Drug - Brand Name (Generic Name) Oseni (alogliptin / pioglitazone) - PA. Obizur (antihemophilic factor, recombinant, porcine sequence-obizur)
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1 Orencia (abatacept) - PA Oseni (alogliptin / pioglitazone) - PA Obizur (antihemophilic factor, recombinant, porcine sequence-obizur) Otezla (apremilast) - PA Olumiant (baricitinib) - PA Omnaris (ciclesonide nasal spray, 50 mcg) - PA Otovel (ciprofloxacin / fluocinolone) - PA Otiprio (ciprofloxacin otic suspension) ^ Onexton (clindamycin / benzoyl peroxide-onexton) - PA Onfi (clobazam) - PA; See Table 20; See Table 71 Olux (clobetasol propionate foam) - PA Olux-E (clobetasol propionate foam / emollient) - PA Ozurdex (dexamethasone intravitreal implant) ^ Oracea (doxycycline monohydrate 40 mg capsule) - PA Orilissa (elagolix) - PA Odefsey (emtricitabine / rilpivirine / tenofovir alafenamide) PD Ogen # (estropipate) Ortho-Novum # (ethinyl estradiol / norethindrone-ortho-novum) Ortho Tri-Cyclen # (ethinyl estradiol / norgestimate-ortho Tri-Cyclen) Ortho Tri-Cyclen Lo # (ethinyl estradiol / norgestimate-ortho Tri-Cyclen Lo) Ortho-Cyclen # (ethinyl estradiol / norgestimate-ortho-cyclen) Oralair (grass pollen allergen extract) - PA Orthovisc (high molecular weight hyaluronan) - PA; Non-Drug Product Octagam (immune globulin IV, human-octagam) - PA Onivyde (irinotecan liposome) - PA Onmel (itraconazole 200 mg tablet) - PA Orkambi (lumacaftor / ivacaftor) - PA Opsumit (macitentan) - PA Ovide (malathion) - PA Otrexup (methotrexate subcutaneous injection-otrexup) - PA Oxsoralen-Ultra # (methoxsalen capsules) Oxsoralen (methoxsalen topical) Oravig (miconazole buccal tablet) - PA Opcon-A (naphazoline / pheniramine) Ofev (nintedanib) - PA DIABETIC AGENTS ANTI-HEMOPHILIA AGENTS NASAL PREPARATIONS OTIC PREPARATIONS OTIC PREPARATIONS HORMONE AGENTS HORMONE REPLACEMENT THERAPY ALLERGENS NON-DRUG PRODUCT BIOLOGICAL FUNGICIDES CYSTIC FIBROSIS AGENTS ANTIPARASITICS PULMONARY FIBROSIS AGENTS
2 Orfadin (nitisinone) Opdivo (nivolumab) - PA Ortho Micronor # (norethindrone 0.35 mg) obeticholic acid - PA Ocaliva (obeticholic acid) - PA obinutuzumab - PA ocrelizumab - PA Ocrevus (ocrelizumab) - PA ocriplasmin ^ octreotide octreotide injectable suspension ofatumumab - PA ofloxacin ophthalmic solution Ocuflox # (ofloxacin ophthalmic solution) ofloxacin otic solution ofloxacin tablet - PA olanzapine / fluoxetine - PA; See Table 17; See Table 24; See Table 71 olanzapine 15 mg tablet - PA < 6 years and PA > 60 units/month; See Table 24; See Table 71 olanzapine 2.5 mg, 5 mg, 7.5 mg, 10 mg, 20 mg tablets - PA < 6 years and PA > 30 units/month; See Table 24; See Table 71 olanzapine 210 mg, 300 mg extended-release injection - PA < 6 years and PA > 2 injections/month; See Table 24; See Table 71 olanzapine 405 mg extended-release injection - PA < 6 years and PA > 1 injection/month; See Table 24; See Table 71 olanzapine injection olanzapine orally disintegrating tablet - PA; See Table 24; See Table 71 olaparib - PA olaratumab - PA olmesartan - PA olmesartan / hydrochlorothiazide - PA olodaterol - PA olopatadine 0.1% eye drops - PA olopatadine 0.2% eye drops - PA olopatadine 0.7% eye drops - PA ENDOCRINE/METABOLIC AGENTS BILE THERAPY BILE THERAPY MULTIPLE SCLEROSIS AGENTS MULTIPLE SCLEROSIS AGENTS ENDOCRINE/METABOLIC AGENTS ENDOCRINE/METABOLIC AGENTS OTIC PREPARATIONS ANTIDEPRESSANTS BRONCHODILATORS ANTIHISTAMINES ANTIHISTAMINES ANTIHISTAMINES 2
