Elite Formulary Drug List
EFFECTIVE: JANUARY 1, 2026
About this drug list
This is a list of the medications included in your prescription plan. It is not, however, a complete list of products that are on the formulary, nor does it guarantee coverage. Please ask your prescriber to consider preferred medications from this list when medically appropriate.
How to read this drug list
Use the chart below to help you read this drug list. This chart is just an example. It may not show how these medications are actually covered on the 2026 Elite Formulary List. Medications are listed by the condition they treat, then listed alphabetically.
The formulary is the list of drugs included in your prescription plan. Ask your prescriber to consider PREFERRED medications from this list when medically appropriate. Inclusion on the list does not guarantee coverage. The following list is not a complete list of products that are on the formulary.
Newly FDA approved medications are subject to evaluation by the Plan for coverage status and formulary placement prior to inclusion in the Prescription Drug Benefit including the Specialty Drug Benefit.
Abbreviations next to medications
In this drug list, formulary status (i.e., generic, preferred, or non-preferred) and extra coverage requirements (i.e., prior authorization) are indicated to the right of the medication. Here’s what they mean:
(G)
(P)
(NP)
Generic Medication
Generic medications are denoted by (G). The most affordable medications.
Preferred Medication
Preferred medications are denoted by (P). Ask your doctor about choosing a preferred medication.
Non-Preferred Medication
Non-preferred medications are denoted by (NP). The more expensive medications.
(EX)
(SP)
(PA)
Excluded Medication
Excluded medications are denoted by (EX). The medications your plan does not cover.
Specialty Medication
Some medications are considered specialty medications. These medications are denoted by (SP) and are available through our specialty pharmacy network.
Prior Authorization
Certain medications require VerusRx’s approval before they are covered by your plan. These medications are denoted by (PA). Unless your doctor requests and receives approval from VerusRx, your plan will not cover these medications.
Abbreviations next to medications
Medications are organized into groups in the table below. First, identify the appropriate group for your medication, then navigate to that section to view the covered medications. If you cannot find your medication within a group, please use the search feature or contact our customer service team for assistance.
This list contains injectable medical drugs covered under medical policies. For specific questions about your coverage, please call the phone number printed on your member ID card.
For the Health Care Provider: Please prescribe PREFERRED products and allow generic substitutions when medically appropriate.
| DRUG CLASS | DRUG NAME | FORMULARY STATUS | SPECIALTY (SP) | PRIOR AUTHORIZATION (PA) |
|---|---|---|---|---|
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | ADDERALL | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | ADDERALL XR | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | AMPHETAMINE SULFATE | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | AMPHETAMINE/DEXTROAMPHETA MINE | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | AMPHETAMINE/DEXTROAMPHETA MINE ER | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | APTENSIO XR | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | ARMODAFINIL | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | ATOMOXETINE | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | ATOMOXETINE HYDROCHLORIDE | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | AZSTARYS | EXCLUDED | PA | |
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | CAFFEINE CITRATE | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | CAFFEINE CITRATE | PREFERRED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | CAFFEINE/SODIUM BENZOATE | PREFERRED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | CLONIDINE HCL ER | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | CLONIDINE HYDROCHLORIDE E R | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | CONCERTA | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | DAYTRANA | EXCLUDED | PA | |
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | DEXMETHYLPHENIDATE HCL | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | DEXMETHYLPHENIDATE HYDROC HLORIDE | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | DEXMETHYLPHENIDATE HYDROC HLORIDE ER | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | DEXTROAMPHETAMINE SULFATE | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | DEXTROAMPHETAMINE SULFATE | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | DEXTROAMPHETAMINE SULFATE ER | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | DIETHYLPROPION HYDROCHLOR IDE ER | PREFERRED | PA | |
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | DOPRAM | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | DYANAVEL XR | PREFERRED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | EVEKEO | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | FOCALIN | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | FOCALIN XR | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | GUANFACINE HYDROCHLORIDE ER | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | INTUNIV | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | JORNAY PM | NON-PREFERRED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | LISDEXAMFETAMINE DIMESYLA TE | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | METADATE CD | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | METHAMPHETAMINE HYDROCHLO RIDE | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | METHYLIN | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | METHYLPHENIDATE | GENERIC | PA | |
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | METHYLPHENIDATE HYDROCHLO RIDE | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | METHYLPHENIDATE HYDROCHLO RIDE ER | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | METHYLPHENIDATE HYDROCHLO RIDE ER | PREFERRED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | METHYLPHENIDATE HYDROCHLO RIDE ER (CD) | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | METHYLPHENIDATE HYDROCHLO RIDE ER (LA) | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | METHYLPHENIDATE HYDROCHLO RIDE ER (OSM) | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | METHYLPHENIDATE HYDROCHLO RIDE ER (XR) | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | MODAFINIL | GENERIC | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | NUVIGIL | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | ONYDA XR | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | PROCENTRA | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | PROVIGIL | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | QELBREE | EXCLUDED | PA | |
