL) COMBIVENT RESPIMAT (INHALATION) INVEGA TRINZA (INTRAMUSC) TOVIAZ ER (ORAL) DASETTA 1/35, DASETTA 7/7/7 (ORAL) DALIRESP (ORAL) LATUDA (ORAL) VESICARE (ORAL) DESOGEN-28 (ORAL) IPRATROPIUM BROMIDE SOLUTION (INHALATION) LOXAPINE (ORAL) Bone Resorption Inhibitors ELINEST-28 (ORAL) SPIRIVA HANDIHALER (INHALATION) MOLINDONE (ORAL) ALENDRONATE TABLET (ORAL) ENPRESSE-28 (ORAL) STIOLTO RESPIMAT (INHALATION) NUPLAZID (ORAL) CALCITONIN-SALMON 200 UNITS SPRAY (NASAL) ESTROSTEP FE-28 (ORAL) OLANZAPINE TABLET, ODT (ORAL) FORTICAL (NASAL) FALMINA-28 (ORAL) CYTOKINE & CAM ANTAGONISTS ‡ ORAP (ORAL) Botulinum Toxins, Injectable FEMCON FE CHEWABLE (ORAL) ENBREL DISP SYRINGE, KIT, PEN (INJECTION) PERPHENAZINE (ORAL) BOTOX (INTRAMUSC) GILDESS FE 1/20, GILDESS FE 1.5/30 (ORAL) (not 24) HUMIRA KIT, PEN INJ KIT (INJECTION) Updated January 1, 2017 Emollients, Topical Hepatitis C Agents, Cont. Immunosuppressives, Oral Iron, Oral, Cont. AMMONIUM LACTATE CREAM/LOTION (TOPICAL) RIBAVIRIN TABLET (ORAL) AZATHIOPRINE (ORAL) SE-TAN PLUS (ORAL) SOVALDI (ORAL) CYCLOSPORINE CAPSULE, SOFTGEL (ORAL) SLOW RELEASE IRON (ORAL) Epinephrine, Self-Injected TECHNIVIE DOSE PACK (ORAL) CYCLOSPORINE MODIFIED CAPSULE, MODIFIED SOLUTION (ORAL) TANDEM DUAL ACTION OTC, TANDEM PLUS (ORAL) EPINEPHRINE 0.15 MG (ADRENACLICK) (INJECTION)* VICTRELIS (ORAL) MYCOPHENOLATE MOFETIL CAPSULE, TABLET (ORAL) TARON FORTE (ORAL) EPINEPHRINE 0.3 MG (ADRENACLICK) (INJECTION)* VIEKIRA PAK, VIEKIRA XR (ORAL) RAPAMUNE SOLUTION (ORAL) TL-FOL 500, TL-HEM 150 (ORAL) EPI-PEN, EPI-PEN JR. (INJECTION) ZEPATIER (ORAL) SANDIMMUNE CAPSULE, SOLUTION (ORAL) VITRON-C OTC (ORAL) Histamine II Receptor Blockers SIROLIMUS (ORAL) Leukotriene Modifiers Erythropoiesis Stimulating Proteins CIMETIDINE TABLET, CIMETIDINE TABLET OTC (ORAL) TACROLIMUS (ORAL) MONTELUKAST CHEW TAB, TABLET (ORAL) ARANESP DISP SYRIN, VIAL (INJECTION) FAMOTIDINE SUSPENSION (ORAL) Intranasal Rhinitis Agents ZAFIRLUKAST (ORAL) PROCRIT (INJECTION) FAMOTIDINE TABLET, FAMOTIDINE TABLET OTC (ORAL) FLUTICASONE, FLUTICASONE OTC (NASAL) Lipotropics, Other Fluoroquinolones, Oral RANITIDINE SYRUP, TABLET, OTC TABLET (ORAL) IPRATROPIUM (NASAL) CHOLESTYRAMINE/ASPARTAME (ORAL) CIPRO SUSPENSION (ORAL) Hypoglycemics, Alpha Glucosidase Inhibitors NASACORT OTC (NASAL)* CHOLESTYRAMINE/SUCROSE (ORAL) CIPROFLOXACIN TABLET (IR) (ORAL) ACARBOSE (ORAL) PATANASE (NASAL) COLESTIPOL TABLET (ORAL) LEVOFLOXACIN TABLET (ORAL) GLYSET (ORAL) TRIAMCINOLONE OTC (NASAL)* FENOFIBRATE 48 MG, 145 MG TABLET (ORAL) Glucocorticoids, Inhaled Hypoglycemics, Incretin Mimetics/Enhancers Iron, Oral GEMFIBROZIL (ORAL) ADVAIR DISKUS (INHALATION) BYDUREON PEN, VIAL (SUBCUTANE.) BIFERA TABLET OTC (ORAL)* NIACIN ER (ORAL) ASMANEX TWISTHALER (INHALATION) BYETTA DOSE PEN (SUBCUTANE.) CENTRATEX (ORAL) TRILIPIX (ORAL) DULERA (INHALATION) JANUMET, JANUMET XR (ORAL) FE C OTC (ORAL) LIPOTROPICS, STATINS ‡ FLOVENT DISKUS, FLOVENT HFA (INHALATION) JANUVIA (ORAL) FE FUMARATE/VIT C/B12-IF/FA (ORAL) ATORVASTATIN (ORAL) PULMICORT 0.25, 0.5 MG/2 ML RESPULES (INHALATION) JENTADUETO (ORAL) FEOSOL OTC (ORAL) CRESTOR (ORAL) PULMICORT FLEXHALER (INHALATION) TRADJENTA (ORAL) FER-IN-SOL DROPS OTC (ORAL) LOVASTATIN (ORAL) QVAR (INHALATION) VICTOZA (SUBCUTANE.) FERATE OTC (ORAL) PRAVASTATIN (ORAL) SYMBICORT (INHALATION) Hypoglycemics, Insulin & Related FERRALET 90 DUAL-IRON (ORAL) SIMVASTATIN (ORAL) Glucocorticoids, Oral HUMALOG CARTRIDGE, VIAL (SUBCUTANE.) FERRAPLUS 90 (ORAL) Macrolides & Ketolides BUDESONIDE EC (ORAL) HUMALOG 100 UNITS/ML PEN (SUBCUTANE.) FERRIMIN 150 OTC (ORAL) AZITHROMYCIN PACKET, SUSPENSION, TABLET (ORAL) DEXAMETHASONE 0.5 MG/5 ML SOLUTION (ORAL) HUMALOG MIX PEN, MIX VIAL (SUBCUTANE.) FERROCITE PLUS (ORAL) CLARITHROMYCIN TABLET (ORAL) DEXAMETHASONE TABLET (ORAL) HUMULIN 500 UNITS/ML VIAL (SUBCUTANE.) FERROUS FUMARATE TABLET OTC (ORAL) E.E.S. 400 FILMTAB (ORAL) HYDROCORTISONE TABLET (ORAL) HUMULIN 70/30 PEN OTC, VIAL OTC (SUBCUTANE.) FERROUS FUMARATE/FA TABLET (ORAL)* ERY-TAB EC (ORAL) METHYLPREDNISOLONE DOSE PACK (ORAL) HUMULIN PEN OTC, VIAL OTC (SUBCUTANE.) FERROUS FUMARATE/ASCORBIC ACID/B12-IF/FA CAPSULE (ORAL) ERYTHROCIN (ORAL) METHYLPREDNISOLONE TABLET (ORAL) LANTUS CARTRIDGE, VIAL (SUBCUTANE.) FERROUS FUMARATE/FA/MULTIVITAMIN & MINERALS ERYTHROMYCIN BASE TABLET (ORAL) ORAPRED ODT (ORAL) LANTUS SOLOSTAR PEN (SUBCUTANE.) CAPSULE (ORAL) Methotrexate PREDNISOLONE SOLUTION (ORAL) LEVEMIR PENS, VIAL (SUBCUTANE.) FERROUS FUMARATE/IRON POLYSACCHARIDES/FA/ METHOTREXATE SODIUM PF VIAL, VIAL (INJECTION) PREDNISONE 5 MG/5 ML SOLUTION (ORAL) NOVOLIN 70/30 VIAL OTC (SUBCUTANE.) MULTIVITAMIN CAPSULE (ORAL) METHOTREXATE TABLET, VIAL (ORAL) PREDNISONE TABLET (ORAL) NOVOLOG CARTRIDGE, PEN, VIAL (SUBCUTANE.) FERROUS GLUCONATE OTC (ORAL) Multiple Sclerosis Agents PREDNISONE TAB DS PK (ORAL)* NOVOLOG MIX 70/30 PEN, VIAL (SUBCUTANE.) FERROUS SULFATE 65 MG TABLET OTC (ORAL) AUBAGIO (ORAL) Hypoglycemics, Meglitinides