3 olopatadine nasal spray - PA olsalazine - PA omacetaxine mepesuccinate - PA omalizumab - PA ombitasvir / paritaprevir / ritonavir - PA ombitasvir / paritaprevir / ritonavir / dasabuvir - PA omega-3 acid ethyl esters - PA omeprazole / clarithromycin / amoxicillin - PA Omeclamox-Pak (omeprazole / clarithromycin / amoxicillin) - PA omeprazole / sodium bicarbonate - PA omeprazole 10 mg - PA > 30 units/month omeprazole 20 mg capsule - PA > 120 units/month omeprazole 40 mg - PA > 60 units/month omeprazole suspension - PA onabotulinumtoxina - PA ondansetron 24 mg tablet - PA ondansetron 4 mg, 8 mg tablet ondansetron film - PA ondansetron injection ondansetron orally disintegrating tablet ondansetron solution - PA opium tincture - PA oprelvekin Ora-Plus suspending vehicle * Ora-Sweet oral syrup * Ora-Sweet-SF oral syrup * oritavancin - PA Orbactiv (oritavancin) - PA orphenadrine - PA < 18 years orphenadrine powder - PA oseltamivir 30mg BP - PA all quantities (June 1st to September 30th); PA > 20 capsules/season (October 1st to May 31st) oseltamivir 45 mg and 75 mg BP - PA all quantities (June 1st to September 30th); PA > 10 capsules/season (October 1st to May 31st) NASAL PREPARATIONS GI ANTI-INFLAMMATORY BIOLOGICAL LIPID LOWERING AGENTS H. PYLORI AGENTS H. PYLORI AGENTS ANTI-ULCER PREPARATIONS BIOLOGICAL ANTIDIARRHEALS HEMATINIC AGENT COMPOUNDING AGENT COMPOUNDING AGENT COMPOUNDING AGENT MUSCLE RELAXANT MUSCLE RELAXANT 3
4 oseltamivir 6 mg/ml suspension BP - PA all quantities (June 1st to September 30th); PA > 180 ml/season (October 1st to May 31st) osimertinib - PA oxacillin oxaliplatin oxandrolone - PA oxaprozin - PA oxazepam - PA < 6 years; See Table 69; See Table 71 oxcarbazepine - PA < 6 years; See Table 20; See Table 71 oxcarbazepine extended-release - PA; See Table 20; See Table 71 Oxtellar XR (oxcarbazepine extended-release) - PA; See Table 20; See Table 71 oxiconazole - PA Oxistat (oxiconazole) - PA oxybutynin extended-release tablet oxybutynin gel - PA oxybutynin immediate-release tablet, syrup oxybutynin transdermal system - PA Oxytrol (oxybutynin transdermal system) - PA oxybutynin transdermal system-oxytrol for Women Oxytrol for Women (oxybutynin transdermal system-oxytrol for Women) oxycodone / acetaminophen - PA > 80 mg/day oxycodone / acetaminophen 300 mg - PA oxycodone / acetaminophen extended-release - PA oxycodone / acetaminophen-percocet - PA > 80 mg/day oxycodone / aspirin - PA > 4 g/day aspirin oxycodone / ibuprofen - PA oxycodone extended-release capsule - PA oxycodone extended-release tablet BP - PA Oxycontin (oxycodone extended-release tablet) BP - PA oxycodone immediate-release-roxicodone - PA > 80 mg/day oxycodone powder - PA oxycodone-immediate-release-oxaydo - PA Oxaydo (oxycodone-immediate-release-oxaydo) - PA ANABOLIC STEROID NONSTEROIDAL ANTI-INFLAMMATORY BENZODIAZEPINES ANALGESICS, NARCOTIC 4
5 oxymetazoline cream - PA oxymetholone oxymorphone extended-release, oral - PA oxymorphone extended-release, oral-opana ER - PA Opana ER (oxymorphone extended-release, oral-opana ER) - PA oxymorphone immediate-release, oral - PA Opana IR (oxymorphone immediate-release, oral) - PA oxymorphone injection - PA Opana (oxymorphone injection) - PA Onpattro (patisiran) - PA Oncaspar (pegaspargase) ^ Omidria (phenylephrine / ketorolac) ^ Orap # (pimozide) - PA < 6 years; See Table 24; See Table 71 Omnipred # (prednisolone acetate 1% ophthalmic suspension-omnipred) Orapred ODT (prednisolone orally disintegrating tablet) - PA Onglyza (saxagliptin) Ozempic (semaglutide) - PA Olysio (simeprevir) - PA Osmoprep (sodium phosphate) - PA Omnitrope (somatropin-omnitrope) - PA Odomzo (sonidegib) - PA Onzetra (sumatriptan nasal powder) - PA Orenitram (treprostinil tablet) - PA Oralone # (triamcinolone paste) ANABOLIC STEROID SMALL INTERFERING RNA AGENTS DIABETIC AGENTS DIABETIC AGENTS LAXATIVES HORMONE AGENTS TRIPTAN 5
6
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Name of Drug Drug Tier Necessary actions, restrictions, or Analgesics Analgesics 8 HOUR ER 650 MG CAPLET MUSCLE ACHES & PAIN 650 MG acetaminophen 650 suppos 650 acetaminophen-codeine oral solution 120-12
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ANALGESICS TREATMENT OF PAIN ANALGESICS, OTHER acetaminophen-codeine oral solution 20-2 /5 ml acetaminophen-codeine oral tablet 300-5, 300-30, 300-60 ASCOMP WITH CODEINE ORAL CAPSULE 30-50-325-40 MG BUTALBITAL
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