PHP Centennial Care Formulary/Preferred Drug Listing

Transcription

1 PHP Centennial Care Formulary/Preferred Drug Listing The Centennial Care Preferred Drug List is subject to change. Presbyterian Centennial Care This list is in alphabetical order. To find a specific drug, use the search feature available in Adobe Acrobat Reader (keyboard shortcut: Ctrl+F). MPC Centennial Care #889

2 lowercase italics = Generic drugs UPPERCASE BOLD = Brand name drugs Presbyterian Health Plan Centennial Care Drug Name Tier Notes A-200 EXTERNAL GEL % abacavir sulfate oral solution 20 /ml QL (900 ML per 30 days) abacavir sulfate oral tablet 300 QL (60 EA per 30 days) abacavir sulfate-lamivudine oral tablet QL (30 EA per 30 days) abacavir-lamivudine-zidovudine oral tablet acamprosate calcium oral tablet delayed release 333 acarbose oral tablet 100, 25, 50 ACCU-CHEK ACTIVE IN VITRO STRIP ACCU-CHEK AVIVA IN VITRO STRIP ACCU-CHEK AVIVA PLUS IN VITRO STRIP ACCU-CHEK COMFORT CURVE IN VITRO STRIP ACCU-CHEK COMCT IN VITRO STRIP ACCU-CHEK COMCT PLUS IN VITRO STRIP QL (60 EA per 30 days) ; QL (180 EA per 30 days) 100 test strips per 30 days are covered for members who are not on insulin. 200 test strips per 30 days are covered for members who are receiving insulin.; QL (100 EA per 30 days) 100 test strips per 30 days are covered for members who are not on insulin. 200 test strips per 30 days are covered for members who are receiving insulin.; QL (100 EA per 30 days) 100 test strips per 30 days are covered for members who are not on insulin. 200 test strips per 30 days are covered for members who are receiving insulin.; QL (100 EA per 30 days) 100 test strips per 30 days are covered for members who are not on insulin. 200 test strips per 30 days are covered for members who are receiving insulin.; QL (100 EA per 30 days) 100 test strips per 30 days are covered for members who are not on insulin. 200 test strips per 30 days are covered for members who are receiving insulin.; QL (100 EA per 30 days) 100 test strips per 30 days are covered for members who are not on insulin. 200 test strips per 30 days are covered for members who are receiving insulin.; QL (100 EA per 30 days) MPC Centennial Care #889

3 ACCU-CHEK COMCT TEST DRUM IN VITRO STRIP ACCU-CHEK FASTCLIX LANCETS ACCU-CHEK GUIDE IN VITRO STRIP 100 test strips per 30 days are covered for members who are not on insulin. 200 test strips per 30 days are covered for members who are receiving insulin.; QL (100 EA per 30 days) 100 lancets per 30 days are covered for members who are not on insulin. 200 lancets per 30 days are covered for members who are receiving insulin.; QL (102 EA per 30 days) 100 test strips per 30 days are covered for members who are not on insulin. 200 test strips per 30 days are covered for members who are receiving insulin.; QL (100 EA per 30 days) ACCU-CHEK GUIDE KIT W/DEVICE QL (1 EA per 180 days) ACCU-CHEK MULTICLIX LANCETS ACCU-CHEK SMARTVIEW IN VITRO STRIP ACCU-CHEK SOFTCLIX LANCETS acebutolol hcl oral capsule 200, lancets per 30 days are covered for members who are not on insulin. 200 lancets per 30 days are covered for members who are receiving insulin.; QL (102 EA per 30 days) 100 test strips per 30 days are covered for members who are not on insulin. 200 test strips per 30 days are covered for members who are receiving insulin.; QL (100 EA per 30 days) 100 lancets per 30 days are covered for members who are not on insulin. 200 lancets per 30 days are covered for members who are receiving insulin.; QL (100 EA per 30 days) ACEPHEN RECTAL SUPPOSITORY 325 MG QL (12 EA per 1 day) ACEPHEN RECTAL SUPPOSITORY 650 MG QL (6 EA per 1 day) acetaminophen extra strength oral liquid 500 /15ml QL (120 ML per 1 day) acetaminophen oral tablet 325 QL (12 EA per 1 day) acetaminophen oral tablet 500 QL (8 EA per 1 day) acetaminophen-codeine #2 oral tablet acetaminophen-codeine #3 oral tablet acetaminophen-codeine #4 oral tablet QL (13 EA per 1 day); AG (Min 12 Years) QL (13 EA per 1 day); AG (Min 12 Years) QL (13 EA per 1 day); AG (Min 12 Years) acetaminophen-codeine oral solution /5ml AG (Min 12 Years) acetazolamide er oral capsule extended release 12 hour 500 acetazolamide oral tablet 125, 250 acetic acid otic solution 2 % MPC Centennial Care #889

4 acetic acid-aluminum acetate otic solution 2 % acetylcysteine inhalation solution 10 %, 20 % acitretin oral capsule 10, 17.5, 25 ; SP; QL (60 EA per 30 days) acyclovir oral capsule 200 acyclovir oral suspension 200 /5ml acyclovir oral tablet 400, 800 ADACEL INTRAMUSCULAR SUSPENSION LF-MCG/0.5 adapalene external cream 0.1 % $0 Copay Preventative Services.; AG (Min 19 Years) The following Prior authorization criteria applies to patients greater than 40 years of age: The patient must have a diagnosis of actinic keratosis OR adult acne.; AG (Max 40 Years) adult aspirin low strength oral tablet dispersible 81 $0 Copay per PCA guidelines. ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/DOSE, MCG/DOSE ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/DOSE ; Step Edit Criteria applies to Dulera and Symbicort. Coverage of Dulera and Symbicort requires a prescription claim history of an orally inhaled corticosteroid or orally inhaled anticholinergic within the past 120 days OR FEV1 of less than 50%.; Advair Diskus 100/50 mcg and 250/50 mcg are covered for patients under 12 years of age only.; QL (60 EA per 30 days); AG (Max 12 Years) ; Step Edit Criteria applies to Dulera and Symbicort. Coverage of Dulera and Symbicort requires a prescription claim history of an orally inhaled corticosteroid or orally inhaled anticholinergic within the past 120 days OR FEV1 of less than 50%.; QL (60 EA per 30 days) AEROCHAMBER PLUS FLOW VU QL (2 EA per 180 days) AEROCHAMBER Z-STAT PLUS QL (2 EA per 180 days) AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG AFLURIA INTRAMUSCULAR SUSPENSION AFTERA ORAL TABLET 1.5 MG A-HYDROCORT INJECTION SOLUTION RECONSTITUTED 100 MG AKNE-MYCIN EXTERNAL OINTMENT 2 % ak-poly-bac ophthalmic ointment unit/gm albuterol sulfate er oral tablet extended release 12 hour 4, 8 ; SP ; SP $0 Copay Preventative Services; QL (0.5 ML per 180 days) $0 Copay per PCA guidelines.; QL (6 EA per 365 days) MPC Centennial Care #889