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | QUILLICHEW ER | PREFERRED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | QUILLIVANT XR | PREFERRED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | RELEXXII | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | RITALIN | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | RITALIN LA | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | VYVANSE | EXCLUDED | ||
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | WAKIX | NON-PREFERRED | SP | PA |
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | XELSTRYM | EXCLUDED | PA | |
| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | ZENZEDI | EXCLUDED | ||
| AMINOGLYCOSIDES | AMIKACIN SULFATE | GENERIC | ||
| AMINOGLYCOSIDES | ARIKAYCE | PREFERRED | SP | PA |
| AMINOGLYCOSIDES | BETHKIS | EXCLUDED | SP | PA |
| AMINOGLYCOSIDES | GENTAMICIN SULFATE | GENERIC | ||
| AMINOGLYCOSIDES | GENTAMICIN SULFATE PEDIAT RIC | GENERIC | ||
| AMINOGLYCOSIDES | GENTAMICIN SULFATE/0.9% S ODIUM CHLORIDE | PREFERRED | ||
| AMINOGLYCOSIDES | HUMATIN | EXCLUDED | ||
| AMINOGLYCOSIDES | ISOTONIC GENTAMICIN | PREFERRED | ||
| AMINOGLYCOSIDES | KITABIS PAK | EXCLUDED | SP | PA |
| AMINOGLYCOSIDES | NEOMYCIN SULFATE | GENERIC | ||
| AMINOGLYCOSIDES | STREPTOMYCIN SULFATE | PREFERRED | ||
| AMINOGLYCOSIDES | TOBI | EXCLUDED | SP | PA |
| AMINOGLYCOSIDES | TOBI PODHALER | PREFERRED | SP | PA |
| AMINOGLYCOSIDES | TOBRAMYCIN | GENERIC | SP | PA |
| AMINOGLYCOSIDES | TOBRAMYCIN | PREFERRED | SP | PA |
| AMINOGLYCOSIDES | TOBRAMYCIN SULFATE | GENERIC | ||
| AMINOGLYCOSIDES | TOBRAMYCIN SULFATE | PREFERRED | ||
| AMINOGLYCOSIDES | ZEMDRI | NON-PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | ABRILADA | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ABRILADA 1-PEN KIT | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ABRILADA 2-PEN KIT | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ACTEMRA | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ACTEMRA ACTPEN | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-AACF (2 PEN) | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-AACF (2 SYRING E) | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-AACF STARTER P ACK/CD/UC/HS (6 PEN) | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-AACF STARTER P ACK/PSORIASIS/UVEITIS (4 PEN) | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-AATY 1-PEN KIT | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-AATY 2-PEN KIT | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-AATY 2-SYRINGE | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-AATY CD/UC/HS STARTER | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-ADAZ | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-ADBM | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-FKJP | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-RYVK | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ADALIMUMAB-RYVK (2 PEN) | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | AMJEVITA | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ARAVA | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | ARCALYST | NON-PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ARTHROTEC 50 | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | ARTHROTEC 75 | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | AURANOFIN | PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | CALDOLOR | NON-PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | CALDOLOR | PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | CELEBREX | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | CELECOXIB | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | COMBOGESIC | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | COXANTO | PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | CYLTEZO | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | CYLTEZO STARTER PACKAGE F OR CROHNS DISEASE/UC/HS | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | CYLTEZO STARTER PACKAGE F OR PSORIASIS | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | DICLOFENAC POTASSIUM | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | DICLOFENAC SODIUM DR | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | DICLOFENAC SODIUM ER | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | DICLOFENAC SODIUM/MISOPRO STOL | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | ENBREL | NON-PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ENBREL | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ENBREL MINI | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ENBREL SURECLICK | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ETODOLAC | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | ETODOLAC ER | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | FENOPROFEN CALCIUM | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | FENOPRON | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | FLURBIPROFEN | PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | HADLIMA | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HADLIMA PUSHTOUCH | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HULIO | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HUMIRA | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HUMIRA | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HUMIRA PEN | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HUMIRA PEN | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HUMIRA PEN-CD/UC/HS START ER | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HUMIRA PEN-PS/UV STARTER | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HYRIMOZ | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HYRIMOZ PEDIATRIC CROHNS DISEASE STARTER PACK | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HYRIMOZ PEDIATRIC CROHN'S DISEASE STARTER PACK | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HYRIMOZ PLAQUE PSORIASIS STARTER PACK | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HYRIMOZ PLAQUE PSORIASIS/ UVEITIS STARTER PACK | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HYRIMOZ SENSOREADY CD/UC/ HS STARTER PACK | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | HYRIMOZ SENSOREADY PENS | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | IBU | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | IBUPROFEN | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | IBUPROFEN | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | IBUPROFEN LYSINE | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | ILARIS | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | INDOCIN | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | INDOCIN | EXCLUDED | PA | |
