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CONNECTICUT MEDICAID ACNE AGENTS, TOPICAL ‡ ANGIOTENSIN MODULATOR COMBINATIONS ANTICONVULSANTS, CONT.
(STEP THERAPY CATEGORY) AMLODIPINE / BENAZEPRIL CAPSULE (ORAL) LACOSAMIDE TABLET, SOLUTION (NOT CUP)
Preferred Drug List (PDL) (DX CODE REQUIRED - DIFFERIN, EPIDUO and RETIN-A) AMLODIPINE / OLMESARTAN TABLET (ORAL) LAMOTRIGINE CHEW DISPERS TAB (not ODT) (ORAL)
ACNE MEDICATION GEL, LOTION (OTC BENZOYL PEROXIDE) (TOPICAL) LAMOTRIGINE TABLET (IR) (not ER) (ORAL)
AMLODIPINE / VALSARTAN TABLET (ORAL)
• The Connecticut Medicaid Preferred Drug List (PDL) is a BENZOYL PEROXIDE 6% CLEANSER (OTC) (TOPICAL) LEVETIRACETAM SOLUTION, IR TABLET (not ER) (ORAL)
listing of prescription products selected by the BENZOYL PEROXIDE 2.5%, 5%, 10% GEL (OTC) (TOPICAL) ANTHELMINTICS NAYZILAM NASAL SPRAY (NASAL)
Pharmaceutical and Therapeutics Committee as efficacious, BENZOYL PEROXIDE 5%, 10% WASH (OTC) (TOPICAL) ALBENDAZOLE TABLET (ORAL) OXCARBAZEPINE TABLET (ORAL)
safe and cost effective choices when prescribing for HUSKY CLINDAMYCIN PH 1% PLEGET (TOPICAL) BILTRICIDE TABLET (ORAL) PHENOBARBITAL ELIXIR, SOLUTION, TABLET (ORAL)
A, HUSKY C, HUSKY D, EMDS, Tuberculosis (TB) and CLINDAMYCIN PH 1% SOLUTION (not GEL or LOTION) (TOPICAL)IVERMECTIN TABLET (ORAL) PHENYTOIN CHEW TABLET, SUSPENSION (ORAL)
Family Planning (FAMPL) clients. CLINDAMYCIN / BENZOYL PEROXIDE 1.2%-5% (DUAC) (TOPICAL) PHENYTOIN SOD EXT 100 MG CAPS (not 200MG, 300MG) (ORAL)
• Preferred or Non-Preferred status ONLY applies to ERYTHROMYCIN 2% SOLUTION (not GEL) (TOPICAL) ANTI-ALLERGENS, ORAL PRIMIDONE TABLET (ORAL)
those medications that fall within the drug classes listed PANOXYL 10% ACNE FOAMING WASH (OTC) (TOPICAL) All agents require non-PDL PA SABRIL 500 MG POWDER PACK (ORAL)
on this PDL RETIN-A CREAM (TOPICAL) (DX CODE REQ.) SABRIL 500 MG TABLET (ORAL)
• HIV medications are excluded from the PDL and do RETIN-A GEL (not MICRO)(TOPICAL) (DX CODE REQ.) ANTIBIOTICS, GI TEGRETOL SUSPENSION (ORAL)
not require prior authorization FIRVANQ SOLUTION (ORAL) TEGRETOL XR (ORAL)
• "OTC" notation will appear for OTC Products Covered METRONIDAZOLE TABLET (not CAPSULE) (ORAL) TOPIRAMATE SPRINKLE CAPSULE (ORAL)
for clients over the age of 21 TINIDAZOLE TABLET (ORAL) TOPIRAMATE TABLET (not ER) (ORAL)
OTC Expansion Coverage List VANCOMYCIN CAPSULE (ORAL) TRILEPTAL SUSPENSION (ORAL)
• Preferred brand-name medications with non-preferred ANTIBIOTICS, INHALED VALPROIC ACID CAPSULE, SOLUTION (ORAL)
generic equivalents are listed in BOLD (LAST ALZHEIMER'S AGENTS BETHKIS AMPULE (INHALATION) VALTOCO NASAL SPRAY (NASAL)
UPDATED 1/1/2023) DONEPEZIL ODT (ORAL) KITABIS PAK 300 MG/5 ML (INHALATION) ZONISAMIDE CAPSULE (ORAL)
• "DX CODE REQUIRED" notation will appear for DONEPEZIL 5MG & 10MG TABLET (not 23MG) (ORAL) TOBI PODHALER 28MG INHALE CAPSULE (INHALATION)
preferred agents that require ICD-10 code for EXELON PATCH (TRANSDERMAL) ANTIDEPRESSANTS, OTHER
reimbursement MEMANTINE IR TABLET (not ER CAPSULES) (ORAL) ANTIBIOTICS, TOPICAL BUPROPION HCL TABLET (ORAL)
HUSKY Therapeutic Class ICD-10 Diagnosis List MEMANTINE 5-10MG TITRATION PACK (ORAL) GENTAMICIN 0.1% CREAM (TOPICAL) BUPROPION SR TABLET (ORAL)
• "CHEWABLE" notation will appear for chewable RIVASTIGMINE CAPSULES (ORAL) GENTAMICIN 0.1% OINTMENT (TOPICAL) BUPROPION XL TABLET (NOT 450MG) (ORAL)
preferred agents MUPIROCIN 2% OINTMENT (not CREAM) (TOPICAL) DESVENLAFAXINE SUC ER (generic PRISTIQ ER) (ORAL)
** New Therapeutic Class added to PDL effective 1/1/23 ANALGESICS, NARCOTICS SHORT ANTIBIOTICS, VAGINAL MIRTAZAPINE TABLET, ODT (ORAL)
* New Drug added to the PDL effective 1/1/23 APAP / CODEINE 300-30 MG/12.5 ML SOLUTION (ORAL) CLEOCIN OVULES (VAGINAL) TRAZODONE TABLET (ORAL)