5 albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083%, (5 /ml) 0.5%, 0.63 /3ml, 1.25 /3ml albuterol sulfate oral syrup 2 /5ml albuterol sulfate oral tablet 2, 4 alclometasone dipropionate external ointment 0.05 % ALDACTAZIDE ORAL TABLET MG ALECENSA ORAL CAPSULE 150 MG ; QL (240 EA per 30 days) alendronate sodium oral tablet 10, 5 alendronate sodium oral tablet 35, 70 QL (4 EA per 28 days) alendronate sodium oral tablet 40 QL (30 EA per 30 days) ALFERON N INJECTION SOLUTION UNIT/ML alfuzosin hcl er oral tablet extended release 24 hour 10 ALLEGRA ALLERGY CHILDRENS ORAL TABLET 30 MG allergy relief oral tablet dispersible 10 allopurinol oral tablet 100, 300 QL (30 EA per 30 days) alogliptin benzoate oral tablet 12.5, 25 ST; QL (30 EA per 30 days) alogliptin benzoate oral tablet 6.25 ST; QL (30 EA per 1 day) alogliptin-metformin hcl oral tablet , ALORA TRANSDERMAL TCH TWICE WEEKLY MG/24HR, 0.05 MG/24HR, MG/24HR, 0.1 MG/24HR alosetron hcl oral tablet 0.5, 1 ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % ST ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML alprazolam oral tablet 0.25 ST; QL (60 EA per 30 days) QL (8 EA per 28 days) Max two Benzodiazepines.; QL (90 EA per 30 days) alprazolam oral tablet 0.5, 1 QL (90 EA per 30 days) alprazolam oral tablet 2 QL (135 EA per 30 days) ALREX OPHTHALMIC SUSPENSION 0.2 % ST ALTAVERA ORAL TABLET MG-MCG ALUNBRIG ORAL TABLET 30 MG ; QL (180 EA per 30 days) alyacen 1/35 oral tablet mcg alyacen 7/7/7 oral tablet 0.5/0.75/1-35 -mcg amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 AMETHIA LO ORAL TABLET & 0.01 MG MPC Centennial Care #889

6 AMETHYST ORAL TABLET MCG AMICAR ORAL SOLUTION 0.25 GM/ML amiloride hcl oral tablet 5 amiloride-hydrochlorothiazide oral tablet 5-50 amiodarone hcl oral tablet 200, 400 amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, , 5-10, 5-20, 5-40 amlodipine besylate oral tablet 10, 2.5, 5 AMNESTEEM ORAL CAPSULE 10 MG, 20 MG, 40 MG amoxapine oral tablet 100, 150, 25, 50 amoxicillin oral capsule 250, 500 amoxicillin oral suspension reconstituted 125 /5ml, 200 /5ml, 250 /5ml, 400 /5ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet chewable 125, 250 amoxicillin-pot clavulanate oral suspension reconstituted /5ml, /5ml, /5ml, /5ml amoxicillin-pot clavulanate oral tablet , , amoxicillin-pot clavulanate oral tablet chewable , amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 5 amphetamine-dextroamphet er oral capsule extended release 24 hour 20, 25, 30 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 20, 5, 7.5 amphetamine-dextroamphetamine oral tablet 30 ampicillin oral capsule 250, 500 Length of therapy is limited to 24 weeks or 336 capsules per 365 days.; QL (60 EA per 30 days) required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 18 Years) required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Min 6 Years and Max 18 Years) required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); AG (Min 3 Years and Max 18 Years) required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Min 3 Years and Max 18 Years) MPC Centennial Care #889

7 ampicillin oral suspension reconstituted 125 /5ml, 250 /5ml AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR 10 MG anagrelide hcl oral capsule 0.5, 1 anastrozole oral tablet 1 ANDRODERM TRANSDERMAL TCH 24 HOUR 2 MG/24HR ANDRODERM TRANSDERMAL TCH 24 HOUR 4 MG/24HR ; QL (60 EA per 30 days) ; QL (60 EA per 30 days) ; QL (30 EA per 30 days) ANDROXY ORAL TABLET 10 MG ; QL (120 EA per 30 days) anti-dandruff external shampoo 1 % antipyrine-benzocaine otic solution % ANZEMET ORAL TABLET 100 MG, 50 MG ; QL (4 EA per 28 days) APOKYN SUBCUTANEOUS SOLUTION 10 MG/ML ; SP aprepitant oral capsule 125, 40 ; QL (1 EA per 30 days) aprepitant oral capsule 80 & 125, 80 ; QL (3 EA per 30 days) APRI ORAL TABLET MG-MCG APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR GM ST; QL (120 EA per 30 days) APTIVUS ORAL CAPSULE 250 MG QL (120 EA per 30 days) APTIVUS ORAL SOLUTION 100 MG/ML QL (300 ML per 30 days) ARANELLE ORAL TABLET 0.5/1/ MG-MCG aripiprazole oral solution 1 /ml ; QL (750 ML per 30 days) aripiprazole oral tablet 10, 15, 2, 20, 30, 5 ; QL (30 EA per 30 days) aripiprazole oral tablet dispersible 10, 15 ; QL (30 EA per 30 days) ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML armodafinil oral tablet 200, 250 ; QL (30 EA per 30 days) armodafinil oral tablet 50 ; QL (90 EA per 30 days) arthritis pain relief oral tablet extended release 650 QL (6 EA per 1 day) artificial tears ophthalmic ointment % artificial tears ophthalmic solution 0.4 % ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT ASPERCREME LIDOCAINE EXTERNAL TCH 4 % SP QL (13 GM per 30 days) ; QL (30 EA per 30 days) aspirin ec oral tablet delayed release 81 $0 Copay per PCA guidelines. aspirin low dose oral tablet 81 $0 Copay per PCA guidelines. aspirin low dose oral tablet chewable 81 $0 Copay per PCA guidelines. aspirin low strength oral tablet chewable 81 aspirin oral tablet 325 $0 Copay per PCA guidelines. MPC Centennial Care #889