| ANALGESICS - ANTI-INFLAMMATORY | INDOMETHACIN | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | INDOMETHACIN | PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | INDOMETHACIN | EXCLUDED | PA | |
| ANALGESICS - ANTI-INFLAMMATORY | INDOMETHACIN | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | INDOMETHACIN ER | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | KETAMINE HYDROCHLORIDE/RO PIVACAINE HYDROCHLORIDE/KETOROLAC T | PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | KETOROLAC TROMETHAMINE | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | KETOROLAC TROMETHAMINE | PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | KETOROLAC TROMETHAMINE/BU PIVACAINE HYDROCHLORIDE/KETAMINE HY | PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | KEVZARA | NON-PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | KINERET | NON-PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | LEFLUNOMIDE | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | LODINE | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | LURBIRO | PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | MECLOFENAMATE SODIUM | PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | MELOXICAM | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | MELOXICAM | PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | NABUMETONE | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | NAPROXEN | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | NAPROXEN | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | NAPROXEN DR | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | NAPROXEN SODIUM | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | NEOPROFEN | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | OLUMIANT | NON-PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ORENCIA | NON-PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | ORENCIA CLICKJECT | NON-PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | OTEZLA | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | OTEZLA XR | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | OTEZLA/OTEZLA XR 28 DAY T REATMENT INITIATION PACK | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | OXAPROZIN | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | OXAPROZIN | PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | PIROXICAM | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | RIDAURA | PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | RINVOQ | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | RINVOQ LQ | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | SIMLANDI | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | SIMLANDI 1-PEN KIT | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | SIMLANDI 2-PEN KIT | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | SIMPONI | NON-PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | SIMPONI ARIA | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | SULINDAC | GENERIC | ||
| ANALGESICS - ANTI-INFLAMMATORY | TOFIDENCE | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | TOLECTIN 600 | NON-PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | TOLMETIN SODIUM | PREFERRED | ||
| ANALGESICS - ANTI-INFLAMMATORY | TRESNI | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | TYENNE | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | XELJANZ | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | XELJANZ XR | EXCLUDED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | XIFYRM | EXCLUDED | ||
| ANALGESICS - ANTI-INFLAMMATORY | YUFLYMA 1-PEN KIT | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | YUFLYMA 2-PEN KIT | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | YUFLYMA 2-SYRINGE KIT | PREFERRED | SP | PA |
| ANALGESICS - ANTI-INFLAMMATORY | YUFLYMA CD/UC/HS STARTER | PREFERRED | SP | PA |
| ANALGESICS - NonNarcotic | ACETAMINOPHEN | GENERIC | ||
| ANALGESICS - NonNarcotic | ACETAMINOPHEN | EXCLUDED | ||
| ANALGESICS - NonNarcotic | BAC | GENERIC | ||
| ANALGESICS - NonNarcotic | BUTALBITAL/ACETAMINOPHEN | GENERIC | ||
| ANALGESICS - NonNarcotic | BUTALBITAL/ACETAMINOPHEN/ CAFFEINE | GENERIC | ||
| ANALGESICS - NonNarcotic | BUTALBITAL/ASPIRIN/CAFFEI NE | GENERIC | ||
| ANALGESICS - NonNarcotic | CLONIDINE HCL | PREFERRED | ||
| ANALGESICS - NonNarcotic | CLONIDINE HCL | GENERIC | ||
| ANALGESICS - NonNarcotic | CLONIDINE HYDROCHLORIDE | GENERIC | ||
| ANALGESICS - NonNarcotic | DIFLUNISAL | GENERIC | ||
| ANALGESICS - NonNarcotic | DOLOBID | EXCLUDED | ||
| ANALGESICS - NonNarcotic | DURACLON | EXCLUDED | ||
| ANALGESICS - NonNarcotic | FIORICET | PREFERRED | ||
| ANALGESICS - NonNarcotic | JOURNAVX | NON-PREFERRED | ||
| ANALGESICS - NonNarcotic | LOTREXONE | EXCLUDED | ||
| ANALGESICS - NonNarcotic | NALTREX | EXCLUDED | ||
| ANALGESICS - NonNarcotic | PRIALT | NON-PREFERRED | SP | PA |
| ANALGESICS - NonNarcotic | SALSALATE | PREFERRED | ||
| ANALGESICS - NonNarcotic | TENCON | PREFERRED | ||
| ANALGESICS - OPIOID | ACETAMINOPHEN/CAFFEINE/DI HYDROCODEINE | EXCLUDED | ||
| ANALGESICS - OPIOID | ACETAMINOPHEN/CODEINE | PREFERRED | ||
| ANALGESICS - OPIOID | ACETAMINOPHEN/CODEINE | GENERIC | ||
| ANALGESICS - OPIOID | ACETAMINOPHEN/CODEINE PHO SPHATE | GENERIC | ||
| ANALGESICS - OPIOID | ASCOMP/CODEINE | GENERIC | ||
| ANALGESICS - OPIOID | BELBUCA | PREFERRED | PA | |
| ANALGESICS - OPIOID | BRIXADI | PREFERRED | SP | PA |
| ANALGESICS - OPIOID | BUPRENORPHINE | GENERIC | PA | |
| ANALGESICS - OPIOID | BUPRENORPHINE HCL | GENERIC | ||
| ANALGESICS - OPIOID | BUPRENORPHINE HCL | EXCLUDED | ||
| ANALGESICS - OPIOID | BUPRENORPHINE HCL/NALOXON E HCL | GENERIC | ||
| ANALGESICS - OPIOID | BUPRENORPHINE HYDROCHLORI DE | GENERIC | ||
| ANALGESICS - OPIOID | BUPRENORPHINE HYDROCHLORI DE | EXCLUDED | ||
| ANALGESICS - OPIOID | BUPRENORPHINE HYDROCHLORI DE/NALOXONE HYDROCHLORIDE | GENERIC | ||
| ANALGESICS - OPIOID | BUTALBITAL/ACETAMINOPHEN/ CAFFEINE/CODEINE | GENERIC | ||
| ANALGESICS - OPIOID | BUTALBITAL/ASPIRIN/CAFFEI NE/CODEINE | GENERIC | ||
| ANALGESICS - OPIOID | BUTORPHANOL TARTRATE | PREFERRED | ||
| ANALGESICS - OPIOID | BUTRANS | EXCLUDED | PA | |
| ANALGESICS - OPIOID | CODEINE SULFATE | PREFERRED | ||
| ANALGESICS - OPIOID | CODEINE SULFATE | GENERIC | ||
| ANALGESICS - OPIOID | DEMEROL | EXCLUDED | ||
| ANALGESICS - OPIOID | DILAUDID | NON-PREFERRED | ||
| ANALGESICS - OPIOID | DILAUDID | PREFERRED | ||
| ANALGESICS - OPIOID | DILAUDID | EXCLUDED | ||
| ANALGESICS - OPIOID | DISKETS | EXCLUDED | PA | |
| ANALGESICS - OPIOID | DURAMORPH | NON-PREFERRED | ||
| ANALGESICS - OPIOID | ENDOCET | GENERIC | ||
| ANALGESICS - OPIOID | FENTANYL | GENERIC | PA | |
| ANALGESICS - OPIOID | FENTANYL CITRATE | PREFERRED | PA | |
| ANALGESICS - OPIOID | FENTANYL CITRATE | EXCLUDED | PA | |