Non - PDL PA Requirements APAP / CODEINE 120-12 MG/5 ML SOLUTION (ORAL) CLINDESSE 2% CREAM (VAGINAL) TRINTELLIX TABLET (BRINTELLIX) (ORAL)
Connecticut Medicaid PDL PA Form APAP / CODEINE #2, #3, #4 TABLET (ORAL) METRONIDAZOLE VAGINAL 0.75% GEL (VAGINAL) VENLAFAXINE ER CASPULES (not TABLET) (ORAL)
HYDROCODONE / APAP SOLUTION (ORAL) NUVESSA VAGINAL 1.3% GEL (VAGINAL) VIIBRYD TABLET (not STARTER PACK) (ORAL)
• Intolerance of the preferred agents
HYDROCODONE / APAP TABLET (ORAL) ANTICOAGULANTS
• Adverse reaction to the preferred agents
• Inadequate response from the preferred agents HYDROMORPHONE TABLET (IR) (ORAL) ELIQUIS STARTER PACK (ORAL) ANTIDEPRESSANTS, SSRIs
• Determined medically necessary appropriate MORPHINE CONC, SOLUTION, SYRUP (ORAL) ELIQUIS TABLET (ORAL) CITALOPRAM TABLET, SOLUTION (ORAL)
• Absence of appropriate formulation of the preferred MORPHINE IR TABLET (ORAL) ENOXAPARIN SYRINGE (SUBCUTANEOUS) ESCITALOPRAM TABLET, SOLUTION (ORAL)
agent OXYCODONE / APAP CAPSULE, TABLET (ORAL) ENOXAPARIN VIAL (SUBCUTANEOUS) FLUOXETINE 20 MG/5 ML SOLUTION (ORAL)
Step Therapy PA Requirements OXYCODONE TABLET (not CAPSULE) (ORAL) JANTOVEN TABLET (ORAL) FLUOXETINE CAPSULE (not 90 MG) (ORAL)
STEP THERAPY PA FORM OXYCODONE 5 MG/5 ML SOLUTION (ORAL) PRADAXA CAPSULE (ORAL) FLUOXETINE 10 MG TABLET (not 20 MG or 60 MG) (ORAL)
‡ Agents from the following FIVE categories: TRAMADOL 50 MG TABLET (not 100 MG) (ORAL) WARFARIN TABLET (ORAL) FLUVOXAMINE TABLET (IR) (ORAL)
TRAMADOL / APAP (ORAL) XARELTO TABLET (ORAL) PAROXETINE TABLET (IR only) (ORAL)
ACNE AGENTS, TOPICAL, ANTIMIGRAINE AGENTS, XARELTO STARTER PACK (ORAL) SERTRALINE TABLET, ORAL CONC (not CAPSULES) (ORAL)
CYTOKINE/CAM ANTAGONISTS, LIPOTROPICS, ANDROGENIC AGENTS ANTICONVULSANTS ANTIEMETIC / ANTIVERTIGO AGENTS
STATINS, PROTON PUMP INHIBITORS ANDROGEL 1.62% GEL PUMP (TRANSDERMAL) CARBAMAZEPINE TAB CHEW, IR TABLET (not ER) (ORAL) APREPITANT CAPSULE (not PACK) (ORAL)
Important Connecticut Medicaid Phone Numbers CARBATROL ER CAPSULE (ORAL) BONJESTA (ORAL)
Gainwell Technologies Pharmacy Prior Authorization Center ANGIOTENSIN MODULATORS CLOBAZAM TABLET (ORAL) DICLEGIS TABLET (ORAL)
Phone #: 1-866-409-8386 (toll-free) BENAZEPRIL TABLET (ORAL) CLONAZEPAM IR TABLET (not ODT or ER) (ORAL) DRONABINOL CAPSULE (ORAL)
Fax #: 1-866-759-4110 (toll-free) BENAZEPRIL / HCTZ (ORAL) DEPAKOTE SPRINKLE (not TABLET) (ORAL) EMEND 80 MG CAPSULE (not TRIPACK) (ORAL)
ENALAPRIL, ENALAPRIL / HCTZ (not SOLUTION) (ORAL) DIASTAT ACUDIAL KIT (RECTAL) ONDANSETRON ODT, SOLUTION, TABLET (ORAL)
PA forms are available on our website: ENTRESTO TABLET (ORAL) DIASTAT 2.5 MG PEDI SYSTEM (RECTAL)
IRBESARTAN, IRBESARTAN / HCTZ (ORAL) DIAZEPAM 2.5 MG RECTAL GEL SYS (RECTAL) ANTIFUNGALS, ORAL
http://www.CTDSSMAP.com
LISINOPRIL, LISINOPRIL / HCTZ (ORAL) DIAZEPAM RECTAL GEL SYSTEM (RECTAL) CLOTRIMAZOLE 10 MG TROCHE (MUCOUS MEM)
Navigate to: Pharmacy Information
or: information > publications > forms LOSARTAN, LOSARTAN / HCTZ (ORAL) DIVALPROEX SOD ER TABLET (ORAL) FLUCONAZOLE SUSPENSION, TABLET (ORAL)
Gainwell Technologies Provider Assistance Center OLMESARTAN, OLMESARTAN / HCTZ (ORAL) DIVALPROEX SOD DR TABLET (not SPRINKLE) (ORAL) GRISEOFULVIN SUSPENSION (not TABLET) (ORAL)
1-800-842-8440 (toll-free) QUINAPRIL, QUINIPRIL / HCTZ (ORAL) EPIDIOLEX SOLUTION (ORAL) NOXAFIL DR 100 MG TABLET (ORAL)
Dept of Social Services Rx Consultant RAMIPRIL CAPSULE (ORAL) ETHOSUXIMIDE CAPSULE, SOLUTION (ORAL) NYSTATIN SUSPENSION (not TABLET) (ORAL)
1-860-424-5150 VALSARTAN, VALSARTAN / HCTZ (ORAL) GABITRIL TABLET (ORAL) TERBINAFINE TABLET (ORAL)
1-1-2023 Page 1
ANTIFUNGALS, TOPICAL ANTIPARKINSON'S AGENTS, CONT. ANTIVIRALS, TOPICAL BRONCHODILATORS, BETA AGONIST, CONT.