8 aspirin oral tablet chewable 81 $0 Copay per PCA guidelines. aspirin oral tablet delayed release 325 $0 Copay per PCA guidelines. ASSESS PEAK FLOW METER DEVICE atazanavir sulfate oral capsule 150, 200, 300 atenolol oral tablet 100, 25, 50 atenolol-chlorthalidone oral tablet , atomoxetine hcl oral capsule 10, 100, 18, 25, 40, 60, 80 atorvastatin calcium oral tablet 10, 20, 40, 80 atovaquone oral suspension 750 /5ml QL (60 EA per 30 days) ST; QL (30 EA per 30 days) QL (30 EA per 30 days) ATRIPLA ORAL TABLET MG QL (30 EA per 30 days) atropine sulfate ophthalmic ointment 1 % atropine sulfate ophthalmic solution 1 % ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT AUBAGIO ORAL TABLET 14 MG, 7 MG ; SP; QL (30 EA per 30 days) AUBRA ORAL TABLET MG-MCG AUSTEDO ORAL TABLET 12 MG ; QL (120 EA per 30 days) AUSTEDO ORAL TABLET 6 MG, 9 MG ; QL (30 EA per 30 days) AVANDAMET ORAL TABLET MG, MG, MG, MG ST; QL (60 EA per 30 days) AVANDIA ORAL TABLET 2 MG, 4 MG ST; QL (60 EA per 30 days) AVANDIA ORAL TABLET 8 MG ST; QL (30 EA per 30 days) AVIANE ORAL TABLET MG-MCG AVONEX INTRAMUSCULAR KIT 30 MCG SP AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 30 MCG/0.5ML AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML azathioprine oral tablet 50 azelastine hcl nasal solution 0.1 % azithromycin oral suspension reconstituted 100 /5ml, 200 /5ml azithromycin oral tablet 250, 500, 600 AZOPT OPHTHALMIC SUSPENSION 1 % AZURETTE ORAL TABLET /0.01 MG (21/5) bacitracin external ointment 500 unit/gm bacitracin ophthalmic ointment 500 unit/gm bacitracin-polymyxin b ophthalmic ointment unit/gm SP; QL (1 EA per 28 days) SP; QL (1 EA per 28 days) MPC Centennial Care #889

9 bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % baclofen oral tablet 10, 20 BACTROBAN NASAL NASAL OINTMENT 2 % balsalazide disodium oral capsule 750 BALZIVA ORAL TABLET MG-MCG BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML BD INSULIN SYRINGE ULTRAFINE 31G X 5/16" 1 ML QL (45 ML per 30 days) QL (200 EA per 30 days) BD PEN NEEDLE MINI U/F 31G X 5 MM QL (200 EA per 30 days) BEKYREE ORAL TABLET /0.01 MG (21/5) BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG benazepril hcl oral tablet 10, 20, 40, 5 benazepril-hydrochlorothiazide oral tablet , , 20-25, BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 120 MG, 400 MG BENLYSTA SUBCUTANEOUS SOLUTION AUTO- INJECTOR 200 MG/ML BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML ; QL (30 EA per 30 days) ; SP ; SP; QL (4 ML per 28 days) ; SP; QL (4 ML per 28 days) benzonatate oral capsule 100, 200 QL (90 EA per 30 days) benzoyl peroxide external gel 10 %, 2.5 %, 5 % benzoyl peroxide wash external liquid 10 %, 5 % benzoyl peroxide-erythromycin external gel 5-3 % benztropine mesylate oral tablet 0.5, 1, 2 betamethasone dipropionate aug external cream 0.05 % betamethasone dipropionate aug external gel 0.05 % betamethasone dipropionate aug external lotion 0.05 % betamethasone dipropionate aug external ointment 0.05 % betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external lotion 0.05 % betamethasone dipropionate external ointment 0.05 % betamethasone valerate external cream 0.1 % betamethasone valerate external lotion 0.1 % betamethasone valerate external ointment 0.1 % BETASEPT SURGICAL SCRUB EXTERNAL LIQUID 4 % betaxolol hcl ophthalmic solution 0.5 % ST MPC Centennial Care #889

10 betaxolol hcl oral tablet 10, 20 bethanechol chloride oral tablet 10, 25, 5, 50 BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 % ST bexarotene oral capsule 75 ; SP bicalutamide oral tablet 50 ST bio-statin oral capsule unit, unit bisoprolol fumarate oral tablet 10, 5 bisoprolol-hydrochlorothiazide oral tablet , , BLEPHAMIDE OPHTHALMIC SUSPENSION % BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT % BLISOVI 24 FE ORAL TABLET 1-20 MG-MCG(24) BLISOVI FE 1.5/30 ORAL TABLET MG-MCG BLISOVI FE 1/20 ORAL TABLET 1-20 MG-MCG BOOST ORAL LIQUID BOOSTRIX INTRAMUSCULAR SUSPENSION $0 Copay Preventative Services.; AG (Min 19 Years) BOSULIF ORAL TABLET 100 MG ; SP; QL (120 EA per 30 days) BOSULIF ORAL TABLET 500 MG ; SP; QL (30 EA per 30 days) briellyn oral tablet mcg BRILINTA ORAL TABLET 60 MG, 90 MG ; QL (60 EA per 30 days) brimonidine tartrate ophthalmic solution 0.15 % ST brimonidine tartrate ophthalmic solution 0.2 % bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 BRONCHO SALINE INHALATION AEROSOL SOLUTION 0.9 % budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml bumetanide oral tablet 0.5, 1, 2 buprenorphine hcl sublingual tablet sublingual 2, 8 buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5, 8-2 BUPROBAN ORAL TABLET EXTENDED RELEASE 12 HOUR 150 MG bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150, 200 bupropion hcl er (xl) oral tablet extended release 24 hour 150 QL (120 ML per 30 days); AG (Max 12 Years) QL (90 EA per 30 days) QL (90 EA per 30 days) $0 Copay per PCA guidelines. $0 Copay per PCA guidelines.; QL (360 EA per 365 days) QL (60 EA per 30 days) QL (90 EA per 30 days) MPC Centennial Care #889

11 bupropion hcl er (xl) oral tablet extended release 24 hour 300 QL (30 EA per 30 days) bupropion hcl oral tablet 100 QL (135 EA per 30 days) bupropion hcl oral tablet 75 QL (120 EA per 30 days) buspirone hcl oral tablet 10, 15, 5, 7.5 QL (90 EA per 30 days) buspirone hcl oral tablet 30 QL (60 EA per 30 days) butalbital-apap-caff-cod oral capsule butalbital-apap-caffeine oral tablet , butalbital-asa-caff-codeine oral capsule QL (180 EA per 30 days); AG (Min 12 Years) QL (180 EA per 30 days) AG (Min 12 Years) butalbital-aspirin-caffeine oral tablet QL (6 EA per 1 day) CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG ; QL (30 EA per 30 days) caffeine citrate intravenous solution 60 /3ml caffeine citrate oral solution 20 /ml CALCIFEROL ORAL SOLUTION 8000 UNIT/ML calcipotriene external cream % calcipotriene external ointment % calcipotriene external solution % calcitonin (salmon) nasal solution 200 unit/act CALCITRENE EXTERNAL OINTMENT % calcitriol oral capsule 0.25 mcg, 0.5 mcg calcitriol oral solution 1 mcg/ml calcium d oral tablet unit calcium-vitamin d oral tablet unit, unit, unit CALQUENCE ORAL CAPSULE 100 MG ; QL (60 EA per 30 days) CAMILA ORAL TABLET 0.35 MG CAMRESE LO ORAL TABLET & 0.01 MG CANASA RECTAL SUPPOSITORY 1000 MG QL (30 EA per 30 days) candesartan cilexetil oral tablet 16, 4, 8 ST; QL (60 EA per 30 days) candesartan cilexetil oral tablet 32 ST; QL (30 EA per 30 days) candesartan cilexetil-hctz oral tablet ST; QL (60 EA per 30 days) candesartan cilexetil-hctz oral tablet , capecitabine oral tablet 150, 500 ; SP ST; QL (30 EA per 30 days) CAPRELSA ORAL TABLET 100 MG ; SP; QL (60 EA per 30 days) CAPRELSA ORAL TABLET 300 MG ; SP; QL (30 EA per 30 days) captopril oral tablet 100, 12.5, 25, 50 captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, MPC Centennial Care #889