| ANALGESICS - OPIOID | FENTANYL CITRATE/BUPIVACA INE HYDROCHLORIDE | PREFERRED | ||
| ANALGESICS - OPIOID | FENTANYL CITRATE/BUPIVACA INE HYDROCHLORIDE/SODIUM CHLORIDE | PREFERRED | ||
| ANALGESICS - OPIOID | FENTANYL CITRATE/ROPIVACA INE HYDROCHLORIDE | EXCLUDED | ||
| ANALGESICS - OPIOID | FENTANYL CITRATE/ROPIVACA INE HYDROCHLORIDE/SODIUM CHLORIDE | PREFERRED | ||
| ANALGESICS - OPIOID | FENTANYL CITRATE/ROPIVACA INE HYDROCHOLRIDE/SODIUM CHLORIDE | PREFERRED | ||
| ANALGESICS - OPIOID | FENTANYL CITRATE/SODIUM C HLORIDE | PREFERRED | PA | |
| ANALGESICS - OPIOID | FENTANYL CITRATE/SODIUM C HLORIDE | EXCLUDED | PA | |
| ANALGESICS - OPIOID | FENTANYL/BUPIVACAINE/NACL | PREFERRED | ||
| ANALGESICS - OPIOID | FENTANYL/ROPIVACAINE HYDR OCHLORIDE/SODIUM CHLORIDE | PREFERRED | ||
| ANALGESICS - OPIOID | HYDROCODONE BITARTRATE/AC ETAMINOPHEN | GENERIC | ||
| ANALGESICS - OPIOID | HYDROCODONE BITARTRATE/AC ETAMINOPHEN | PREFERRED | ||
| ANALGESICS - OPIOID | HYDROCODONE BITARTRATE/AC ETAMINOPHEN | EXCLUDED | ||
| ANALGESICS - OPIOID | HYDROCODONE/ACETAMINOPHEN | GENERIC | ||
| ANALGESICS - OPIOID | HYDROCODONE/IBUPROFEN | GENERIC | ||
| ANALGESICS - OPIOID | HYDROCODONE/IBUPROFEN | PREFERRED | ||
| ANALGESICS - OPIOID | HYDROMORPHONE HCL | GENERIC | ||
| ANALGESICS - OPIOID | HYDROMORPHONE HCL | PREFERRED | ||
| ANALGESICS - OPIOID | HYDROMORPHONE HCL ER | GENERIC | ||
| ANALGESICS - OPIOID | HYDROMORPHONE HCL/SODIUM CHLORIDE | PREFERRED | ||
| ANALGESICS - OPIOID | HYDROMORPHONE HYDROCHLORI DE | PREFERRED | ||
| ANALGESICS - OPIOID | HYDROMORPHONE HYDROCHLORI DE | GENERIC | ||
| ANALGESICS - OPIOID | HYDROMORPHONE HYDROCHLORI DE | EXCLUDED | ||
| ANALGESICS - OPIOID | HYDROMORPHONE HYDROCHLORI DE ER | GENERIC | ||
| ANALGESICS - OPIOID | HYDROMORPHONE HYDROCHLORI DE/SODIUM CHLORIDE | PREFERRED | ||
| ANALGESICS - OPIOID | HYDROMORPHONE HYDROCHLORI DE/SODIUM CHLORIDE | EXCLUDED | ||
| ANALGESICS - OPIOID | INFUMORPH 200 | NON-PREFERRED | ||
| ANALGESICS - OPIOID | INFUMORPH 500 | NON-PREFERRED | ||
| ANALGESICS - OPIOID | MEPERIDINE HCL | EXCLUDED | ||
| ANALGESICS - OPIOID | MEPERIDINE HYDROCHLORIDE | GENERIC | ||
| ANALGESICS - OPIOID | METHADONE HCL | PREFERRED | PA | |
| ANALGESICS - OPIOID | METHADONE HCL | GENERIC | PA | |
| ANALGESICS - OPIOID | METHADONE HCL | EXCLUDED | PA | |
| ANALGESICS - OPIOID | METHADONE HYDROCHLORIDE | GENERIC | PA | |
| ANALGESICS - OPIOID | METHADONE HYDROCHLORIDE | PREFERRED | PA | |
| ANALGESICS - OPIOID | METHADONE HYDROCHLORIDE | EXCLUDED | PA | |
| ANALGESICS - OPIOID | METHADONE HYDROCHLORIDE I NTENSOL | GENERIC | PA | |
| ANALGESICS - OPIOID | METHADONE HYDROCHLORIDE/S ODIUM CHLORIDE | EXCLUDED | ||
| ANALGESICS - OPIOID | METHADOSE | GENERIC | PA | |
| ANALGESICS - OPIOID | METHADOSE | EXCLUDED | PA | |
| ANALGESICS - OPIOID | METHADOSE SUGAR-FREE | EXCLUDED | PA | |
| ANALGESICS - OPIOID | MITIGO | GENERIC | ||
| ANALGESICS - OPIOID | MORPHINE SULFATE | PREFERRED | ||
| ANALGESICS - OPIOID | MORPHINE SULFATE | GENERIC | ||
| ANALGESICS - OPIOID | MORPHINE SULFATE | NON-PREFERRED | ||
| ANALGESICS - OPIOID | MORPHINE SULFATE | EXCLUDED | ||
| ANALGESICS - OPIOID | MORPHINE SULFATE ER | GENERIC | ||
| ANALGESICS - OPIOID | MORPHINE SULFATE ER | PREFERRED | ||
| ANALGESICS - OPIOID | MORPHINE SULFATE ER | EXCLUDED | ||
| ANALGESICS - OPIOID | MORPHINE SULFATE/SODIUM C HLORIDE | PREFERRED | ||
| ANALGESICS - OPIOID | MORPHINE SULFATE/SODIUM C HLORIDE | EXCLUDED | ||
| ANALGESICS - OPIOID | MS CONTIN | EXCLUDED | ||
| ANALGESICS - OPIOID | NALBUPHINE HYDROCHLORIDE | GENERIC | ||
| ANALGESICS - OPIOID | NUCYNTA | EXCLUDED | ||
| ANALGESICS - OPIOID | OXYCODONE HCL | GENERIC | ||
| ANALGESICS - OPIOID | OXYCODONE HYDROCHLORIDE | GENERIC | ||
| ANALGESICS - OPIOID | OXYCODONE/ACETAMINOPHEN | GENERIC | ||
| ANALGESICS - OPIOID | OXYCONTIN | PREFERRED | PA | |
| ANALGESICS - OPIOID | OXYCONTIN | EXCLUDED | PA | |
| ANALGESICS - OPIOID | OXYMORPHONE HYDROCHLORIDE | GENERIC | ||
| ANALGESICS - OPIOID | OXYMORPHONE HYDROCHLORIDE ER | PREFERRED | ||
| ANALGESICS - OPIOID | OXYMORPHONE HYDROCHLORIDE ER | PREFERRED | ||
| ANALGESICS - OPIOID | PENTAZOCINE/NALOXONE HCL | GENERIC | ||
| ANALGESICS - OPIOID | PERCOCET | PREFERRED | ||
| ANALGESICS - OPIOID | REMIFENTANIL HYDROCHLORID E | EXCLUDED | ||
| ANALGESICS - OPIOID | ROXICODONE | EXCLUDED | ||
| ANALGESICS - OPIOID | SUBLOCADE | PREFERRED | SP | PA |
| ANALGESICS - OPIOID | SUBOXONE | EXCLUDED | ||
| ANALGESICS - OPIOID | TRAMADOL HYDROCHLORIDE | GENERIC | ||
| ANALGESICS - OPIOID | TRAMADOL HYDROCHLORIDE | EXCLUDED | ||
| ANALGESICS - OPIOID | TRAMADOL HYDROCHLORIDE/AC ETAMINOPHEN | GENERIC | ||
| ANALGESICS - OPIOID | TREZIX | EXCLUDED | ||
| ANALGESICS - OPIOID | ULTIVA | EXCLUDED | ||
| ANALGESICS - OPIOID | ZUBSOLV | PREFERRED | ||
| ANDROGENS-ANABOLIC | AZMIRO | EXCLUDED | PA | |
| ANDROGENS-ANABOLIC | DANAZOL | GENERIC | PA | |
| ANDROGENS-ANABOLIC | DEPO-TESTOSTERONE | EXCLUDED | PA | |
| ANDROGENS-ANABOLIC | KYZATREX | EXCLUDED | PA | |
| ANDROGENS-ANABOLIC | METHITEST | EXCLUDED | PA | |
| ANDROGENS-ANABOLIC | METHYLTESTOSTERONE | EXCLUDED | PA | |
| ANDROGENS-ANABOLIC | TESTONE CIK | NON-PREFERRED | PA | |
| ANDROGENS-ANABOLIC | TESTOSTERONE CYPIONATE | GENERIC | PA | |
| ANDROGENS-ANABOLIC | TESTOSTERONE CYPIONATE | PREFERRED | PA | |
| ANDROGENS-ANABOLIC | TESTOSTERONE ENANTHATE | PREFERRED | PA | |
| ANORECTAL AND RELATED PRODUCTS | ANALPRAM HC | EXCLUDED | ||
| ANORECTAL AND RELATED PRODUCTS | ANUCORT-HC | PREFERRED | ||
| ANORECTAL AND RELATED PRODUCTS | ANUSOL-HC | EXCLUDED | ||
| ANORECTAL AND RELATED PRODUCTS | BARRIGEL | EXCLUDED | ||
| ANORECTAL AND RELATED PRODUCTS | BUDESONIDE | EXCLUDED | ||
| ANORECTAL AND RELATED PRODUCTS | CORTENEMA | EXCLUDED | ||
| ANORECTAL AND RELATED PRODUCTS | HEMMOREX-HC | EXCLUDED | ||
| ANORECTAL AND RELATED PRODUCTS | HYDROCORTISONE | GENERIC | ||
| ANORECTAL AND RELATED PRODUCTS | HYDROCORTISONE | PREFERRED | ||
| ANORECTAL AND RELATED PRODUCTS | HYDROCORTISONE ACETATE | PREFERRED | ||
| ANORECTAL AND RELATED PRODUCTS | HYDROCORTISONE ACETATE/PR AMOXINE | PREFERRED | ||
| ANORECTAL AND RELATED PRODUCTS | LIDOCAINE HCL/HYDROCORTIS ONE ACETATE | EXCLUDED | ||
| ANORECTAL AND RELATED PRODUCTS | LIDOCAINE HCL-HYDROCORTIS ONE ACETATE WITH ALOE | PREFERRED | ||
| ANORECTAL AND RELATED PRODUCTS | LIDOCAINE HYDROCHLORIDE/H YDROCORTISONE ACETATE | EXCLUDED | ||
| ANORECTAL AND RELATED PRODUCTS | LIDOCORT | EXCLUDED | ||
| ANORECTAL AND RELATED PRODUCTS | NITROGLYCERIN | GENERIC | ||
| ANORECTAL AND RELATED PRODUCTS | PROCORT | EXCLUDED | ||
| ANORECTAL AND RELATED PRODUCTS | PROCTOCORT | EXCLUDED | ||
| ANORECTAL AND RELATED PRODUCTS | PROCTOFOAM HC | EXCLUDED | ||
| ANORECTAL AND RELATED PRODUCTS | PROCTO-MED HC | GENERIC | ||