FERROUS SULFATE DROPS (ORAL) AVONEX ADMIN PACK, PEN, PREFILLED SYRINGE (INTRAMUSC.) GI Motility, Chronic NATEGLINIDE (ORAL) FERROUS SULFATE OTC (ORAL) BETASERON KIT (SUBCUTANE.) AMITIZA (ORAL) REPAGLINIDE (ORAL) FERROUS SULFATE SOLUTION OTC (ORAL) COPAXONE SYRINGE (SUBCUTANE.) LINZESS (ORAL) Hypoglycemics, Metformins FERROUS SULFATE TABLET ER OTC (ORAL) GILENYA (ORAL) MOVANTIK (ORAL) GLIPIZIDE-METFORMIN (ORAL) FERROUS SULFATE, DRIED TABLET ER OTC (ORAL) PLEGRIDY (SUBCUTANE.) Growth Factors METFORMIN (ORAL) FERROUS SULFATE/ASCORBIC ACID/FA TABLET ER OTC (ORAL) REBIF REBIDOSE, SYRINGE, TITRATION PACK (SUBCUTANE.) EGRIFTA (SUBCUTANE.) METFORMIN ER (GLUCOPHAGE XR) (ORAL) FOLITAB 500 OTC (ORAL) TECFIDERA (ORAL) INCRELEX (SUBCUTANE.) Hypoglycemics, SGLT2 FOLIVANE-F, FOLIVANE-PLUS (ORAL) Neuropathic Pain Growth Hormones FARXIGA (ORAL) HEMATOGEN, HEMATOGEN FA (ORAL) DULOXETINE 20MG, 30MG, 60MG CAPSULES (ORAL) NORDITROPIN FLEXPRO (INJECTION) INVOKAMET (IR) (ORAL) HEMOCYTE PLUS, HEMOCYTE-F (ORAL) GABAPENTIN 100MG, 300MG, 400MG CAPSULE (ORAL) NUTROPIN AQ NUSPIN, PEN CARTRIDGE (INJECTION) INVOKANA (ORAL) IFEREX 150 FORTE (ORAL) LIDOCAINE 5% PATCH (TOPICAL) H. Pylori Agents JARDIANCE (ORAL) INTEGRA F, INTEGRA OTC, INTEGRA PLUS (ORAL) LYRICA CAPSULE (ORAL) PYLERA (ORAL) Hypoglycemics, TZDs IRON 45 MG TABLET OTC (ORAL) PIOGLITAZONE (ORAL) IRON POLYSACCHARIDES COMPLEX OTC (ORAL) Non-Steroidal Anti-Inflammatory Hepatitis C Agents Immunomodulators, Asthma** IRON PS CMPLX/VIT B12/FA (ORAL) FLECTOR PATCH (TOPICAL) DAKLINZA (ORAL) XOLAIR (SUBCUTANE.)* IRON,CARBONYL/ASCORBIC ACID OTC (ORAL) FLURBIPROFEN (ORAL) EPCLUSA (ORAL) Immunomodulators, Atopic Dermatitis MV COMB18/FEFM-FEPOL CB1/FA (ORAL) IBUPROFEN SUSPENSION, TABLET (ORAL) HARVONI (ORAL) ELIDEL (TOPICAL) NEPHRON FA (ORAL) INDOCIN SUSPENSION (ORAL) OLYSIO (ORAL) PROTOPIC (TOPICAL)* NOVAFERRUM 50 CAPSULE OTC (ORAL) INDOMETHACIN CAPSULE (IR) (ORAL) PEGASYS KIT, PROCLICK, SYRINGE, VIAL (SUBCUTANE.) Immunomodulators, Topical NOVAFERRUM DROPS OTC (ORAL) KETOROLAC (ORAL) PEG-INTRON KIT (SUBCUTANE.) IMIQUIMOD CREAM PACKET (TOPICAL) NU-IRON 150 CAPSULE OTC (ORAL) MELOXICAM TABLET, SUSPENSION (ORAL) Updated January 1, 2017 Non-Steroidal Anti-Inflammatory, Cont. Oncology Agents, Prostate Ophthalmic, Anti-Inflammatories, Cont. Pituitary Suppressive Agents, LNRH MOBIC SUSPENSION (ORAL) BICALUTAMIDE (ORAL) KETOROLAC, KETOROLAC LS (OPHTHALMIC) ELIGARD (SUBCUTANE.) NABUMETONE (ORAL) EMCYT (ORAL) LOTEMAX DROPS (OPHTHALMIC) LEUPROLIDE ACETATE KIT (SUB-Q) NAPROXEN 250MG, 375MG, 500MG TABLET, SUSPENSION (ORAL) FLUTAMIDE (ORAL) MAXIDEX (OPHTHALMIC) LUPRON DEPOT KIT (INTRAMUSC) SULINDAC (ORAL) NILANDRON (ORAL) PRED MILD (OPHTHALMIC) LUPRON DEPOT-PED KIT (INJECTION) VOLTAREN GEL (TOPICAL) XTANDI (ORAL) PREDNISOLONE ACETATE (OPHTHALMIC) SYNAREL (NASAL) Oncology Agents, Breast Cancer ZYTIGA (ORAL) PREDNISOLONE SOD PHOSPHATE (OPHTHALMIC) Platelet Aggregation Inhibitors ANASTROZOLE (ORAL)* Oncology Agents, Renal Cell Ophthalmic, Anti-Inflammatories/Immunomodulator** AGGRENOX (ORAL) CYCLOPHOSPHAMIDE (ORAL) AFINITOR (ORAL) (not DISPERZ) RESTASIS (OPHTHALMIC)* BRILINTA (ORAL) EXEMESTANE (ORAL) CABOMETYX (ORAL) Ophthalmics, Glaucoma Agents CLOPIDOGREL (ORAL) IBRANCE (ORAL) INLYTA (ORAL) ALPHAGAN P 0.15% (OPHTHALMIC) DIPYRIDAMOLE (ORAL) LETROZOLE (ORAL) LENVIMA (ORAL) AZOPT (OPHTHALMIC) EFFIENT (ORAL) TAMOXIFEN CITRATE (ORAL) NEXAVAR (ORAL) BETIMOL (OPHTHALMIC) Prenatal Vitamins XELODA (ORAL) SUTENT (ORAL) BETOPTIC S (OPHTHALMIC) CITRANATAL HARMONY CAPSULE Oncology Agents, Hematologic VOTRIENT (ORAL) BRIMONIDINE 0.2% (OPHTHALMIC) COMPLETE NATAL DHA, COMPLETENATE TABLET CHEW ALKERAN (ORAL) Oncology Agents, Skin CARTEOLOL (OPHTHALMIC) CONCEPT DHA CAPSULE BOSULIF (ORAL) COTELLIC (ORAL) COMBIGAN (OPTHALMIC) DOTHELLE DHA SOFTGEL FARYDAK (ORAL) ERIVEDGE (ORAL) DORZOLAMIDE (OPHTHALMIC) FE C PLUS TABLET GLEEVEC (ORAL) MEKINIST (ORAL) DORZOLAMIDE / TIMOLOL (OPHTHALMIC) FOLIVANE-OB CAPSULE HYDROXYUREA (ORAL) ODOMZO (ORAL) ISTALOL (OPHTHALMIC) INATAL ULTRA TABLET ICLUSIG (ORAL) TAFINLAR (ORAL) LATANOPROST (OPHTHALMIC) NATALVIRT 90 DHA COMBO PACK IMBRUVICA (ORAL) ZELBORAF (ORAL) LEVOBUNOLOL (OPHTHALMIC) NESTABS TABLET JAKAFI (ORAL) Ophthalmics, Allergic Conjunctivitis METIPRANOLOL (OPHTHALMIC) OB COMPLETE WITH DHA SOFTGEL LEUKERAN (ORAL) ALREX (OPHTHALMIC) PILOCARPINE (OPHTHALMIC) O-CAL FA TABLET MATULANE (ORAL) CROMOLYN SODIUM (OPHTHALMIC) SIMBRINZA (OPHTHALMIC) PNV 29-1 TABLET MERCAPTOPURINE TABLET (ORAL) PATADAY (OPHTHALMIC) TIMOLOL EYE DROPS, GEL-SOLUTION (OPHTHALMIC) PNV-DHA + DOCUSATE SOFTGEL MYLERAN (ORAL) PAZEO (OPTHALMIC) TRAVATAN Z (OPHTHALMIC) PR NATAL 400 COMBO PACK NINLARO (ORAL) Ophthalmics, Antibiotics PREFERA-OB ONE SOFTGEL POMALYST (ORAL)* BACITRACIN-POLYMYXIN B SULFATE OINTMENT (OPTHALMIC) Opiate Dependence Treatments PRENAISSANCE CAPSULE REVLIMID (ORAL)* ERYTHROMYCIN (OPHTHALMIC) BUPRENORPHINE HCL TABLET (SUBLINGUAL) PRENAISSANCE