12 CARAFATE ORAL SUSPENSION 1 GM/10ML carbamazepine er oral capsule extended release 12 hour 100, 200, 300 carbamazepine er oral tablet extended release 12 hour 100, 200, 400 carbamazepine oral suspension 100 /5ml carbamazepine oral tablet 200 carbamazepine oral tablet chewable 100 carbidopa-levodopa er oral tablet extended release , carbidopa-levodopa oral tablet , , carbidopa-levodopa oral tablet dispersible , , carteolol hcl ophthalmic solution 1 % CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG carvedilol oral tablet 12.5, 25, 3.125, 6.25 CAYA VAGINAL DIAPHRAGM CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG CAZIANT ORAL TABLET 0.1/0.125/ MG cefaclor oral capsule 250, 500 cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml cefpodoxime proxetil oral tablet 100, 200 cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml cefprozil oral tablet 250, 500 cefuroxime axetil oral suspension reconstituted 125 /5ml cefuroxime axetil oral tablet 250, 500 celecoxib oral capsule 100, 200, 400, 50 cephalexin oral capsule 250, 500 cephalexin oral suspension reconstituted 125 /5ml, 250 /5ml CERVARIX INTRAMUSCULAR SUSPENSION CESIA ORAL TABLET 0.1/0.125/ MG ; SP; QL (84 ML per 56 days) ST; QL (60 EA per 30 days) $0 Copay Preventative Services.; AG (Min 19 Years) MPC Centennial Care #889

13 cetirizine hcl childrens alrgy oral syrup 1 /ml OTC not covered for ABP plans cetirizine hcl oral tablet 10, 5 OTC not covered for ABP plans cetirizine hcl oral tablet chewable 10, 5 OTC not covered for ABP plans CHANTIX ORAL TABLET 0.5 MG, 1 MG ST; $0 Copay per PCA guidelines. CHANTIX STARTING MONTH K ORAL TABLET 0.5 MG X 11 & 1 MG X 42 CHATEAL ORAL TABLET MG-MCG CHEMSTRIP UGK IN VITRO STRIP ST; $0 Copay per PCA guidelines. childrens aspirin oral tablet chewable 81 $0 Copay per PCA guidelines. childrens ibuprofen oral suspension 40 /ml childrens loratadine oral syrup 5 /5ml chlordiazepoxide hcl oral capsule 10, 25, 5 QL (120 EA per 30 days) chlorhexidine gluconate mouth/throat solution 0.12 % chloroquine phosphate oral tablet 250, 500 chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 chlorpropamide oral tablet 100, 250 chlorthalidone oral tablet 100, 25, 50 chlorzoxazone oral tablet 500 cholestyramine light oral packet 4 gm cholestyramine light oral powder 4 gm/dose cholestyramine oral packet 4 gm cholestyramine oral powder 4 gm/dose ciclopirox external gel 0.77 % ciclopirox external solution 8 % QL (6.6 ML per 30 days) ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % cilostazol oral tablet 100, 50 cimetidine hcl oral solution 300 /5ml cimetidine oral tablet 200, 300, 400, 800 CIPRODEX OTIC SUSPENSION % ciprofloxacin hcl ophthalmic solution 0.3 % ciprofloxacin hcl oral tablet 100, 250, 500, 750 ciprofloxacin oral suspension reconstituted 250 /5ml (5%), 500 /5ml (10%) ST; QL (7.5 ML per 30 days); AG (Max 12 Years) citalopram hydrobromide oral solution 10 /5ml QL (600 ML per 30 days) citalopram hydrobromide oral tablet 10, 20 QL (60 EA per 30 days) citalopram hydrobromide oral tablet 40 QL (30 EA per 30 days) MPC Centennial Care #889

14 CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG clarithromycin oral suspension reconstituted 125 /5ml, 250 /5ml Length of therapy is limited to 24 weeks or 336 capsules per 365 days.; QL (60 EA per 30 days) clarithromycin oral tablet 250, 500 QL (28 EA per 30 days) CLEOCIN VAGINAL SUPPOSITORY 100 MG CLINDAMAX EXTERNAL GEL 1 % CLINDAMAX EXTERNAL LOTION 1 % clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml clindamycin phosphate external gel 1 % clindamycin phosphate external lotion 1 % clindamycin phosphate external solution 1 % clindamycin phosphate external swab 1 % clindamycin phosphate vaginal cream 2 % CLINPRO 5000 DENTAL STE 1.1 % clobetasol propionate emollient cream 0.05 % external clobetasol propionate external gel 0.05 % clobetasol propionate external ointment 0.05 % clobetasol propionate external solution 0.05 % clomipramine hcl oral capsule 25, 50, 75 clonazepam oral tablet 0.5, 1, 2 QL (90 EA per 30 days) clonazepam oral tablet dispersible 0.125, 0.25, 0.5, 1, 2 clonidine hcl oral tablet 0.1, 0.2, 0.3 clopidogrel bisulfate oral tablet 75 QL (90 EA per 30 days) clorazepate dipotassium oral tablet 15 QL (180 EA per 30 days) clorazepate dipotassium oral tablet 3.75, 7.5 QL (90 EA per 30 days) clotrimazole anti-fungal external cream 1 % clotrimazole mouth/throat troche 10 clotrimazole vaginal cream 1 % clotrimazole-betamethasone external cream % clotrimazole-betamethasone external lotion % clozapine oral tablet 100 QL (270 EA per 30 days) clozapine oral tablet 200 QL (135 EA per 30 days) clozapine oral tablet 25, 50 QL (60 EA per 30 days) clozapine oral tablet dispersible 100 ; QL (270 EA per 30 days) clozapine oral tablet dispersible 12.5 ; QL (60 EA per 30 days) clozapine oral tablet dispersible 25 ; QL (180 EA per 30 days) MPC Centennial Care #889