| ANORECTAL AND RELATED PRODUCTS | PROCTOSOL HC | GENERIC | ||
| ANORECTAL AND RELATED PRODUCTS | PROCTOZONE-HC | GENERIC | ||
| ANORECTAL AND RELATED PRODUCTS | RECTIV | EXCLUDED | ||
| ANORECTAL AND RELATED PRODUCTS | UCERIS | NON-PREFERRED | ||
| ANTHELMINTICS | ALBENDAZOLE | GENERIC | ||
| ANTHELMINTICS | BENZNIDAZOLE | PREFERRED | ||
| ANTHELMINTICS | BILTRICIDE | EXCLUDED | ||
| ANTHELMINTICS | IVERMECTIN | GENERIC | PA | |
| ANTHELMINTICS | IVERMECTIN | PREFERRED | ||
| ANTHELMINTICS | PRAZIQUANTEL | GENERIC | ||
| ANTHELMINTICS | STROMECTOL | EXCLUDED | PA | |
| ANTIANGINAL AGENTS | ISORDIL TITRADOSE | EXCLUDED | ||
| ANTIANGINAL AGENTS | ISOSORBIDE DINITRATE | GENERIC | ||
| ANTIANGINAL AGENTS | ISOSORBIDE MONONITRATE | PREFERRED | ||
| ANTIANGINAL AGENTS | ISOSORBIDE MONONITRATE ER | GENERIC | ||
| ANTIANGINAL AGENTS | NITRO-BID | PREFERRED | ||
| ANTIANGINAL AGENTS | NITRO-DUR | NON-PREFERRED | ||
| ANTIANGINAL AGENTS | NITRO-DUR | EXCLUDED | ||
| ANTIANGINAL AGENTS | NITROGLYCERIN | GENERIC | ||
| ANTIANGINAL AGENTS | NITROGLYCERIN IN DEXTROSE 5% | PREFERRED | ||
| ANTIANGINAL AGENTS | NITROGLYCERIN TRANSDERMAL | GENERIC | ||
| ANTIANGINAL AGENTS | NITROSTAT | EXCLUDED | ||
| ANTIANGINAL AGENTS | NITRO-TIME | PREFERRED | ||
| ANTIANGINAL AGENTS | RANOLAZINE ER | GENERIC | ||
| ANTIANXIETY AGENTS | ALPRAZOLAM | GENERIC | ||
| ANTIANXIETY AGENTS | ALPRAZOLAM ER | GENERIC | ||
| ANTIANXIETY AGENTS | ALPRAZOLAM INTENSOL | PREFERRED | ||
| ANTIANXIETY AGENTS | ALPRAZOLAM ODT | GENERIC | ||
| ANTIANXIETY AGENTS | ALPRAZOLAM XR | GENERIC | ||
| ANTIANXIETY AGENTS | ATIVAN | EXCLUDED | ||
| ANTIANXIETY AGENTS | BUCAPSOL | EXCLUDED | ||
| ANTIANXIETY AGENTS | BUSPIRONE HCL | GENERIC | ||
| ANTIANXIETY AGENTS | BUSPIRONE HYDROCHLORIDE | GENERIC | ||
| ANTIANXIETY AGENTS | CHLORDIAZEPOXIDE HCL | GENERIC | ||
| ANTIANXIETY AGENTS | CHLORDIAZEPOXIDE HYDROCHL ORIDE | GENERIC | ||
| ANTIANXIETY AGENTS | CLORAZEPATE DIPOTASSIUM | GENERIC | ||
| ANTIANXIETY AGENTS | DIAZEPAM | GENERIC | ||
| ANTIANXIETY AGENTS | DIAZEPAM | PREFERRED | ||
| ANTIANXIETY AGENTS | DIAZEPAM INTENSOL | GENERIC | ||
| ANTIANXIETY AGENTS | DROPERIDOL | GENERIC | ||
| ANTIANXIETY AGENTS | HYDROXYZINE HCL | GENERIC | ||
| ANTIANXIETY AGENTS | HYDROXYZINE HCL | PREFERRED | ||
| ANTIANXIETY AGENTS | HYDROXYZINE HYDROCHLORIDE | GENERIC | ||
| ANTIANXIETY AGENTS | HYDROXYZINE HYDROCHLORIDE | PREFERRED | ||
| ANTIANXIETY AGENTS | HYDROXYZINE PAMOATE | GENERIC | ||
| ANTIANXIETY AGENTS | HYDROXYZINE PAMOATE | PREFERRED | ||
| ANTIANXIETY AGENTS | LORAZEPAM | GENERIC | ||
| ANTIANXIETY AGENTS | LORAZEPAM | PREFERRED | ||
| ANTIANXIETY AGENTS | LORAZEPAM INTENSOL | GENERIC | ||
| ANTIANXIETY AGENTS | MEPROBAMATE | GENERIC | ||
| ANTIANXIETY AGENTS | OXAZEPAM | GENERIC | ||
| ANTIANXIETY AGENTS | VALIUM | EXCLUDED | ||
| ANTIANXIETY AGENTS | XANAX | EXCLUDED | ||
| ANTIANXIETY AGENTS | XANAX XR | EXCLUDED | ||
| ANTIARRHYTHMICS | ADENOSINE | GENERIC | ||
| ANTIARRHYTHMICS | AMIODARONE HCL | GENERIC | ||
| ANTIARRHYTHMICS | AMIODARONE HYDROCHLORIDE | GENERIC | ||
| ANTIARRHYTHMICS | AMIODARONE HYDROCHLORIDE/ DEXTROSE | PREFERRED | ||
| ANTIARRHYTHMICS | CORVERT | EXCLUDED | ||
| ANTIARRHYTHMICS | DISOPYRAMIDE PHOSPHATE | GENERIC | ||
| ANTIARRHYTHMICS | DOFETILIDE | GENERIC | PA | |
| ANTIARRHYTHMICS | FLECAINIDE ACETATE | GENERIC | ||
| ANTIARRHYTHMICS | IBUTILIDE FUMARATE | GENERIC | ||
| ANTIARRHYTHMICS | LIDOCAINE HCL | EXCLUDED | ||
| ANTIARRHYTHMICS | LIDOCAINE HCL IN D5W | GENERIC | ||
| ANTIARRHYTHMICS | LIDOCAINE HCL/DEXTROSE | GENERIC | ||
| ANTIARRHYTHMICS | LIDOCAINE HYDROCHLORIDE | PREFERRED | ||
| ANTIARRHYTHMICS | LIDOCAINE HYDROCHLORIDE | EXCLUDED | ||
| ANTIARRHYTHMICS | LIDOCAINE HYDROCHLORIDE/S ODIUM CHLORIDE | PREFERRED | ||
| ANTIARRHYTHMICS | MEXILETINE HYDROCHLORIDE | GENERIC | ||
| ANTIARRHYTHMICS | MULTAQ | EXCLUDED | ||
| ANTIARRHYTHMICS | NEXTERONE | NON-PREFERRED | ||
| ANTIARRHYTHMICS | NORPACE | EXCLUDED | ||
| ANTIARRHYTHMICS | NORPACE CR | NON-PREFERRED | ||
| ANTIARRHYTHMICS | PACERONE | GENERIC | ||
| ANTIARRHYTHMICS | PROCAINAMIDE HYDROCHLORID E | GENERIC | ||
| ANTIARRHYTHMICS | PROPAFENONE HCL | GENERIC | ||
| ANTIARRHYTHMICS | PROPAFENONE HYDROCHLORIDE | GENERIC | ||
| ANTIARRHYTHMICS | PROPAFENONE HYDROCHLORIDE ER | GENERIC | ||
| ANTIARRHYTHMICS | QUINIDINE GLUCONATE CR | GENERIC | ||
| ANTIARRHYTHMICS | QUINIDINE GLUCONATE ER | GENERIC | ||
| ANTIARRHYTHMICS | QUINIDINE SULFATE | PREFERRED | ||
| ANTIARRHYTHMICS | TIKOSYN | EXCLUDED | PA | |
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ACCOLATE | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ADVAIR DISKUS | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ADVAIR HFA | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | AIRSUPRA | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ALBUTEROL SULFATE | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ALBUTEROL SULFATE | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ALBUTEROL SULFATE HFA | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ALBUTEROL SULFATE HFA | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ALVESCO | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | AMINOPHYLLINE | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ANORO ELLIPTA | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ARFORMOTEROL TARTRATE | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ARNUITY ELLIPTA | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ASMANEX HFA | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ASMANEX TWISTHALER 120 ME TERED DOSES | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ASMANEX TWISTHALER 30 MET ERED DOSES | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ASMANEX TWISTHALER 60 MET ERED DOSES | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ATROVENT HFA | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | BEVESPI AEROSPHERE | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | BREO ELLIPTA | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | BREYNA | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | BREZTRI AEROSPHERE | PREFERRED | PA | |
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | BUDESONIDE | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | BUDESONIDE/FORMOTEROL FUM ARATE DIHYDRATE | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | CINQAIR | EXCLUDED | SP | PA |
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | COMBIVENT RESPIMAT | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | CROMOLYN SODIUM | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | DALIRESP | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | DULERA | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | FASENRA | EXCLUDED | SP | PA |
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | FASENRA PEN | EXCLUDED | SP | PA |