CLOTRIMAZOLE 1% CREAM (RX and OTC) (TOPICAL) CARBIDOPA / LEVODOPA / ENTACAPONE TABLET (ORAL) ACYCLOVIR 5% OINTMENT (not CREAM) (TOPICAL) PROAIR HFA 90 MCG INHALER (INHALATION)
CLOTRIMAZOLE 1% SOLUTION (TOPICAL) PRAMIPEXOLE IR TABLET (not ER) (ORAL) ZOVIRAX 5% CREAM (TOPICAL) PROVENTIL HFA (INHALATION)*
CLOTRIMAZOLE-BETAMETHASONE CREAM (not LOTION) (TOPRICOAPL)INIROLE IR TABLET (not ER) (ORAL) SEREVENT DISKUS (INHALATION)
KETOCONAZOLE 2% CREAM (not FOAM) (TOPICAL) SELEGILINE CAPSULE, TABLET (ORAL) ANXIOLYTICS CALCIUM CHANNEL BLOCKERS
KETOCONAZOLE 2% SHAMPOO (TOPICAL) TRIHEXYPHENIDYL ELIXIR, TABLET (ORAL) ALPRAZOLAM IR TABLET (not ER or ODT) (ORAL) AMLODIPINE TABLET (ORAL)
MICONAZOLE 2% CREAM (OTC) (TOPICAL) ANTIPSORIATICS, ORAL BUSPIRONE TABLET (ORAL) CARTIA XT CAPSULE (ORAL)
MICONAZOLE 2% POWDER (OTC) (TOPICAL) ACITRETIN CAPSULE (ORAL) CHLORDIAZEPOXIDE CAPSULE (ORAL) DILTIAZEM 12HR ER CAPSULE (ORAL)
NYSTATIN CREAM, OINTMENT, POWDER (TOPICAL) ANTIPSORIATICS, TOPICAL DIAZEPAM 5 MG/5 ML SOLUTION (not 5 MG/ML CONC) (ORAL) DILTAIZEM 24HR ER CAPSULE (not TABLET) (ORAL)
NYSTATIN-TRIAMCINOLONE CREAM, OINTMENT (TOPICAL) CALCIPOTRIENE 0.005% OINTMENT (not CREAM) (TOPICAL) DIAZEPAM TABLET (ORAL) DILTIAZEM TABLET (ORAL)
ANTIHISTAMINES, MINIMALLY SEDATING CALCIPOTRIENE 0.005% SOLUTION (TOPICAL) LORAZEPAM TABLET, 2MG/ML INTENSOL (ORAL) FELODIPINE ER TABLET (ORAL)
CETIRIZINE TABLET (OTC) (NOT CHEWABLE) DOVONEX 0.005% CREAM (TOPICAL) NIFEDIPINE ER TABLET (ORAL)
CETIRIZINE SOLUTION, SYRUP (RX & OTC) (ORAL) TACLONEX OINTMENT (TOPICAL) BETA-BLOCKERS TAZTIA XT CAPSULE (ORAL)
CETIRIZINE-D TABLET (OTC) (ORAL) VECTICAL 3 MCG/G OINTMENT (TOPICAL) ATENOLOL TABLET (ORAL) VERAPAMIL TABLET (ORAL)
FEXOFENADINE 30 MG/5 ML SUSP (OTC) (ORAL) ANTIPSYCHOTICS ATENOLOL / CHLORTHALIDONE (ORAL) VERAPAMIL TABLET ER TABLET (not CAPSULE) (ORAL)
FEXOFENADINE-D TABLET (OTC) (ORAL) ABILIFY MAINTENA ER SYRINGE, VIAL (INTRAMUSC.) BISOPROLOL TABLET (ORAL)
LEVOCETIRIZINE TABLETS (RX & OTC) (ORAL) ADASUVE 10 MG INHALATION POWDER (INHALATION) CARVEDILOL TABLET (not ER) (ORAL) CEPHALOSPORINS AND RELATED ANTIBIOTICS
LORATADINE SOLUTION, SYRUP (OTC) (ORAL) ARIPIPRAZOLE SOLUTION, TABLET (not ODT) (ORAL) LABETALOL TABLET (ORAL) AMOXICILLIN / CLAV SUSPENSION (ORAL)
LORATADINE OTC TABLET (not ODT & CHEW) (ORAL) ARISTADA (INTRAMUSC)* METOPROLOL TARTRATE TABLET (ORAL) AMOXICILLIN / CLAV TABLET (not CHEW TAB or ER) (ORAL)
ARISTADA INITIO (INTRAMUSC)* METOPROLOL SUCCINATE ER TABLET (ORAL) CEFACLOR CAPSULE (not SUSPENSION) (ORAL)
ANTIHYPERTENSIVES, SYMPATHOLYTICS CHLORPROMAZINE AMPULE (INJECTION) PROPRANOLOL SOLUTION, TABLET (ORAL) CEFADROXIL CAPSULE, SUSPENSION (not TABLET) (ORAL)
CATAPRES-TTS PATCH (TRANSDERM) CHLORPROMAZINE ORAL CONC, TABLET (ORAL) PROPRANOLOL ER CAPSULE(ORAL) CEFDINIR CAPSULE, SUSPENSION (ORAL)
CLONIDINE PATCH (TRANSDERM) CLOZAPINE TABLET (not ODT) (ORAL) SOTALOL TABLET (ORAL) CEFPROZIL SUSPENSION, TABLET (ORAL)
CLONIDINE TABLET (IR & ER) (ORAL) FLUPHENAZINE DECANOATE (INJECTION) CEFUROXIME TABLET (ORAL)
GUANFACINE TABLET (ORAL) FLUPHENAZINE ELIXIR/SOLN, TABLET (ORAL) BILE SALTS CEPHALEXIN CAPSULE, SUSPENSION (not TABLET) (ORAL)
METHYLDOPA TABLET (ORAL) HALOPERIDOL TABLET (ORAL) URSODIOL 250MG, 500MG TABLET (ORAL)
ANTIHYPERURICEMICS HALOPERIDOL DECANOATE, LACTATE (INJECTION) URSODIOL 300MG CAPSULE (ORAL) COLONY STIMULATING FACTORS