15 codeine sulfate oral tablet 15, 30, 60 COGENTIN INJECTION SOLUTION 1 MG/ML colchicine oral tablet 0.6 colchicine-probenecid oral tablet COLCRYS ORAL TABLET 0.6 MG COLY-MYCIN S OTIC SUSPENSION MG/ML COLYTE WITH FLAVOR CKS ORAL SOLUTION RECONSTITUTED GM COMBITCH TRANSDERMAL TCH TWICE WEEKLY MG/DAY, MG/DAY COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG Schedule II medications are limited to a 34 day maximum.; QL (180 EA per 30 days); AG (Min 12 Years) $0 Copay per PCA guidelines.; QL (8000 ML per 365 days); AG (Min 50 Years) ST; QL (8 EA per 28 days) QL (4 GM per 30 days) COMPLERA ORAL TABLET MG QL (30 EA per 30 days) completenate oral tablet chewable 29-1 COMPRO RECTAL SUPPOSITORY 25 MG COMVAX INTRAMUSCULAR SUSPENSION MCG/0.5ML CO-NATAL FA ORAL TABLET condoms constulose oral solution 10 gm/15ml CORMAX SCALP APPLICATION EXTERNAL SOLUTION 0.05 % CORTAID INTENSIVE THERAPY EXTERNAL SOLUTION 1 % CORTISPORIN EXTERNAL CREAM CORTISPORIN EXTERNAL OINTMENT 1 % CREON ORAL CAPSULE DELAYED RELEASE RTICLES UNIT, UNIT, UNIT, UNIT, 6000 UNIT CRINONE VAGINAL GEL 8 % $0 Copay Preventative Services.; AG (Min 19 Years) CRIXIVAN ORAL CAPSULE 200 MG, 400 MG QL (180 EA per 30 days) cromolyn sodium inhalation nebulization solution 20 /2ml cromolyn sodium nasal aerosol solution 5.2 /act cromolyn sodium ophthalmic solution 4 % CRYSELLE-28 ORAL TABLET MG-MCG MPC Centennial Care #889

16 CUPRIMINE ORAL CAPSULE 250 MG cvs lubricant eye drops ophthalmic solution % CYCLAFEM 1/35 ORAL TABLET 1-35 MG-MCG CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG- MCG cyclobenzaprine hcl oral tablet 10, 5 cyclophosphamide oral capsule 25, 50 cycloserine oral capsule 250 cyclosporine modified oral capsule 100, 25, 50 cyclosporine modified oral solution 100 /ml cyclosporine oral capsule 100, 25 cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 cytra-2 oral solution /5ml d 400 oral tablet 400 unit d-400 oral tablet 400 unit (Min 60 Years) (Min 60 Years) DALIRESP ORAL TABLET 500 MCG ; QL (30 EA per 30 days) danazol oral capsule 100, 200, 50 dapsone external gel 5 % dapsone oral tablet 100, 25 daptomycin intravenous solution reconstituted 500 DASETTA 1/35 ORAL TABLET 1-35 MG-MCG DASETTA 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG- MCG DEBLITANE ORAL TABLET 0.35 MG delta d3 oral tablet 400 unit DELYLA ORAL TABLET MG-MCG DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG DEPEN TITRATABS ORAL TABLET 250 MG (Min 60 Years) ST; QL (180 EA per 30 days) DESCOVY ORAL TABLET MG QL (30 EA per 30 days) desipramine hcl oral tablet 10, 150, 25, 50 desmopressin ace rhinal tube nasal solution 0.01 % desmopressin acetate oral tablet 0.1, 0.2 desmopressin acetate spray nasal solution 0.01 % desogestrel-ethinyl estradiol oral tablet /0.01 (21/5), mcg MPC Centennial Care #889

17 DEXAMETHASONE INTENSOL ORAL CONCENTRATE 1 MG/ML dexamethasone oral elixir 0.5 /5ml dexamethasone oral solution 0.5 /5ml dexamethasone oral tablet 0.5, 0.75, 1, 1.5, 2, 4, 6 dexamethasone sodium phosphate ophthalmic solution 0.1 % dexmethylphenidate hcl er oral capsule extended release 24 hour 10, 15, 20, 30, 35, 40, 5 dexmethylphenidate hcl er oral capsule extended release 24 hour 25 dexmethylphenidate hcl oral tablet 10, 2.5 dexmethylphenidate hcl oral tablet 5 dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15, 5 dextroamphetamine sulfate oral tablet 10, 5 DIALYVITE ORAL TABLET ST; required for patients 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Max 18 Years) ST; required for patients 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Max 18 Years) ST; required for patients 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Max 18 Years) ST; required for patients 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 60 days); AG (Max 18 Years) required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Min 6 Years and Max 18 Years) required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); AG (Min 3 Years and Max 18 Years) diazepam oral tablet 10, 2, 5 QL (120 EA per 30 days) diazepam rectal gel 10, 2.5, 20 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium ophthalmic solution 0.1 % diclofenac sodium oral tablet delayed release 25, 50, 75 ST; QL (5 EA per 30 days); AG (Max 17 Years) diclofenac sodium transdermal gel 1 % QL (100 GM per 30 days) dicloxacillin sodium oral capsule 250, 500 dicyclomine hcl intramuscular solution 10 /ml MPC Centennial Care #889

18 dicyclomine hcl oral capsule 10 dicyclomine hcl oral solution 10 /5ml dicyclomine hcl oral tablet 20 didanosine oral capsule delayed release 125, 200, 250, 400 DIFFERIN EXTERNAL GEL 0.1 % QL (30 EA per 30 days) The following Prior authorization criteria applies to patients greater than 40 years of age: The patient must have a diagnosis of actinic keratosis OR adult acne.; AG (Max 40 Years) DIFICID ORAL TABLET 200 MG ; QL (20 EA per 30 days) diflunisal oral tablet 500 digoxin oral solution 0.05 /ml digoxin oral tablet 125 mcg, 250 mcg DILANTIN ORAL CAPSULE 30 MG DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE 40 MG dilt-cd oral capsule extended release 24 hour 120, 180, 240, 300 diltiazem cd oral capsule extended release 24 hour 240 diltiazem hcl er beads oral capsule extended release 24 hour 120, 180, 240, 300, 360, 420 diltiazem hcl er coated beads oral capsule extended release 24 hour 120, 180, 240, 300 diltiazem hcl er oral capsule extended release 12 hour 120, 60, 90 diltiazem hcl er oral capsule extended release 24 hour 120, 180, 240 diltiazem hcl intravenous solution 50 /10ml diltiazem hcl oral tablet 120, 30, 60, 90 diltzac oral capsule extended release 24 hour 120, 180, 240, 300, 360 diocto oral syrup 60 /15ml QL (900 ML per 30 days) diphenoxylate-atropine oral liquid /5ml dipyridamole oral tablet 25, 50, 75 disopyramide phosphate oral capsule 100, 150 disulfiram oral tablet 250 divalproex sodium er oral tablet extended release 24 hour 250, 500 divalproex sodium oral capsule sprinkle 125 divalproex sodium oral tablet delayed release 125, 250, 500 MPC Centennial Care #889