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | FLUTICASONE FUROATE ELLIP TA | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | FLUTICASONE FUROATE/VILAN TEROL ELLIPTA | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | FLUTICASONE PROPIONATE DI SKUS | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | FLUTICASONE PROPIONATE HF A | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | FLUTICASONE PROPIONATE/SA LMETEROL | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | FLUTICASONE PROPIONATE/SA LMETEROL DISKUS | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | FLUTICASONE PROPIONATE/SA LMETEROL HFA | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | FORMOTEROL FUMARATE | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | INCRUSE ELLIPTA | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | IPRATROPIUM BROMIDE | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | IPRATROPIUM BROMIDE/ALBUT EROL SULFATE | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ISOPROTERENOL HYDROCHLORI DE | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | LEVALBUTEROL HCL | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | LEVALBUTEROL HYDROCHLORID E | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | LEVALBUTEROL TARTRATE HFA | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | MONTELUKAST SODIUM | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | NUCALA | PREFERRED | SP | PA |
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | OHTUVAYRE | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | PERFOROMIST | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | PULMICORT | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | PULMICORT FLEXHALER | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | QVAR REDIHALER | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ROFLUMILAST | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | SEREVENT DISKUS | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | SINGULAIR | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | SPIRIVA HANDIHALER | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | SPIRIVA RESPIMAT | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | STIOLTO RESPIMAT | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | STRIVERDI RESPIMAT | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | SYMBICORT | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | TERBUTALINE SULFATE | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | TEZSPIRE | PREFERRED | SP | PA |
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | THEO-24 | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | THEOPHYLLINE | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | THEOPHYLLINE ER | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | THEOPHYLLINE ER | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | TIOTROPIUM BROMIDE | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | TRELEGY ELLIPTA | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | UMECLIDINIUM/VILANTEROL E LLIPTA | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | VENTOLIN HFA | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | WIXELA INHUB | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | XOLAIR | PREFERRED | SP | PA |
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | XOPENEX HFA | EXCLUDED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | YUPELRI | PREFERRED | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ZAFIRLUKAST | GENERIC | ||
| ANTIASTHMATIC AND BRONCHODILATOR AGENTS | ZILEUTON ER | EXCLUDED | PA | |
| ANTICOAGULANTS | ACD FORMULA A | NON-PREFERRED | ||
| ANTICOAGULANTS | ACD-A NOCLOT-50 | NON-PREFERRED | ||
| ANTICOAGULANTS | ANTICOAGULANT SODIUM CITR ATE | PREFERRED | ||
| ANTICOAGULANTS | ANTICOAGULANT SODIUM CITR ATE | EXCLUDED | ||
| ANTICOAGULANTS | ARGATROBAN | NON-PREFERRED | ||
| ANTICOAGULANTS | ARGATROBAN | GENERIC | ||
| ANTICOAGULANTS | ARGATROBAN/SODIUM CHLORID E | NON-PREFERRED | ||
| ANTICOAGULANTS | ARIXTRA | EXCLUDED | ||
| ANTICOAGULANTS | BD HEPARIN POSIFLUSH | PREFERRED | ||
| ANTICOAGULANTS | BIVALIRUDIN | GENERIC | ||
| ANTICOAGULANTS | BIVALIRUDIN | PREFERRED | ||
| ANTICOAGULANTS | DABIGATRAN ETEXILATE | GENERIC | ||
| ANTICOAGULANTS | DEFENCATH | EXCLUDED | ||
| ANTICOAGULANTS | ELIQUIS | PREFERRED | ||
| ANTICOAGULANTS | ELIQUIS STARTER PACK | PREFERRED | ||
| ANTICOAGULANTS | ENOXAPARIN SODIUM | GENERIC | ||
| ANTICOAGULANTS | FONDAPARINUX SODIUM | GENERIC | ||
| ANTICOAGULANTS | FRAGMIN | EXCLUDED | ||
| ANTICOAGULANTS | HEPARIN LOCK FLUSH | PREFERRED | ||
| ANTICOAGULANTS | HEPARIN SODIUM | GENERIC | ||
| ANTICOAGULANTS | HEPARIN SODIUM | PREFERRED | ||
| ANTICOAGULANTS | HEPARIN SODIUM/D5W | PREFERRED | ||
| ANTICOAGULANTS | HEPARIN SODIUM/DEXTROSE | PREFERRED | ||
| ANTICOAGULANTS | HEPARIN SODIUM/NACL 0.45% | NON-PREFERRED | ||
| ANTICOAGULANTS | HEPARIN SODIUM/NACL 0.45% | PREFERRED | ||
| ANTICOAGULANTS | HEPARIN SODIUM/SODIUM CHL ORIDE | PREFERRED | ||
| ANTICOAGULANTS | HEPARIN SODIUM/SODIUM CHL ORIDE | EXCLUDED | ||
| ANTICOAGULANTS | HEPARIN SODIUM/SODIUM CHL ORIDE 0.9% | PREFERRED | ||
| ANTICOAGULANTS | HEPARIN SODIUM/SODIUM CHL ORIDE 0.9% PREMIX | PREFERRED | ||
| ANTICOAGULANTS | HEPARIN SODIUM/SODIUM CHL ORIDE 0.9% PREMIX | GENERIC | ||
| ANTICOAGULANTS | HEPARIN/SODIUM CHLORIDE | PREFERRED | ||
| ANTICOAGULANTS | JANTOVEN | GENERIC | ||
| ANTICOAGULANTS | LOVENOX | EXCLUDED | ||
| ANTICOAGULANTS | PRADAXA | EXCLUDED | ||
| ANTICOAGULANTS | RIVAROXABAN | EXCLUDED | ||
| ANTICOAGULANTS | SAVAYSA | EXCLUDED | ||
| ANTICOAGULANTS | SODIUM CITRATE | EXCLUDED | ||
| ANTICOAGULANTS | SODIUM CITRATE LOCK FLUSH | PREFERRED | ||
| ANTICOAGULANTS | SODIUM CITRATE/GENTAMICIN | PREFERRED | ||
| ANTICOAGULANTS | SODIUM CITRATE/GENTAMICIN | EXCLUDED | ||
| ANTICOAGULANTS | TRICITRASOL | PREFERRED | ||
| ANTICOAGULANTS | WARFARIN SODIUM | GENERIC | ||
| ANTICOAGULANTS | XARELTO | PREFERRED | ||
| ANTICOAGULANTS | XARELTO STARTER PACK | PREFERRED | ||
| ANTICONVULSANTS | APTIOM | EXCLUDED | PA | |
| ANTICONVULSANTS | BANZEL | EXCLUDED | ||
| ANTICONVULSANTS | BRIVIACT | NON-PREFERRED | PA | |
| ANTICONVULSANTS | BRIVIACT | EXCLUDED | PA | |
| ANTICONVULSANTS | CARBAMAZEPINE | GENERIC | ||
| ANTICONVULSANTS | CARBAMAZEPINE | EXCLUDED | ||
| ANTICONVULSANTS | CARBAMAZEPINE ER | GENERIC | ||
| ANTICONVULSANTS | CARBATROL | EXCLUDED | ||
| ANTICONVULSANTS | CELONTIN | EXCLUDED | ||
| ANTICONVULSANTS | CEREBYX | EXCLUDED | ||
| ANTICONVULSANTS | CLOBAZAM | GENERIC | ||
| ANTICONVULSANTS | CLONAZEPAM | GENERIC | ||
| ANTICONVULSANTS | CLONAZEPAM ODT | GENERIC | ||
| ANTICONVULSANTS | DEPAKOTE | EXCLUDED | ||
| ANTICONVULSANTS | DEPAKOTE ER | EXCLUDED | ||
| ANTICONVULSANTS | DEPAKOTE SPRINKLES | EXCLUDED | ||
| ANTICONVULSANTS | DIACOMIT | NON-PREFERRED | SP | PA |