BALANCE, PRENAISSANCE NEXT TABLET SPRYCEL (ORAL) GENTAMICIN DROPS, OINTMENT (OPHTHALMIC) NALOXONE SYRINGE, VIAL (INJECTION) PRENATA CHEWABLE TABLET TABLOID (ORAL) MOXEZA (OPHTHALMIC) NALTREXONE (ORAL) PRENATAL PLUS TABLET TASIGNA (ORAL) NEOMYCIN-POLYMYXIN-GRAMICIDIN (OPTHALMIC) NARCAN NASAL SPRAY (NASAL) PNV PRENATAL PLUS MULTIVIT TAB THALOMID (ORAL)* OFLOXACIN (OPHTHALMIC) SUBOXONE FILM (SUBLINGUAL) PRENATAL PLUS MULTIVITAMIN TAB TRETINOIN (ORAL) POLYMYXIN B-TMP (OPHTHALMIC) Otic, Antibiotics PRENATAL VITAMIN PLUS LOW IRON VENCLEXTA (ORAL) SULFACETAMIDE SOLUTION (OPHTHALMIC) CIPRODEX (OTIC) PREPLUS CA-FE 27 MG-FA 1 MG TB ZOLINZA (ORAL) TOBRAMYCIN (OPHTHALMIC) CIPROFLOXACIN (OTIC) SELECT-OB CHEWABLE CAPLET ZYDELIG (ORAL) TOBREX OINTMENT (OPHTHALMIC) NEOMYCIN/POLYMYXIN/HC SOLUTION, SUSPENSION (OTIC) SE-NATAL 19 CHEWABLE TABLET, TABLET Oncology Agents, Lung VIGAMOX (OPTHALMIC) TARON-C DHA CAPSULE ALECENSA (ORAL) Ophthalmics, Antibiotic-Steroid Combination Otic, Anti-Infectives & Anesthetics THRIVITE 19, THRIVITE RX TABLET GILOTRIF (ORAL) BLEPHAMIDE EYE DROPS (OPHTHALMIC) ACETIC ACID (OTIC) TRINATAL RX 1 TABLET HYCAMTIN (ORAL) NEOMYCIN/BACITRACIN/POLY/HC OINTMENT (OPHTHALMIC) PAH Agents, Oral & Inhaled TRIVEEN-DUO DHA COMBO PACK IRESSA (ORAL) NEOMYCIN/POLYMYXIN/DEXAMETHASONE (OPHTHALMIC) LETAIRIS (ORAL) TRUST NATAL DHA TAGRISSO (ORAL) NEOMYCIN/POLYMYXIN/HC OINTMENT (OPHTHALMIC) SILDENAFIL (ORAL) VEMAVITE-PRX 2 CAPSULE TARCEVA (ORAL) PRED-G DROPS SUSP, S.O.P. OINTMENT (OPHTHALMIC) TRACLEER (ORAL) VIRT NATE, VIRT-ADVANCE, VIRTPREX TABLET XALKORI (ORAL) SULFACETAMIDE / PREDNISOLONE (OPHTHALMIC) VENTAVIS (INHALATION) VIRT-C DHA, VIRT-SELECT CAPSULE ZYKADIA (ORAL) TOBRADEX EYE DROPS, OINTMENT (OPHTHALMIC) VITAFOL ULTRA SOFTGEL Pancreatic Enzymes VITAFOL-OB, VITAFOL-ONE CAPSULE Oncology Agents, Other Ophthalmic, Anti-Inflammatories CREON (ORAL) VOL-NATE, VOL-PLUS, VOL-TAB TABLET CAPRELSA (ORAL) DEXAMETHASONE (OPHTHALMIC) PANCRELIPASE (ORAL) VP-CH-PNV PRENATAL SOFTGEL COMETRIQ (ORAL) DICLOFENAC (OPHTHALMIC) ZENPEP (ORAL) VP-GGR-B6 TABLET HEXALEN (ORAL) DUREZOL (OPHTHALMIC) ZINGIBER TABLET LOMUSTINE (ORAL) FLAREX (OPHTHALMIC) Phosphate Binders PROTON PUMP INHIBITORS ‡ LONSURF (ORAL) FLUOROMETHOLONE (OPHTHALMIC) CALCIUM ACETATE CAPSULE, TABLET (ORAL) NEXIUM CAPSULE (ORAL) LYNPARZA (ORAL) FLURBIPROFEN (OPHTHALMIC) PHOSLYRA SOLUTION (ORAL) NEXIUM PACKET (ORAL) STIVARGA (ORAL) FML FORTE, FML S.O.P. (OPHTHALMIC) RENAGEL (ORAL) PANTOPRAZOLE (ORAL) TEMODAR (ORAL)* ILEVRO (OPHTHALMIC) RENVELA TABLET (ORAL) PROTONIX SUSPENSION (ORAL) Updated January 1, 2017 Sedative Hypnotics Tetracyclines, Oral FLURAZEPAM (ORAL) DOXYCYCLINE HYCLATE CAPSULE, TABLET (ORAL) TEMAZEPAM 15MG, 30MG (ORAL) DOXYCYCLINE MONOHYDRATE 50 MG, 100 MG CAPSULE (ORAL) ZOLPIDEM TARTRATE 5MG, 10MG (ORAL) MINOCYCLINE CAPSULES (ORAL) Skeletal Muscle Relaxants Ulcerative Colitis Agents BACLOFEN (ORAL) APRISO (ORAL) CHLORZOXAZONE (ORAL) CANASA (RECTAL) CYCLOBENZAPRINE (ORAL) LIALDA (ORAL) METHOCARBAMOL (ORAL) PENTASA (ORAL) Smoking Cessation SULFASALAZINE (ORAL) CHANTIX TAB DS PK, TABLET (ORAL) SULFASALAZINE DR (ORAL) NICOTINE GUM OTC (BUCCAL) Vasodilators, Coronary NICOTINE LOZENGE OTC (MUCOUS MEM) ISOSORBIDE DINITRATE (ORAL) NICOTINE PATCH OTC (TRANSDERMAL) ISOSORBIDE DINITRATE (SUBLINGUAL) ISOSORBIDE MONONITRATE (ORAL) Steroids, Topical-High Potency ISOSORBIDE MONONITRATE SR (ORAL) BETAMETHASONE DIPROPIONATE CREAM, LOTION (TOPICAL) NITRO-BID OINTMENT (TRANSDERM) BETAMETHASONE VALERATE CREAM, LOTION, OINT (TOPICAL) NITROGLYCERIN (SUBLINGUAL) TRIAMCINOLONE ACETONIDE CREAM, LOTION, OINT (TOPICAL) NITROGLYCERIN (TRANSDERM) Steroids, Topical-Low Potency NITROGLYCERIN ER (ORAL) ALCLOMETASONE DIPROPIONATE CREAM, OINTMENT (TOPICAL)* NITROLINGUAL SPRAY (TRANSLINGUAL) CAPEX SHAMPOO (TOPICAL) FLUOCINOLONE 0.01% OIL (TOPICAL) HYDROCORTISONE / MIN OIL / PET OINT. (TOPICAL) HYDROCORTISONE CREAM, GEL, LOTION, OINTMENT (TOPICAL)

Steroids, Topical-Medium Potency FLUTICASONE PROPIONATE CREAM, OINTMENT (TOPICAL)* HYDROCORTISONE BUTYRATE CREAM, SOLUTION (TOPICAL) MOMETASONE FUROATE CREAM, OINT, SOLUTION (TOPICAL)

Steroids, Topical-Very High Potency CLOBETASOL EMOLLIENT (TOPICAL) CLOBETASOL PROPIONATE CREAM, GEL, OINT, SOLUTION (TOPICAL) CLOBEX SHAMPOO (TOPICAL) HALOBETASOL PROPIONATE CREAM, OINT (TOPICAL) Stimulants & Related Agents ADDERALL XR (ORAL) AMPHETAMINE SALT COMBO (IR) (ORAL) DEXMETHYLPHENIDATE (IR) (ORAL) DEXTROAMPHETAMINE TABLET (IR) (ORAL) FOCALIN, FOCALIN XR (ORAL) GUANFACINE ER (ORAL) KAPVAY (ORAL) METADATE CD (ORAL) METHYLIN CHEWABLE TABLET (ORAL) METHYLPHENIDATE ER (CONCERTA) (AG) (ORAL) METHYLPHENIDATE ER (CONCERTA) (ORAL) METHYLPHENIDATE SOLUTION (ORAL) METHYLPHENIDATE TABLET (ORAL) METHYLPHENIDATE ER (METHLYN ) (ORAL) METHYLPHENIDATE ER (RITALIN LA) (ORAL) PROCENTRA SOLUTION (ORAL) PROVIGIL (ORAL) QUILLIVANT XR (ORAL) STRATTERA (ORAL) VYVANSE (ORAL) Updated January 1, 2017