ALLOPURINOL TABLET (ORAL) HALOPERIDOL LACTATE CONC (ORAL) FULPHILA SYRINGE (SUBCUTANEOUS)
COLCHINE TABLET (ORAL) INVEGA HAFYERA (INTRAMUSC)* BLADDER RELAXANT PREPARATIONS NEUPOGEN DISP SYRINGE, VIAL (INJECTION)
PROBENECID TABLET (ORAL) INVEGA SUSTENNA (INTRAMUSC) OXYBUTYNIN ER TABLET (ORAL) NYVEPRIA SYRINGE (SUBCUTANEOUS)
PROBENECID / COLCHICINE TABLET (ORAL) INVEGA TRINZA (INTRAMUSC) OXYBUTYNIN SYRUP, TABLET (ORAL)
ANTIMIGRAINE AGENTS, OTHER LATUDA TABLET (ORAL) SOLIFENACIN TABLET (ORAL) CONTRACEPTIVES, ORAL
AJOVY AUTOINJECT, SYRINGE (SUBCUTANEOUS) LOXAPINE CAPSULE (ORAL) TOVIAZ ER TABLET (ORAL) *** PREFERRED EMERGENCY CONTRACEPTIVES ***
EMGALITY 120 MG/ML PEN (SUBCUTANEOUS) MOLINDONE TABLET (ORAL)
EMGALITY 120MG SYRINGE (not 100 MG) (SUBCUTANEOUS) OLANZAPINE TABLET, ODT (ORAL) BONE RESORPTION SUPPRESSION & RELATED AGENTS ELLA 30 MG TABLET (ORAL)
NURTEC ODT (ORAL) OLANZAPINE / FLUOXETINE (ORAL) ALENDRONATE TABLET (ORAL) OPCICON ONE-STEP 1.5 MG TABLET (ORAL)
UBRELVY TABLET (ORAL) PALIPERIDONE ER TABLET (ORAL) CALCITONIN-SALMON 200 UNITS SPRAY (NASAL)
ANTIMIGRAINE AGENTS, TRIPTANS ‡ PERPHENAZINE TABLET (ORAL) FORTEO (SUBCUTANE.) ALTAVERA-28 TABLET (ORAL)
(STEP THERAPY CATEGORY) PERPHENAZINE / AMITRIPTYLINE TABLET (ORAL) IBANDRONATE TABLETS (ORAL) ALYACEN 1-35 28 TABLET (ORAL)
IMITREX NASAL SPRAY (NASAL) PERSERIS ER SYRINGE (SUBCUTANEOUS) AMETHIA 0.15-0.03-0.01 MG TAB (not AMETHIA LO) (ORAL)
RELPAX TABLET (ORAL) PIMOZIDE TABLET (ORAL) BOTULINUM TOXINS APRI 28 DAY TABLET (ORAL)
RIZATRIPTAN ODT (ORAL) QUETIAPINE TABLET, ER TABLET (ORAL) BOTOX VIAL (not COSMETIC) (INTRAMUSC) AUBRA-28 (not AUBRA EQ) (ORAL)
RIZATRIPTAN TABLET (ORAL) REXULTI TABLET(ORAL) AUROVELA 1 MG-20 MCG (ORAL)
SUMATRIPTAN TABLET (ORAL) RISPERDAL CONSTA (INTRAMUSC.) BPH TREATMENTS AUROVELA 21 1.5-30 TABLET (ORAL)
SUMATRIPTAN VIAL (not CARTRIDGE) (SUBCUTANEOUS) RISPERIDONE ODT, SOLUTION, TABLET (ORAL) (DX CODE REQUIRED - TADALAFIL) AUROVELA FE 1-20 MCG, FE 1.5-30 MCG (ORAL)
THIORIDAZINE TABLET (ORAL) ALFUZOSIN ER TABLET (ORAL) AVIANE-28 TABLET (ORAL)
ANTIPARASITICS, TOPICAL THIOTHIXENE CAPSULE (ORAL) DOXAZOSIN MESYLATE TABLET (ORAL) BLISOVI FE 1.5-30, BLISOVI FE 1-20 (ORAL)
NATROBA 0.9% SUSPENSION (TOPICAL) TRIFLUOPERAZINE TABLET (ORAL) DUTASTERIDE CAPSULE (ORAL) CAMILA 0.35 MG TABLET (ORAL)
PERMETHRIN 1% CREAM RINSE (OTC) (TOPICAL) VRAYLAR CAPSULE, PACK (ORAL) FINASTERIDE 5 MG TABLET (not 1 MG) (ORAL) CHARLOTTE 24 FE CHEWABLE (ORAL)
PERMETHRIN 5% CREAM (TOPICAL) ZIPRASIDONE CAPSULE (ORAL) TAMSULOSIN CAPSULE (ORAL) CHATEAL-28 (not CHATEAL EQ) (ORAL)
PIPERONYL BUTOXIDE / PYRETHRINS SHAMPOO (OTC) (TOPICAL) ANTIVIRALS, ORAL TERAZOSIN CAPSULE (ORAL) CYCLAFEM 1-35-28, CYCLAFEM 7-7-7-28 (ORAL)
ACYCLOVIR CAPSULE, TABLET (ORAL) DASETTA 1-35-28 TABLET (ORAL)
ANTIPARKINSON'S AGENTS ACYCLOVIR SUSPENSION (ORAL) BRONCHODILATORS, BETA AGONIST DEBLITANE 0.35 MG TABLET (ORAL)
AMANTADINE CAPSULE, SOLUTION, TABLET (ORAL) FAMCICLOVIR TABLET (ORAL) ALBUTEROL NEB SOLN 100 MG/20 ML (INHALATION) DESOGESTREL / ETHINYL ESTRADIOL 0.15-0.03 MG (ORAL)
BENZTROPINE MES TABLET (ORAL) OSELTAMIVIR CAPSULE (ORAL) ALBUTEROL NEB SOLN 0.63, 1.25, 2.5 MG/3 ML (INHALATION) DROSPIRENONE-EE 3-0.02 MG TAB (ORAL)
CARBIDOPA / LEVODOPA TABLET (not ODT) (ORAL) OSELTAMIVIR SUSPENSION (ORAL) ALBUTEROL NEB SOLN 2.5 MG/0.5 ML (INHALATION) DROSPIRENONE-EE 3-0.03 MG TAB (ORAL)