19 docu oral liquid 50 /5ml QL (900 ML per 30 days) docusate sodium oral capsule 100, 250 QL (60 EA per 30 days) DOLGIC PLUS ORAL TABLET MG QL (180 EA per 30 days) donepezil hcl oral tablet 10, 5 QL (30 EA per 30 days) donepezil hcl oral tablet dispersible 10, 5 QL (30 EA per 30 days) dorzolamide hcl ophthalmic solution 2 % dorzolamide hcl-timolol mal ophthalmic solution /ml doxazosin mesylate oral tablet 1, 2, 4, 8 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg doxycycline hyclate oral tablet 20 QL (60 EA per 30 days) doxycycline monohydrate oral capsule 100, 50 drospirenone-ethinyl estradiol oral tablet , DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT duloxetine hcl oral capsule delayed release particles 20, 30 duloxetine hcl oral capsule delayed release particles 60 ST; QL (13 GM per 30 days) QL (60 EA per 30 days) QL (30 EA per 30 days) dutasteride oral capsule 0.5 ST; QL (30 EA per 30 days) DYRENIUM ORAL CAPSULE 100 MG, 50 MG E.E.S. 400 ORAL TABLET 400 MG E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML econazole nitrate external cream 1 % ECONTRA EZ ORAL TABLET 1.5 MG EDURANT ORAL TABLET 25 MG $0 Copay per PCA guidelines.; QL (6 EA per 365 days) efavirenz oral capsule 200, 50 QL (30 EA per 30 days) ELIDEL EXTERNAL CREAM 1 % ST ELINEST ORAL TABLET MG-MCG ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML ELLA ORAL TABLET 30 MG $0 Copay Preventative Services.; AG ELMIRON ORAL CAPSULE 100 MG ; QL (90 EA per 30 days) EMCYT ORAL CAPSULE 140 MG ; SP EMEND ORAL SUSPENSION RECONSTITUTED 125 MG EMOQUETTE ORAL TABLET MG-MCG ; QL (6 EA per 28 days) MPC Centennial Care #889

20 EMSAM TRANSDERMAL TCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR ; QL (30 EA per 30 days) EMTRIVA ORAL CAPSULE 200 MG QL (30 EA per 30 days) EMTRIVA ORAL SOLUTION 10 MG/ML QL (720 ML per 30 days) enalapril maleate oral tablet 10, 2.5, 20, 5 enalapril-hydrochlorothiazide oral tablet 10-25, ENBREL SUBCUTANEOUS KIT 25 MG ; SP ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML ENCARE VAGINAL SUPPOSITORY 100 MG ENDOCET ORAL TABLET MG, MG, MG ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 MCG/ML ENGERIX-B INTRAMUSCULAR INJECTABLE 10 MCG/0.5ML, 20 MCG/ML ; SP ; SP QL (12 EA per 1 day) $0 Copay Preventative Services.; AG (Min 19 Years) $0 Copay Preventative Services.; AG (Min 19 Years) enoxaparin sodium injection solution 300 /3ml Maximum 30 syringes per 90 days. enoxaparin sodium subcutaneous solution 100 /ml, 60 /0.6ml enoxaparin sodium subcutaneous solution 120 /0.8ml enoxaparin sodium subcutaneous solution 150 /ml, 40 /0.4ml enoxaparin sodium subcutaneous solution 30 /0.3ml, 80 /0.8ml ENPRESSE-28 ORAL TABLET ENSKYCE ORAL TABLET MG-MCG entacapone oral tablet 200 ENTRESTO ORAL TABLET MG, MG, MG epinephrine injection solution auto-injector 0.15 /0.3ml, 0.3 /0.3ml EPIVIR HBV ORAL SOLUTION 5 MG/ML eq lubricant eye drops ophthalmic solution % Maximum 30 syringes in 90 days. Maximum 30 syringes in 90 days.; QL (1.6 ML per 1 day) Maximum 30 syringes per 90 days. Maximum 30 syringes per 90 days. ; QL (60 EA per 30 days) eq nicotine mouth/throat gum 4 $0 Copay per PCA guidelines. eql vitamin d-3 oral tablet 400 unit ergoloid mesylates oral tablet 1 (Min 60 Years) ergotamine-caffeine oral tablet QL (40 EA per 30 days) ERIVEDGE ORAL CAPSULE 150 MG ; SP; QL (30 EA per 30 days) ERRIN ORAL TABLET 0.35 MG MPC Centennial Care #889

21 ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 MG/5ML ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG ERYTHROCIN STEARATE ORAL TABLET 250 MG erythromycin base oral tablet 250, 500 erythromycin ethylsuccinate oral tablet 400 erythromycin external gel 2 % erythromycin external solution 2 % erythromycin ophthalmic ointment 5 /gm erythromycin-sulfisoxazole oral suspension reconstituted /5ml escitalopram oxalate oral solution 5 /5ml QL (600 ML per 30 days) escitalopram oxalate oral tablet 10 QL (45 EA per 30 days) escitalopram oxalate oral tablet 20, 5 QL (30 EA per 30 days) ESTARYLLA ORAL TABLET MG-MCG estradiol oral tablet 0.5, 1, 2 estradiol transdermal patch twice weekly /24hr, /24hr, 0.05 /24hr, /24hr, 0.1 /24hr estradiol transdermal patch weekly /24hr, /24hr, 0.05 /24hr, 0.06 /24hr, /24hr, 0.1 /24hr estradiol vaginal cream 0.1 /gm estradiol-norethindrone acet oral tablet , estropipate oral tablet 0.75, 1.5, 3 QL (8 EA per 28 days) eszopiclone oral tablet 1, 2, 3 ST; QL (30 EA per 30 days) ethacrynic acid oral tablet 25 ethambutol hcl oral tablet 100, 400 ethosuximide oral capsule 250 ethosuximide oral solution 250 /5ml ethynodiol diac-eth estradiol oral tablet mcg etodolac er oral tablet extended release 24 hour 400, 500, 600 etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 etoposide oral capsule 50 EVOMELA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG EVOTAZ ORAL TABLET MG QL (30 EA per 30 days) MPC Centennial Care #889

22 EXTAVIA SUBCUTANEOUS KIT 0.3 MG ; SP; QL (1 EA per 30 days) ezetimibe oral tablet 10 ezetimibe-simvastatin oral tablet 10-10, 10-20, 10-40, FALLBACK SOLO ORAL TABLET 1.5 MG FALMINA ORAL TABLET MG-MCG famciclovir oral tablet 125, 250, 500 famotidine oral tablet 20, 40 ST $0 Copay per PCA guidelines.; QL (6 EA per 365 days) FARESTON ORAL TABLET 60 MG ; SP; QL (30 EA per 30 days) FARXIGA ORAL TABLET 10 MG, 5 MG ; QL (30 EA per 30 days) FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG ; QL (6 EA per 21 days) FC FEMALE CONDOM felodipine er oral tablet extended release 24 hour 10, 2.5, 5 FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral tablet 145, 160, 48, 54 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FEROSUL ORAL ELIXIR 220 (44 FE) MG/5ML ferrous gluconate oral tablet 240 (27 fe), 324 (38 fe), 325 (36 fe) ferrous sulfate oral syrup 300 (60 fe) /5ml FEVERALL RECTAL SUPPOSITORY 120 MG, 325 MG, 80 MG fexofenadine hcl oral tablet 180, 60 FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML ST; Schedule II medications are limited to a 34 day maximum.; QL (10 EA per 30 days) AG (Min 6 Months and Max 12 Months) AG (Min 6 Months and Max 12 Months) QL (45 ML per 30 days) FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML QL (50 ML per 30 days) FINACEA EXTERNAL FOAM 15 % ST FINACEA EXTERNAL GEL 15 % ST finasteride oral tablet 5 FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 GM/100ML FLEBOGAMMA DIF INTRAVENOUS SOLUTION 5 GM/50ML FLONASE ALLERGY RELIEF NASAL SUSPENSION 50 MCG/ACT ; SP MPC Centennial Care #889