| ANTICONVULSANTS | DIAZEPAM RECTAL GEL | GENERIC | PA | |
| ANTICONVULSANTS | DIAZEPAM RECTAL GEL | PREFERRED | PA | |
| ANTICONVULSANTS | DILANTIN | PREFERRED | ||
| ANTICONVULSANTS | DILANTIN | EXCLUDED | ||
| ANTICONVULSANTS | DILANTIN INFATABS | EXCLUDED | ||
| ANTICONVULSANTS | DILANTIN-125 | EXCLUDED | ||
| ANTICONVULSANTS | DIVALPROEX SODIUM DR | GENERIC | ||
| ANTICONVULSANTS | DIVALPROEX SODIUM ER | GENERIC | ||
| ANTICONVULSANTS | EPIDIOLEX | PREFERRED | SP | PA |
| ANTICONVULSANTS | EPRONTIA | EXCLUDED | ||
| ANTICONVULSANTS | ESLICARBAZEPINE ACETATE | EXCLUDED | PA | |
| ANTICONVULSANTS | ETHOSUXIMIDE | GENERIC | ||
| ANTICONVULSANTS | FELBAMATE | GENERIC | ||
| ANTICONVULSANTS | FELBATOL | EXCLUDED | ||
| ANTICONVULSANTS | FINTEPLA | NON-PREFERRED | SP | PA |
| ANTICONVULSANTS | FOSPHENYTOIN SODIUM | GENERIC | ||
| ANTICONVULSANTS | FYCOMPA | NON-PREFERRED | PA | |
| ANTICONVULSANTS | FYCOMPA | EXCLUDED | PA | |
| ANTICONVULSANTS | GABAPENTIN | GENERIC | ||
| ANTICONVULSANTS | GABARONE | EXCLUDED | ||
| ANTICONVULSANTS | KEPPRA | EXCLUDED | ||
| ANTICONVULSANTS | KEPPRA XR | EXCLUDED | ||
| ANTICONVULSANTS | KLONOPIN | EXCLUDED | ||
| ANTICONVULSANTS | LACOSAMIDE | GENERIC | ||
| ANTICONVULSANTS | LACOSAMIDE | EXCLUDED | ||
| ANTICONVULSANTS | LAMICTAL | EXCLUDED | ||
| ANTICONVULSANTS | LAMICTAL CHEWABLE DISPERS IBLE | EXCLUDED | ||
| ANTICONVULSANTS | LAMOTRIGINE | GENERIC | ||
| ANTICONVULSANTS | LEVETIRACETAM | GENERIC | ||
| ANTICONVULSANTS | LEVETIRACETAM ER | GENERIC | ||
| ANTICONVULSANTS | LEVETIRACETAM/SODIUM CHLO RIDE | GENERIC | ||
| ANTICONVULSANTS | LEVETIRACETAM/SODIUM CHLO RIDE | PREFERRED | ||
| ANTICONVULSANTS | LYRICA | EXCLUDED | ||
| ANTICONVULSANTS | METHSUXIMIDE | GENERIC | ||
| ANTICONVULSANTS | MIDAZOLAM HYDROCHLORIDE | PREFERRED | PA | |
| ANTICONVULSANTS | MOTPOLY XR | EXCLUDED | ||
| ANTICONVULSANTS | MYSOLINE | EXCLUDED | ||
| ANTICONVULSANTS | NAYZILAM | PREFERRED | PA | |
| ANTICONVULSANTS | NEURONTIN | EXCLUDED | ||
| ANTICONVULSANTS | ONFI | EXCLUDED | ||
| ANTICONVULSANTS | OXCARBAZEPINE | GENERIC | ||
| ANTICONVULSANTS | PERAMPANEL | EXCLUDED | PA | |
| ANTICONVULSANTS | PHENYTEK | GENERIC | ||
| ANTICONVULSANTS | PHENYTEK | EXCLUDED | ||
| ANTICONVULSANTS | PHENYTOIN | GENERIC | ||
| ANTICONVULSANTS | PHENYTOIN INFATABS | GENERIC | ||
| ANTICONVULSANTS | PHENYTOIN SODIUM | GENERIC | ||
| ANTICONVULSANTS | PHENYTOIN SODIUM | PREFERRED | ||
| ANTICONVULSANTS | PHENYTOIN SODIUM EXTENDED | GENERIC | ||
| ANTICONVULSANTS | PREGABALIN | GENERIC | ||
| ANTICONVULSANTS | PRIMIDONE | GENERIC | ||
| ANTICONVULSANTS | PRIMIDONE | PREFERRED | ||
| ANTICONVULSANTS | ROWEEPRA | EXCLUDED | ||
| ANTICONVULSANTS | RUFINAMIDE | GENERIC | ||
| ANTICONVULSANTS | SABRIL | EXCLUDED | SP | PA |
| ANTICONVULSANTS | SPRITAM | EXCLUDED | PA | |
| ANTICONVULSANTS | SUBVENITE | GENERIC | ||
| ANTICONVULSANTS | SUBVENITE | EXCLUDED | ||
| ANTICONVULSANTS | TEGRETOL | EXCLUDED | ||
| ANTICONVULSANTS | TEGRETOL-XR | EXCLUDED | ||
| ANTICONVULSANTS | TIAGABINE HYDROCHLORIDE | GENERIC | ||
| ANTICONVULSANTS | TOPAMAX | EXCLUDED | ||
| ANTICONVULSANTS | TOPAMAX SPRINKLE | EXCLUDED | ||
| ANTICONVULSANTS | TOPIRAMATE | GENERIC | ||
| ANTICONVULSANTS | TOPIRAMATE | EXCLUDED | ||
| ANTICONVULSANTS | TRILEPTAL | EXCLUDED | ||
| ANTICONVULSANTS | VALPROATE SODIUM | GENERIC | ||
| ANTICONVULSANTS | VALPROIC ACID | GENERIC | ||
| ANTICONVULSANTS | VALTOCO 10 MG DOSE | NON-PREFERRED | PA | |
| ANTICONVULSANTS | VALTOCO 15 MG DOSE | NON-PREFERRED | PA | |
| ANTICONVULSANTS | VALTOCO 20 MG DOSE | NON-PREFERRED | PA | |
| ANTICONVULSANTS | VALTOCO 5 MG DOSE | NON-PREFERRED | PA | |
| ANTICONVULSANTS | VIGABATRIN | GENERIC | SP | PA |
| ANTICONVULSANTS | VIGADRONE | GENERIC | SP | PA |
| ANTICONVULSANTS | VIGAFYDE | EXCLUDED | SP | PA |
| ANTICONVULSANTS | VIMPAT | NON-PREFERRED | ||
| ANTICONVULSANTS | VIMPAT | EXCLUDED | ||
| ANTICONVULSANTS | XCOPRI | NON-PREFERRED | PA | |
| ANTICONVULSANTS | ZARONTIN | EXCLUDED | ||
| ANTICONVULSANTS | ZONEGRAN | EXCLUDED | ||
| ANTICONVULSANTS | ZONISADE | EXCLUDED | ||
| ANTICONVULSANTS | ZONISAMIDE | GENERIC | ||
| ANTICONVULSANTS | ZTALMY | NON-PREFERRED | SP | PA |
| ANTIDEPRESSANTS | AMITRIPTYLINE HCL | GENERIC | ||
| ANTIDEPRESSANTS | AMITRIPTYLINE HYDROCHLORI DE | GENERIC | ||
| ANTIDEPRESSANTS | AMOXAPINE | GENERIC | ||
| ANTIDEPRESSANTS | BUPROPION HYDROCHLORIDE | GENERIC | ||
| ANTIDEPRESSANTS | BUPROPION HYDROCHLORIDE E R (SR) | GENERIC | ||
| ANTIDEPRESSANTS | BUPROPION HYDROCHLORIDE E R (XL) | GENERIC | ||
| ANTIDEPRESSANTS | BUPROPION HYDROCHLORIDE E R (XL) | EXCLUDED | ||
| ANTIDEPRESSANTS | CELEXA | EXCLUDED | ||
| ANTIDEPRESSANTS | CITALOPRAM HYDROBROMIDE | GENERIC | ||
| ANTIDEPRESSANTS | CITALOPRAM HYDROBROMIDE | EXCLUDED | ||
| ANTIDEPRESSANTS | CLOMIPRAMINE HCL | GENERIC | ||
| ANTIDEPRESSANTS | CLOMIPRAMINE HYDROCHLORID E | GENERIC | ||
| ANTIDEPRESSANTS | DESIPRAMINE HCL | GENERIC | ||
| ANTIDEPRESSANTS | DESIPRAMINE HYDROCHLORIDE | GENERIC | ||
| ANTIDEPRESSANTS | DESVENLAFAXINE ER | GENERIC | ||
| ANTIDEPRESSANTS | DESVENLAFAXINE ER | EXCLUDED | ||
| ANTIDEPRESSANTS | DESVENLAFAXINE SUCCINATE ER | GENERIC | ||
| ANTIDEPRESSANTS | DOXEPIN HCL | GENERIC | ||
| ANTIDEPRESSANTS | DOXEPIN HCL | PREFERRED | ||
| ANTIDEPRESSANTS | DOXEPIN HYDROCHLORIDE | GENERIC | ||
| ANTIDEPRESSANTS | DULOXETINE HYDROCHLORIDE DR | GENERIC | ||
| ANTIDEPRESSANTS | EFFEXOR XR | EXCLUDED | ||
| ANTIDEPRESSANTS | EMSAM | NON-PREFERRED | PA | |
| ANTIDEPRESSANTS | ESCITALOPRAM OXALATE | GENERIC | ||
| ANTIDEPRESSANTS | FETZIMA | EXCLUDED | PA | |
| ANTIDEPRESSANTS | FETZIMA TITRATION PACK | EXCLUDED | PA | |
| ANTIDEPRESSANTS | FLUOXETINE HYDROCHLORIDE | GENERIC | ||
| ANTIDEPRESSANTS | FLUVOXAMINE MALEATE | GENERIC | ||
| ANTIDEPRESSANTS | IMIPRAMINE HCL | GENERIC | ||
| ANTIDEPRESSANTS | IMIPRAMINE HYDROCHLORIDE | GENERIC | ||
| ANTIDEPRESSANTS | IMIPRAMINE PAMOATE | GENERIC | ||
| ANTIDEPRESSANTS | LEXAPRO | EXCLUDED | ||
| ANTIDEPRESSANTS | MARPLAN | EXCLUDED | ||
| ANTIDEPRESSANTS | MIRTAZAPINE | GENERIC | ||
| ANTIDEPRESSANTS | MIRTAZAPINE ODT | GENERIC | ||
| ANTIDEPRESSANTS | NARDIL | EXCLUDED | ||
| ANTIDEPRESSANTS | NEFAZODONE HYDROCHLORIDE | PREFERRED | ||
| ANTIDEPRESSANTS | NORPRAMIN | EXCLUDED | ||
| ANTIDEPRESSANTS | NORTRIPTYLINE HCL | GENERIC | ||
| ANTIDEPRESSANTS | NORTRIPTYLINE HYDROCHLORI DE | GENERIC | ||
| ANTIDEPRESSANTS | PARNATE | EXCLUDED | ||
| ANTIDEPRESSANTS | PAROXETINE HCL | GENERIC | ||
| ANTIDEPRESSANTS | PAROXETINE HYDROCHLORIDE | GENERIC | ||
| ANTIDEPRESSANTS | PAROXETINE HYDROCHLORIDE | EXCLUDED | ||
| ANTIDEPRESSANTS | PAXIL | EXCLUDED | ||
| ANTIDEPRESSANTS | PHENELZINE SULFATE | PREFERRED | ||
| ANTIDEPRESSANTS | PRISTIQ | EXCLUDED | ||
| ANTIDEPRESSANTS | PROTRIPTYLINE HCL | GENERIC | ||