CARBIDOPA / LEVODOPA ER TABLET (ORAL) VALACYCLOVIR TABLET (ORAL) ALBUTEROL SOLUTION, SYRUP (not TABLET) (ORAL) ELINEST-28 TABLET (ORAL)
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CONTRACEPTIVES, ORAL, CONT. CONTRACEPTIVES, ORAL, CONT. GLUCAGON AGENTS HEPATITIS C AGENTS
EMOQUETTE 28 DAY TABLET (ORAL) TRI-LINYAH (ORAL) BAQSIMI SPRAY (NASAL) PEGASYS SYRINGE, VIAL (SUBCUTANEOUS)
ENSKYCE 28 TABLET (ORAL) TRI-LO-ESTARYLLA (ORAL) GLUCAGON VIAL (INJECTION) PEG-INTRON KIT (SUBCUTANEOUS)
ERRIN 0.35 MG TABLET (ORAL) TRI-LO-MARZIA (ORAL) GLUCAGON EMERGENCY KIT (LILLY) (INJECTION) RIBAVIRIN 200 MG TABLET (not CAPSULE) (ORAL)
ESTARYLLA 0.25-0.035 MG (ORAL) TRI-LO-MILI (ORAL) PROGLYCEM SUSPENSION (ORAL)
ETHYNODIOL/ETHINYL ESTRADIOL 1MG-50MCG (ORAL) TRI-LO-SPRINTEC (ORAL) ZEGALOGUE AUTOINJECTOR (not SYRINGE) (SUBCUTAN.) ***CURATIVE HEPATITIS C AGENTS REQUIRE***
FALMINA-28 (ORAL) TRI-PREVIFEM (ORAL) GLUCOCORTICOIDS, INHALED ***HEPATITIS C FORM***
GIANVI 3 MG-0.02 MG (ORAL) TRI-SPRINTEC (ORAL) ADVAIR DISKUS (INHALATION) SOFOSBUVIR / VELPATASVIR TABLET (ORAL)
HEATHER 0.35 MG TABLET (ORAL) TRIVORA-28 (ORAL) ADVAIR HFA (INHALATION) MAVYRET TABLET (ORAL)
ISIBLOOM 28 (ORAL) VIENVA-28 (ORAL) ASMANEX TWISTHALER (not HFA) (INHALATION) VOSEVI TABLET (ORAL)
JENCYCLA 0.35 MG (ORAL) WERA (ORAL) BREO ELLIPTA (INHALATION)
JULEBER-28 (ORAL) BUDESONIDE 0.25, 0.5, 1 MG RESPULES (INHALATION)
JUNEL 1 MG/20 MCG, JUNEL 1.5 MG/30 MCG (ORAL) COPD AGENTS DULERA INHALER (INHALATION) HISTAMINE II RECEPTOR BLOCKER
JUNEL FE 1 MG/20 MCG, JUNEL FE 1.5 MG /30 MCG (not 24) (ORAALBL)U TEROL / IPRATROPIUM NEB SOLUTION (INHALATION) FLOVENT DISKUS (INHALATION) CIMETIDINE 200 MG OTC TABLET (not RX) (ORAL)
KURVELO 28 (ORAL) ANORO ELLIPTA (INHALATION) FLOVENT HFA (INHALATION) FAMOTIDINE SUSPENSION (ORAL)
LARIN FE 1/20, LARIN FE 1.5/30 (ORAL) (not 24) ATROVENT 17 MCG HFA (INHALATION) PULMICORT FLEXHALER (INHALATION) FAMOTIDINE TABLET (Rx and OTC) (ORAL)
LARISSIA-28 (ORAL) COMBIVENT RESPIMAT (INHALATION) SYMBICORT INHALER (INHALATION) HYPOGLYCEMICS, ALPHA-GLUCOSIDASE INHIBITORS
LESSINA-28 (ORAL) DALIRESP TABLET (ORAL) TRELEGY ELLIPTA (INHALATION) ACARBOSE TABLET (ORAL)
LEVONOR-ETH ESTRADIOL-28 0.1/0.02 (ORAL) (not 91) IPRATROPIUM BR 0.02% SOLUTION (INHALATION)
LEVONOR-ETH ESTRADIOL-28 0.15/0.03 (ORAL) (not 91) SPIRIVA HANDIHALER (not RESPIMAT) (INHALATION) GLUCOCORTICOIDS, ORAL HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS
LEVORA-28 (ORAL) STIOLTO RESPIMAT (INHALATION) BUDESONIDE EC CAPSULE (ORAL) BYDUREON PEN INJECT (not BCISE) (SUBCUTANEOUS)
LILLOW-28 (ORAL) DEXAMETHASONE TABLET (ORAL) BYETTA DOSE PEN (SUBCUTANEOUS)
LO LOESTRIN FE (ORAL) CYTOKINE & CAM ANTAGONISTS ‡ HYDROCORTISONE TABLET (ORAL) JANUMET TABLET (ORAL)
LOESTRIN 21 1/20, LOESTRIN 21 1.5/30 (ORAL) (STEP THERAPY CATEGORY) METHYLPREDNISOLONE DOSE PACK (4 MG) (ORAL) JANUMET XR TABLET (ORAL)
LOESTRIN FE 1/20, LOESTRIN FE 1/5.30 (ORAL) ENBREL DISP SYRINGE, KIT, PEN (INJECTION) PREDNISOLONE 15 MG/5 ML SOLUTION (ORAL) JANUVIA TABLET (ORAL)
LORYNA 3 MG-0.02 MG (ORAL) ENBREL MINI CARTRIDGE (SUBCUTANE.) PREDNISOLONE 5 MG/5 ML SOLUTION (ORAL) JENTADUETO TABLET (IR) (not XR) (ORAL)
LOSEASONIQUE (ORAL) ENBREL VIAL (SUBCUTANEOUS) PREDNISOLONE SOD PH 25MG/5 ML SOLUTION (ORAL) ONGLYZA TABLET (ORAL)
LOW-OGESTREL-28 (ORAL) HUMIRA KIT, PEN INJ KIT (INJECTION) PREDNISONE TABLET (not DOSE PACK) (ORAL) OZEMPIC (SUBCUTANE.)