23 FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML FLUBLOK INTRAMUSCULAR SOLUTION FLUCELVAX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 fludrocortisone acetate oral tablet 0.1 FLULAVAL INTRAMUSCULAR SUSPENSION FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML fluocinolone acetonide body external oil 0.01 % fluocinolone acetonide external cream 0.01 %, % fluocinolone acetonide external ointment % fluocinolone acetonide external solution 0.01 % fluocinolone acetonide otic oil 0.01 % fluocinolone acetonide scalp external oil 0.01 % fluocinonide external cream 0.05 % fluocinonide external gel 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % FLUORABON ORAL SOLUTION 0.55 (0.25 F) MG/0.6ML fluorometholone ophthalmic suspension 0.1 % fluorouracil external cream 5 % fluorouracil external solution 2 %, 5 % $0 Copay Preventative Services; QL (0.5 ML per 180 days) $0 Copay Preventative Services; QL (0.5 ML per 180 days) $0 Copay Preventative Services; QL (0.5 ML per 180 days) $0 Copay Preventative Services; QL (0.5 ML per 180 days) $0 Copay Preventative Services; QL (0.5 ML per 180 days) $0 Copay Preventative Services; QL (0.5 ML per 180 days) (Max 6 Years) fluoxetine hcl oral capsule 10 QL (30 EA per 30 days) fluoxetine hcl oral capsule 20 QL (120 EA per 30 days) fluoxetine hcl oral capsule 40 QL (60 EA per 30 days) fluoxetine hcl oral solution 20 /5ml QL (600 ML per 30 days) fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml MPC Centennial Care #889

24 fluphenazine hcl oral tablet 1, 10, 2.5, 5 FLURA-DROPS ORAL SOLUTION (0.125 F) MG/DROP, 0.55 (0.25 F) MG/DROP flurbiprofen oral tablet 100, 50 flutamide oral capsule 125 fluticasone propionate external cream 0.05 % fluticasone propionate external ointment % fluticasone propionate nasal suspension 50 mcg/act fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act, mcg/act, mcg/act FLUVIRIN PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML fluvoxamine maleate er oral capsule extended release 24 hour 100, 150 (Max 6 Years) ST $0 Copay Preventative Services; QL (0.5 ML per 180 days) ST; QL (30 EA per 30 days) fluvoxamine maleate oral tablet 100 QL (90 EA per 30 days) fluvoxamine maleate oral tablet 25 QL (30 EA per 30 days) fluvoxamine maleate oral tablet 50 QL (45 EA per 30 days) FLUZONE INTRAMUSCULAR SUSPENSION FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML FML FORTE OPHTHALMIC SUSPENSION 0.25 % FML OPHTHALMIC OINTMENT 0.1 % folic acid oral tablet 1 folic acid oral tablet 400 mcg, 800 mcg fondaparinux sodium subcutaneous solution 10 /0.8ml, 2.5 /0.5ml, 5 /0.4ml, 7.5 /0.6ml FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML $0 Copay Preventative Services; QL (0.5 ML per 180 days) $0 Copay Preventative Services; QL (0.5 ML per 180 days) ; SP fosamprenavir calcium oral tablet 700 QL (120 EA per 30 days) fosinopril sodium oral tablet 10, 20, 40 fosinopril sodium-hctz oral tablet , furosemide oral solution 10 /ml, 8 /ml furosemide oral tablet 20, 40, 80 FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG gabapentin oral capsule 100, 300, 400 gabapentin oral solution 250 /5ml gabapentin oral tablet 600, 800 QL (60 EA per 30 days) MPC Centennial Care #889

25 galantamine hydrobromide er oral capsule extended release 24 hour 16, 24, 8 galantamine hydrobromide oral solution 4 /ml galantamine hydrobromide oral tablet 12, 4, 8 GARAMYCIN OPHTHALMIC OINTMENT 0.3 % GARDASIL 9 INTRAMUSCULAR SUSPENSION GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 GM GAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM GAVILYTE-N WITH FLAVOR CK ORAL SOLUTION RECONSTITUTED 420 GM gemfibrozil oral tablet 600 GENGRAF ORAL CAPSULE 100 MG, 25 MG GENGRAF ORAL SOLUTION 100 MG/ML GENTAK OPHTHALMIC OINTMENT 0.3 % gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % gentamicin sulfate ophthalmic solution 0.3 % GENTEAL PM OPHTHALMIC OINTMENT % $0 Copay PCA Guidelines. For females ages 9 through 26 (up until their 27th birthday) and males ages 11 through 22 (up until their 23rd birthday). 18 years and under must be administered in a doctors office under VFC program.; AG (Min 9 Years and Max 26 Years) $0 Copay PCA Guidelines. For females ages 9 through 26 (up until their 27th birthday) and males ages 11 through 22 (up until their 23rd birthday). 18 years and under must be administered in a doctors office under VFC program.; AG (Min 9 Years and Max 26 Years) $0 Copay per PCA guidelines.; QL (8000 ML per 365 days) $0 Copay per PCA guidelines.; QL (8000 ML per 365 days) $0 Copay per PCA guidelines.; QL (8000 ML per 365 days) GENVOYA ORAL TABLET MG QL (30 EA per 30 days) GIANVI ORAL TABLET MG GILDAGIA ORAL TABLET MG-MCG GILDESS 1.5/30 ORAL TABLET MG-MCG GILDESS 1/20 ORAL TABLET 1-20 MG-MCG GILDESS 24 FE ORAL TABLET 1-20 MG-MCG(24) GILDESS FE 1.5/30 ORAL TABLET MG-MCG GILDESS FE 1/20 ORAL TABLET 1-20 MG-MCG GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG MPC Centennial Care #889

26 glatiramer acetate subcutaneous solution prefilled syringe 40 /ml GLATO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML glimepiride oral tablet 1, 2, 4 glipizide er oral tablet extended release 24 hour 10, 2.5, 5 glipizide oral tablet 10, 5 glipizide-metformin hcl oral tablet , , GLUCAGEN DIAGNOSTIC INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG glyburide oral tablet 1.25, 2.5, 5 glyburide-metformin oral tablet , ST; SP; QL (12 ML per 28 days) SP; QL (30 ML per 30 days) QL (60 EA per 30 days) glyburide-metformin oral tablet QL (120 EA per 30 days) glycopyrrolate injection solution 0.2 /ml, 0.4 /2ml, 1 /5ml, 4 /20ml glycopyrrolate oral tablet 1, 2 QL (120 EA per 30 days) GOLYTELY ORAL SOLUTION RECONSTITUTED GM granisetron hcl intravenous solution 0.1 /ml, 4 /4ml $0 Copay per PCA guidelines.; QL (8000 EA per 365 days); AG (Min 50 Years) granisetron hcl oral tablet 1 ST; QL (20 EA per 30 days) GRIFULVIN V ORAL TABLET 500 MG griseofulvin microsize oral suspension 125 /5ml griseofulvin ultramicrosize oral tablet 125, 250 guanfacine hcl er oral tablet extended release 24 hour 1, 2, 3, 4 guanfacine hcl oral tablet 1, 2 HALFPRIN ORAL TABLET DELAYED RELEASE 162 MG haloperidol decanoate intramuscular solution 100 /ml, 50 /ml haloperidol oral tablet 0.5, 1, 10, 2, 5 HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 720 EL U/0.5ML HEATHER ORAL TABLET 0.35 MG HECORIA ORAL CAPSULE 0.5 MG, 1 MG, 5 MG HEPLISAV-B INTRAMUSCULAR SOLUTION 20 MCG/0.5ML HEXALEN ORAL CAPSULE 50 MG ; SP QL (30 EA per 30 days) (Min 44 Years and Max 78 Years) $0 Copay Preventative Services.; AG (Min 19 Years) $0 Copay Preventative Services; QL (1 ML per 1 lifetime); AG (Min 19 Years) MPC Centennial Care #889