LO-ZUMANDIMINE (ORAL) OTEZLA STARTER PACK, TABLET (ORAL) TRADJENTA TABLET (ORAL)
MARLISSA-28 (ORAL) TRULICITY PEN (SUBCUTANE.)
MELODETTA 24 FE CHEWABLE (ORAL) EMOLLIENTS GROWTH FACTORS VICTOZA PEN (SUBCUTANEOUS)
MICROGESTIN FE 1.5-30 TABLET (ORAL) AMMONIUM LACTATE 12% CREAM (TOPICAL) INCRELEX VIAL (SUBCUTANEOUS)
MICROGESTIN FE 1-20 TABLET (ORAL) AMMONIUM LACTATE 12% LOTION (TOPICAL) HYPOGLYCEMICS, INSULIN & RELATED AGENTS
MILI 0.25-0.035 MG(ORAL) GROWTH HORMONE HUMALOG 100 UNIT/ML CARTRIDGE (SUBCUTANEOUS)
MIRCETTE-28 (ORAL) ENZYME REPLACEMENT, GAUCHERS DISEASE GENOTROPIN CARTRIDGE (INJECTION) HUMALOG 100 UNIT/ML KWIKPEN (not 200 UNIT/ML) (SUBCUTANEOUS)
MONO-LINYAH-28 (ORAL) ZAVESCA 100 MG CAPSULE (ORAL) GENOTROPIN MINIQUICK (INJECTION) HUMALOG 100 UNIT/ML VIAL (not 200 UNIT/ML) (SUBCUTANEOUS)
NATAZIA-28 (ORAL) NORDITROPIN FLEXPRO (INJECTION) HUMALOG JR 100 UNIT/ML KWIKPEN (SUBCUTANEOUS)
NIKKI 3 MG-0.02 MG (ORAL) EPINEPHRINE, SELF-INJECTED HUMALOG MIX 50-50 KWIKPEN, VIAL (SUBCUTANEOUS)
NORETHINDRONE 0.35 (ORAL) EPINEPHRINE 0.15 MG (49502-0101-02) (INJECTION) H. PYLORI TREATMENT HUMALOG MIX 75-25 KWIKPEN, VIAL (SUBCUTANEOUS)
NORETHINDRONE/ETHINYL ESTRADIOL 1-0.02 MG (ORAL) EPINEPHRINE 0.3 MG (49502-0102-02) (INJECTION) PYLERA CAPSULE (ORAL) HUMULIN 70/30 KWIKPEN OTC (SUBCUTANE.)
NORETHINDRONE/ETHINYL ESTRADIOL 1.5-0.03 MG(21) (ORAL)EPIPEN AUTO-INJECTOR (INTRAMUSC) HUMULIN 70/30 VIAL OTC (SUBCUTANEOUS)
NORETHINDRONE/ETHINYL ESTRADIOL FE MONOPHASIC (LOEEPSITPREINN JR24 FAEU)T (OO-RINAJEL)CTOR (INTRAMUSC) HUMULIN N 100 UNITS/ML VIAL (not KWIKPEN) (SUBCUTANEOUS)
NORGESTIMATE/ETHINYL ESTRADIOL MONOPHASIC 0.25-0.035 MG (ORAL) HEMOPHILIA TREATMENT HUMULIN R 100 UNITS/ML VIAL (SUBCUTANEOUS)
NORGESTIMATE/ETHINYL ESTRADIOL TRIPHASIC (ORAL) ERYTHROPOIESIS STIMULATING PROTEINS ALPHANATE VIAL (INTRAVEN.) HUMULIN R 500 UNITS/ML KWIKPEN, VIAL (SUBCUTANEOUS)
NORLYDA 0.35 MG (ORAL) (DX CODE REQUIRED - ARANESP and RETACRIT) BENEFIX KIT (INTRAVEN.) INSULIN ASPART 100 UNIT/ML CARTRIDGE, PEN, VIAL (SUBCUTANEOUS)
PHILITH 0.4-0.035 MG (ORAL) ARANESP DISP SYRIN, VIAL (INJECTION) (DX CODE REQ.) COAGADEX VIAL (INTRAVEN) INSULIN ASPART PROT (MIX 70-30) FLEXPEN, VIAL (SUBCUTANEOUS)
PIMTREA (ORAL) RETACRIT VIAL (INJECTION) (DX CODE REQ.) CORIFACT KIT (INTRAVEN) INSULIN LISPRO 100 UNIT/ML PEN (SUBCUTANEOUS)
PIRMELLA 1-35 28, PIRMELLA 7-7-7-28 (ORAL) FEIBA NF (INTRAVEN) INSULIN LISPRO 100 UNIT/ML VIAL (SUBCUTANEOUS)
PORTIA-28 (ORAL) FLUOROQUINOLONES, ORAL HEMLIBRA VIAL (SUBCUTANE.) INSULIN LISPRO JR 100 UNIT/ML KWIKPEN (SUBCUTANEOUS)
PREVIFEM (ORAL) CIPRO SUSPENSION (ORAL) HUMATE-P KIT (INTRAVEN.) INSULIN LISPRO MIX 75-25 KWIKPEN (SUBCUTANEOUS)
RECLIPSEN-28 (ORAL) CIPROFLOXACIN TABLET (IR) (ORAL) NOVOEIGHT VIAL (INTRAVEN) LANTUS SOLOSTAR (SUBCUTANEOUS)
SEASONIQUE (ORAL) LEVOFLOXACIN TABLET (ORAL) NUWIQ VIAL (INTRAVEN) LANTUS VIAL (SUBCUTANEOUS)
SHAROBEL 0.35 MG (ORAL) SEVENFACT VIAL(INTRAVEN) LEVEMIR FLEXTOUCH (SUBCUTANEOUS)
SPRINTEC-28 (ORAL) GI MOTILITY, CHRONIC WILATE VIAL (INTRAVEN) LEVEMIR VIAL (SUBCUTANEOUS)
SRONYX 0.1/0.02 (ORAL) AMITIZA CAPSULE (ORAL) XYNTHA KIT (INTRAVEN) NOVOLOG 100 UNIT/ML CARTRIDGE, FLEXPEN, VIAL (SUBCUTANEOUS)
SYEDA-28 (ORAL) LINZESS CAPSULE (ORAL) XYNTHA SOLOFUSE SYRINGE KIT (INTRAVEN.) NOVOLOG MIX 70-30 FLEXPEN (SUBCUTANEOUS)
TRI FEMYNOR (ORAL) MOVANTIK TABLET (ORAL) TRESIBA FLEXTOUCH (not VIAL) (SUBCUTANEOUS)
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HYPOGLYCEMICS, MEGLITINIDES INTRANASAL RHINITIS AGENTS MACROLIDES/KETOLIDES ONCOLOGY, ORAL - BREAST
NATEGLINIDE TABLET (ORAL) AZELASTINE 0.1% SPRAY 137MCG (not 0.15%) (NASAL) AZITHROMYCIN 1 GM POWDER PACKET (ORAL) ANASTROZOLE TABLET (ORAL)
REPAGLINIDE TABLET (ORAL) FLUTICASONE PROP 50 MCG SPRAY (RX & OTC) (NASAL) AZITHROMYCIN SUSPENSION, TABLET (ORAL) CAPECITABINE TABLET (ORAL)
IPRATROPIUM 0.03%, 0.06% SPRAY (NASAL) CLARITHROMYCIN IR TABLET (not ER) (ORAL) CYCLOPHOSPHAMIDE CAPSULE, TABLET (ORAL)
TRIAMCINOLONE 55 MCG SPRAY OTC (NASAL) ERYTHROMYCIN ETHYLSUCCINATE 200 SUSPENSION (AG) (OERXAEL)MESTANE TABLET (ORAL)
ERYTHROMYCIN BASE TABLET DR (ORAL) IBRANCE CAPSULE (not TABLET) (ORAL)
ERYTHROCIN 250 MG FILMTAB (ORAL) LETROZOLE TABLET (ORAL)
HYPOGLYCEMICS, METFORMINS ERYTHROMYCIN DR 250 MG CAPSULE (not FILMTAB) (ORAL) TAMOXIFEN CITRATE TABLET (ORAL)
GLIPIZIDE-METFORMIN TABLET (ORAL) ERYTHROMYCIN DR TABLET (not ES 400MG) (ORAL)
GLUMETZA (ORAL)
GLYBURIDE-METFORMIN TABLET (ORAL) IRON, ORAL
METFORMIN IR TABLET (ORAL) CHILD FERROUS SULFATE 15 MG/ML DROPS OTC (ORAL)
METFORMIN ER TABLET (generic GLUCOPHAGE XR) (ORAL) FERATE 27 MG OTC TABLET (ORAL) METHOTREXATE
FERROUS FUMARATE 324 MG OTC TABLET (ORAL) METHOTREXATE SODIUM PF VIAL (INJECTION)
HYPOGLYCEMICS, SGLT2 FERROUS GLUCONATE 324 MG OTC TABLET (ORAL) METHOTREXATE TABLET, VIAL (ORAL)
FARXIGA TABLET (ORAL) FERROUS SULFATE 15 MG/ML DROPS OTC (ORAL)
INVOKAMET TABLET (not XR) (ORAL) FERROUS SULF 44 MG IRON/5ML LIQUID OTC (ORAL) MOVEMENT DISORDERS
INVOKANA TABLET (ORAL) FERROUS SULFATE 65 MG TABLET OTC (ORAL) AUSTEDO TABLET (ORAL)
JARDIANCE TABLET (ORAL) FERROUS SULFATE 300 MG/5 ML LIQUID OTC (ORAL) INGREZZA CAPSULE (ORAL)
SYNJARDY TABLET (not XR) (ORAL) FERROUS SULFATE 220 MG/5 ML ELIXIR OTC (ORAL) INGREZZA INITIATION PACK (ORAL) ONCOLOGY, ORAL - HEMATOLOGIC
XIGDUO XR TABLET (ORAL) FERROUS SULFATE 300 MG/6.8ML SOLUTION OTC (ORAL) TETRABENAZINE TABLET (ORAL) ALKERAN TABLET (ORAL)
FERROUS SULFATE 325 MG OTC (ORAL) BOSULIF TABLET (ORAL)
FERROUS SULFATE EC 324 MG OTC TABLET (ORAL) BRUKINSA CAPSULE (ORAL)
HYPOGLYCEMICS, TZD FERROUS SULFATE EC 325 MG OTC TABLET (ORAL) MULTIPLE SCLEROSIS AGENTS CALQUENCE CAPSULE (ORAL)
PIOGLITAZONE TABLET (ORAL) IFEREX 150, IFEREX 150 FORTE CAPSULE (OTC) (ORAL) AVONEX PEN, PREFILLED SYRINGE, VIAL (INTRAMUSC.) COPIKTRA CAPSULE (ORAL)
IRON 45 MG TABLET OTC (ORAL) BETASERON 0.3 MG KIT (not VIAL) (SUBCUTANEOUS) DAURISMO TABLET (ORAL)
IRON-VITAMIN C 100-250 MG TABLET OTC (ORAL) DIMETHYL FUMARATE DR (ORAL) FARYDAK CAPSULE (ORAL)