27 hm vitamin d oral tablet 400 unit HOMATROIRE OPHTHALMIC SOLUTION 5 % HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 20 MG/0.4ML, 40 MG/0.8ML (Min 60 Years) ; SP; QL (2 EA per 28 days) ; SP; Approve 1 box quantity of 6 to start initial therapy.; QL (6 EA per 30 days) ; Approve 1 box quantity of 4 to start initial therapy.; QL (4 EA per 30 days) ; SP; Approve 1 box quantity of 4 to start initial therapy.; QL (4 EA per 30 days) ; QL (2 EA per 28 days) ; SP HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG ; SP hydralazine hcl oral tablet 10, 100, 25, 50 hydrochlorothiazide oral capsule 12.5 hydrochlorothiazide oral tablet 25, 50 hydrocodone-acetaminophen oral solution /5ml, /10ml, /15ml hydrocodone-acetaminophen oral solution /15ml hydrocodone-acetaminophen oral tablet , 5-325, hydrocodone-acetaminophen oral tablet , 5-500, hydrocodone-acetaminophen oral tablet , , hydrocodone-acetaminophen oral tablet , hydrocodone-ibuprofen oral tablet hydrocortisone external cream 0.5 %, 1 %, 2.5 % hydrocortisone external lotion 2.5 % hydrocortisone external ointment 0.5 %, 1 %, 2.5 % hydrocortisone oral tablet 10, 20, 5 hydrocortisone rectal enema 100 /60ml hydrocortisone valerate external cream 0.2 % Schedule II medications are limited to a 34 day maximum. Schedule II medications are limited to a 34 day maximum.; QL (12 EA per 1 day) Schedule II medications are limited to a 34 day maximum.; QL (8 EA per 1 day) Schedule II medications are limited to a 34 day maximum.; QL (6 EA per 1 day) Schedule II medications are limited to a 34 day maximum.; QL (5 EA per 1 day) Schedule II medications are limited to a 34 day maximum.; QL (5 EA per 1 day) MPC Centennial Care #889

28 hydrocortisone-acetic acid otic solution 1-2 % HYDROGESIC ORAL CAPSULE MG hydromorphone hcl oral liquid 1 /ml hydromorphone hcl oral tablet 2, 4, 8 hydroxychloroquine sulfate oral tablet 200 hydroxyurea oral capsule 500 hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100, 25, 50 hyoscyamine sulfate er oral tablet extended release 12 hour hyoscyamine sulfate oral elixir /5ml hyoscyamine sulfate oral solution /ml hyoscyamine sulfate oral tablet hyoscyamine sulfate oral tablet dispersible hyoscyamine sulfate sublingual tablet sublingual Schedule II medications are limited to a 34 day maximum.; QL (8 EA per 1 day) Schedule II medications are limited to a 34 day maximum.; QL (50 ML per 1 day) Schedule II medications are limited to a 34 day maximum.; QL (6 EA per 1 day) ibandronate sodium oral tablet 150 ST; QL (1 EA per 28 days) IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG ibuprofen junior strength oral tablet chewable 100 ibuprofen lysine intravenous solution 10 /ml ibuprofen oral suspension 100 /5ml ibuprofen oral tablet 200, 400, 600, 800 imatinib mesylate oral tablet 100, 400 ; SP IMBRUVICA ORAL CAPSULE 140 MG imipramine hcl oral tablet 10, 25, 50 ; QL (21 EA per 28 days) ; Quantity limit is 90 capsules per 30 days for CLL, WM and cgvhd and 120 capsules per 30 days for MCL and MZL.; QL (120 EA per 30 days) imiquimod external cream 5 % QL (12 EA per 28 days) INATAL ADVANCE ORAL TABLET INATAL GT ORAL TABLET INATAL ULTRA ORAL TABLET, 90-1 MG INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML indapamide oral tablet 1.25, 2.5 ; SP MPC Centennial Care #889

29 INDOCIN ORAL SUSPENSION 25 MG/5ML INDOCIN RECTAL SUPPOSITORY 50 MG indomethacin er oral capsule extended release 75 indomethacin oral capsule 25, 50 INLYTA ORAL TABLET 1 MG, 5 MG ; SP; QL (4 EA per 1 day) INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG INTRON A INJECTION SOLUTION UNIT/ML, UNIT/ML INTROVALE ORAL TABLET MG QL (60 EA per 30 days) INVIRASE ORAL CAPSULE 200 MG QL (300 EA per 30 days) INVIRASE ORAL TABLET 500 MG QL (120 EA per 30 days) ipratropium bromide inhalation solution 0.02 % ipratropium bromide nasal solution 0.03 %, 0.06 % ipratropium-albuterol inhalation solution (3) /3ml irbesartan oral tablet 150, 300, 75 ST; QL (30 EA per 30 days) irbesartan-hydrochlorothiazide oral tablet ST; QL (60 EA per 30 days) irbesartan-hydrochlorothiazide oral tablet ST; QL (30 EA per 30 days) IRESSA ORAL TABLET 250 MG ; QL (30 EA per 30 days) iron (ferrous gluconate) oral tablet 256 (28 fe) ISENTRESS HD ORAL TABLET 600 MG QL (60 EA per 30 days) ISENTRESS ORAL CKET 100 MG QL (60 EA per 30 days) ISENTRESS ORAL TABLET 400 MG QL (60 EA per 30 days) ISENTRESS ORAL TABLET CHEWABLE 100 MG QL (60 EA per 30 days) ISENTRESS ORAL TABLET CHEWABLE 25 MG QL (120 EA per 30 days) isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 ISOPTO CARBACHOL OPHTHALMIC SOLUTION 1.5 %, 3 % ISOPTO HOMATROPINE OPHTHALMIC SOLUTION 2 % ISOPTO HYOSCINE OPHTHALMIC SOLUTION 0.25 % isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30, 5 isosorbide dinitrate sublingual tablet sublingual 2.5 isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 itraconazole oral capsule 100 ST; QL (168 EA per 365 days) MPC Centennial Care #889