IDIOPATHIC PULMONARY FIBROSIS POLYSACCHARIDE IRON 150 MG CAPSULE OTC (ORAL) DIMETHYL FUMARATE DR STARTER PACK (ORAL) HYDROXYUREA CAPSULE (ORAL)
OFEV CAPSULE (ORAL) SLOW RELEASE IRON OTC TABLET (ORAL) ICLUSIG TABLET (ORAL)
COPAXONE 20 MG/ML SYRINGE (not 40 MG/ML) (SUBCUTANEOUS)
TRICON CAPSULE OTC (ORAL) IDHIFA TABLET (ORAL)
IMATINIB TABLET (ORAL)
IMMUNOMODULATORS, ASTHMA IMBRUVICA CAPSULE, TABLET (ORAL)
FASENRA PEN, SYRINGE (SUBCUTANEOUS) LEUKOTRIENE MODIFIERS NEUROPATHIC PAIN INQOVI TABLET (ORAL)
XOLAIR SYRINGE, VIAL (SUBCUTANEOUS) MONTELUKAST CHEW TABLET (not GRANULES) (ORAL) CAPSAICIN 0.025%, 0.075%, 0.1% CREAM (OTC) (TOPICAL) INREBIC CAPSULE (ORAL)
MONTELUKAST TABLET (ORAL) CAPSAICIN 0.15% LIQUID (OTC) (TOPICAL) JAKAFI TABLET (ORAL)
IMMUNOMODULATORS, ATOPIC DERMATITIS DULOXETINE 20MG, 30MG, 60MG CAPSULES (not 40MG) (ORAL)LE UKERAN TABLET (ORAL)
ELIDEL 1% CREAM (TOPICAL) GABAPENTIN CAPSULE (ORAL) MATULANE CAPSULE (ORAL)
EUCRISA 2% OINTMENT (TOPICAL) LIPOTROPICS, OTHER GABAPENTIN TABLET (ORAL) MERCAPTOPURINE TABLET (ORAL)
CHOLESTYRAMINE PACKET (with SUCROSE) (not LIGHT) (ORAL) MYLERAN TABLET (ORAL)
PROTOPIC 0.03% OINTMENT (TOPICAL) LIDODERM 5% PATCH (TOPICAL)
PROTOPIC 0.1% OINTMENT (TOPICAL) COLESTIPOL TABLET (not PACKET) (ORAL) LYRICA CAPSULE (IR) (not CR) (ORAL) NINLARO CAPSULE (ORAL)
EZETIMIBE TABLET (ORAL) PREGABALIN CAPSULE (ORAL) ONUREG TABLET (ORAL)
FENOFIBRATE 67MG, 134MG, 200MG CAPSULE (ORAL) POMALYST CAPSULE (ORAL)
IMMUNOMODULATORS, TOPICAL FENOFIBRATE 48MG, 54MG, 145MG, 160MG TABLET (ORAL) REVLIMID CAPSULE (ORAL)
IMIQUIMOD 5% CREAM PACKET (not 3.75%) (TOPICAL) GEMFIBROZIL TABLET (ORAL) RYDAPT CAPSULE (ORAL)
PODOFILOX 0.5% SOLUTION (TOPICAL) NIACIN CAPLET, CAPSULE, TABLET (RX & OTC) (ORAL) NSAIDS SCEMBLIX TABLET (ORAL)
NIACIN ER TABLET CELECOXIB CAPSULES (ORAL)* SPRYCEL TABLET (ORAL)
OMEGA-3 ACID ETHYL ESTERS 1GM CAPSULE (ORAL) DICLOFENAC 1% GEL (TOPICAL) TABLOID TABLET (ORAL)
IMMUNOSUPPRESSIVES, ORAL DICLOFENAC SODIUM DR & EC TABLET (not ER 100 MG) (ORAL)TASIGNA CAPSULE (ORAL)
AZATHIOPRINE TABLET (ORAL) IBUPROFEN SUSPENSION, TABLET (ORAL) THALOMID CAPSULE (ORAL)
CELLCEPT SUSPENSION (ORAL) INDOMETHACIN CAPSULE (IR) (not ER 75 MG) (ORAL) TIBSOVO TABLET (ORAL)
CYCLOSPORINE MODIFIED CAPSULE (not 50MG) (ORAL) LIPOTROPICS, STATINS ‡ MELOXICAM TABLET (not CAPSULE) (ORAL) TRETINOIN CAPSULE (ORAL)
CYCLOSPORINE MODIFIED SOLUTION (ORAL) (STEP THERAPY CATEGORY) NABUMETONE TABLET (ORAL) UKONIQ TABLET (ORAL)
EVEROLIMUS TABLET (ORAL) ATORVASTATIN TABLET (ORAL) NAPROXEN 250MG, 375MG, 500MG TABLET (not DR or ER) (ORAVL)ENCLEXTA TABLET, STARTING PACK (ORAL)
GENGRAF CAPSULE, SOLUTION (ORAL) LOVASTATIN TABLET (ORAL) NAPROXEN SUSPENSION (ORAL) XOSPATA TABLET (ORAL)
MYCOPHENOLATE MOFETIL CAPSULE, TABLET (ORAL) PRAVASTATIN TABLET (ORAL) SULINDAC TABLET (ORAL) XPOVIO WEEKLY DOSE (ORAL)
RAPAMUNE SOLUTION (not TABLET) (ORAL) ROSUVASTATIN TABLET (ORAL) ZOLINZA CAPSULE (ORAL)
TACROLIMUS CAPSULE (ORAL) SIMVASTATIN TABLET (ORAL) ZYDELIG TABLET (ORAL)
1-1-2023 Page 4
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