| ANTIDEPRESSANTS | RALDESY | EXCLUDED | ||
| ANTIDEPRESSANTS | REMERON | EXCLUDED | ||
| ANTIDEPRESSANTS | REMERON SOLTAB | EXCLUDED | ||
| ANTIDEPRESSANTS | SERTRALINE HCL | GENERIC | ||
| ANTIDEPRESSANTS | SERTRALINE HYDROCHLORIDE | GENERIC | ||
| ANTIDEPRESSANTS | SERTRALINE HYDROCHLORIDE | PREFERRED | ||
| ANTIDEPRESSANTS | TRANYLCYPROMINE SULFATE | GENERIC | ||
| ANTIDEPRESSANTS | TRAZODONE HYDROCHLORIDE | GENERIC | ||
| ANTIDEPRESSANTS | TRIMIPRAMINE MALEATE | GENERIC | ||
| ANTIDEPRESSANTS | TRINTELLIX | NON-PREFERRED | ||
| ANTIDEPRESSANTS | VENLAFAXINE BESYLATE ER | EXCLUDED | ||
| ANTIDEPRESSANTS | VENLAFAXINE HCL | GENERIC | ||
| ANTIDEPRESSANTS | VENLAFAXINE HYDROCHLORIDE | GENERIC | ||
| ANTIDEPRESSANTS | VENLAFAXINE HYDROCHLORIDE ER | GENERIC | ||
| ANTIDEPRESSANTS | VIIBRYD | EXCLUDED | ||
| ANTIDEPRESSANTS | VILAZODONE HYDROCHLORIDE | GENERIC | ||
| ANTIDEPRESSANTS | WELLBUTRIN SR | EXCLUDED | ||
| ANTIDEPRESSANTS | ZOLOFT | EXCLUDED | ||
| ANTIDEPRESSANTS | ZURZUVAE | NON-PREFERRED | SP | PA |
| ANTIDIABETICS | ACARBOSE | GENERIC | ||
| ANTIDIABETICS | ACTOPLUS MET | EXCLUDED | ||
| ANTIDIABETICS | ACTOS | EXCLUDED | ||
| ANTIDIABETICS | ADMELOG | EXCLUDED | ||
| ANTIDIABETICS | ADMELOG SOLOSTAR | EXCLUDED | ||
| ANTIDIABETICS | AFREZZA | NON-PREFERRED | ||
| ANTIDIABETICS | ALOGLIPTIN | EXCLUDED | ||
| ANTIDIABETICS | ALOGLIPTIN/METFORMIN HCL | EXCLUDED | ||
| ANTIDIABETICS | ALOGLIPTIN/METFORMIN HYDR OCHLORIDE | EXCLUDED | ||
| ANTIDIABETICS | ALOGLIPTIN/PIOGLITAZONE | EXCLUDED | ||
| ANTIDIABETICS | APIDRA | EXCLUDED | ||
| ANTIDIABETICS | APIDRA SOLOSTAR | EXCLUDED | ||
| ANTIDIABETICS | BAQSIMI ONE PACK | NON-PREFERRED | ||
| ANTIDIABETICS | BAQSIMI TWO PACK | NON-PREFERRED | ||
| ANTIDIABETICS | BASAGLAR KWIKPEN | NON-PREFERRED | ||
| ANTIDIABETICS | BRENZAVVY | EXCLUDED | ||
| ANTIDIABETICS | BRYNOVIN | EXCLUDED | ||
| ANTIDIABETICS | CYCLOSET | EXCLUDED | ||
| ANTIDIABETICS | DAPAGLIFLOZIN PROPANEDIOL | EXCLUDED | ||
| ANTIDIABETICS | DAPAGLIFLOZIN PROPANEDIOL /METFORMIN HYDROCHLORIDE | EXCLUDED | ||
| ANTIDIABETICS | DIAZOXIDE | GENERIC | ||
| ANTIDIABETICS | DUETACT | EXCLUDED | ||
| ANTIDIABETICS | EXENATIDE | PREFERRED | PA | |
| ANTIDIABETICS | FARXIGA | EXCLUDED | ||
| ANTIDIABETICS | FIASP | EXCLUDED | ||
| ANTIDIABETICS | FIASP FLEXTOUCH | EXCLUDED | ||
| ANTIDIABETICS | FIASP PENFILL | EXCLUDED | ||
| ANTIDIABETICS | FIASP PUMPCART | EXCLUDED | ||
| ANTIDIABETICS | GLIMEPIRIDE | GENERIC | ||
| ANTIDIABETICS | GLIMEPIRIDE | EXCLUDED | ||
| ANTIDIABETICS | GLIPIZIDE | GENERIC | ||
| ANTIDIABETICS | GLIPIZIDE | PREFERRED | ||
| ANTIDIABETICS | GLIPIZIDE ER | GENERIC | ||
| ANTIDIABETICS | GLIPIZIDE/METFORMIN HYDRO CHLORIDE | GENERIC | ||
| ANTIDIABETICS | GLUCAGON EMERGENCY KIT FO R LOW BLOOD SUGAR | GENERIC | ||
| ANTIDIABETICS | GLUCAGON EMERGENCY KIT FO R LOW BLOOD SUGAR | NON-PREFERRED | ||
| ANTIDIABETICS | GLYBURIDE | GENERIC | ||
| ANTIDIABETICS | GLYBURIDE MICRONIZED | PREFERRED | ||
| ANTIDIABETICS | GLYBURIDE/METFORMIN HYDRO CHLORIDE | GENERIC | ||
| ANTIDIABETICS | GLYXAMBI | PREFERRED | ||
| ANTIDIABETICS | GVOKE HYPOPEN 1-PACK | PREFERRED | ||
| ANTIDIABETICS | GVOKE HYPOPEN 2-PACK | PREFERRED | ||
| ANTIDIABETICS | GVOKE KIT | PREFERRED | ||
| ANTIDIABETICS | GVOKE PFS | PREFERRED | ||
| ANTIDIABETICS | HUMALOG | PREFERRED | ||
| ANTIDIABETICS | HUMALOG JUNIOR KWIKPEN | PREFERRED | ||
| ANTIDIABETICS | HUMALOG KWIKPEN | PREFERRED | ||
| ANTIDIABETICS | HUMALOG MIX 50/50 KWIKPEN | PREFERRED | ||
| ANTIDIABETICS | HUMALOG MIX 75/25 | PREFERRED | ||
| ANTIDIABETICS | HUMALOG MIX 75/25 KWIKPEN | PREFERRED | ||
| ANTIDIABETICS | HUMULIN R U-500 KWIKPEN | PREFERRED | ||
| ANTIDIABETICS | INSULIN ASPART | EXCLUDED | ||
| ANTIDIABETICS | INSULIN ASPART FLEXPEN | EXCLUDED | ||
| ANTIDIABETICS | INSULIN ASPART PENFILL | EXCLUDED | ||
| ANTIDIABETICS | INSULIN ASPART PROTAMINE/ INSULIN ASPART | EXCLUDED | ||
| ANTIDIABETICS | INSULIN ASPART PROTAMINE/ INSULIN ASPART FLEXPEN | EXCLUDED | ||
| ANTIDIABETICS | INSULIN DEGLUDEC | PREFERRED | ||
| ANTIDIABETICS | INSULIN DEGLUDEC FLEXTOUC H | PREFERRED | ||
| ANTIDIABETICS | INSULIN GLARGINE MAX SOLO STAR | EXCLUDED | ||
| ANTIDIABETICS | INSULIN GLARGINE SOLOSTAR | EXCLUDED | ||
| ANTIDIABETICS | INSULIN GLARGINE-YFGN | PREFERRED | ||
| ANTIDIABETICS | INSULIN LISPRO | PREFERRED | ||
| ANTIDIABETICS | INSULIN LISPRO JUNIOR KWI KPEN | PREFERRED | ||
| ANTIDIABETICS | INSULIN LISPRO KWIKPEN | PREFERRED | ||
| ANTIDIABETICS | INSULIN LISPRO PROTAMINE/ INSULIN LISPRO KWIKPEN | PREFERRED | ||
| ANTIDIABETICS | INVOKAMET | EXCLUDED | ||
| ANTIDIABETICS | INVOKAMET XR | EXCLUDED | ||
| ANTIDIABETICS | INVOKANA | EXCLUDED | ||
| ANTIDIABETICS | JANUMET | PREFERRED | ||
| ANTIDIABETICS | JANUMET XR | PREFERRED | ||
| ANTIDIABETICS | JANUVIA | PREFERRED | ||
| ANTIDIABETICS | JARDIANCE | PREFERRED | ||
| ANTIDIABETICS | JENTADUETO | EXCLUDED | ||
| ANTIDIABETICS | JENTADUETO XR | EXCLUDED | ||
| ANTIDIABETICS | KORLYM | EXCLUDED | SP | PA |
| ANTIDIABETICS | LANTIDRA | NON-PREFERRED | SP | PA |
| ANTIDIABETICS | LANTUS | EXCLUDED | ||
| ANTIDIABETICS | LANTUS SOLOSTAR | EXCLUDED | ||
| ANTIDIABETICS | LIRAGLUTIDE | GENERIC | PA | |
| ANTIDIABETICS | LYUMJEV | PREFERRED | ||
| ANTIDIABETICS | LYUMJEV KWIKPEN | PREFERRED | ||
| ANTIDIABETICS | MERILOG | EXCLUDED | ||
| ANTIDIABETICS | MERILOG SOLOSTAR | EXCLUDED | ||
| ANTIDIABETICS | METFORMIN HYDROCHLORIDE | GENERIC | ||
| ANTIDIABETICS | METFORMIN HYDROCHLORIDE | EXCLUDED | ||
| ANTIDIABETICS | METFORMIN HYDROCHLORIDE E R | GENERIC | ||
| ANTIDIABETICS | MIFEPRISTONE | GENERIC | SP | PA |
| ANTIDIABETICS | MIGLITOL | PREFERRED | ||
| ANTIDIABETICS | MOUNJARO | PREFERRED | PA | |
| ANTIDIABETICS | MYXREDLIN | NON-PREFERRED | ||
| ANTIDIABETICS | NATEGLINIDE | GENERIC | ||
| ANTIDIABETICS | NOVOLOG | EXCLUDED | ||
| ANTIDIABETICS | NOVOLOG FLEXPEN | EXCLUDED | ||
| ANTIDIABETICS | NOVOLOG FLEXPEN RELION | EXCLUDED | ||
| ANTIDIABETICS | NOVOLOG MIX 70/30 | EXCLUDED | ||
| ANTIDIABETICS | NOVOLOG MIX 70/30 PREFILL ED FLEXPEN | EXCLUDED | ||
| ANTIDIABETICS | NOVOLOG MIX 70/30 PREFILL ED FLEXPEN RELION | EXCLUDED | ||
| ANTIDIABETICS | NOVOLOG MIX 70/30 RELION | EXCLUDED | ||
| ANTIDIABETICS | NOVOLOG PENFILL | EXCLUDED | ||
| ANTIDIABETICS | NOVOLOG RELION | EXCLUDED | ||
| ANTIDIABETICS | OZEMPIC | PREFERRED | PA | |
| ANTIDIABETICS | PIOGLITAZONE HCL | GENERIC | ||
| ANTIDIABETICS | PIOGLITAZONE HCL/METFORMI N HCL | GENERIC | ||
| ANTIDIABETICS | PIOGLITAZONE HCL-GLIMEPIR IDE | GENERIC | ||
| ANTIDIABETICS | PIOGLITAZONE HYDROCHLORID E | GENERIC | ||
| ANTIDIABETICS | PROGLYCEM | EXCLUDED | ||
| ANTIDIABETICS | REPAGLINIDE | GENERIC | ||
| ANTIDIABETICS | REZVOGLAR KWIKPEN | EXCLUDED | ||
| ANTIDIABETICS | RIOMET | EXCLUDED | ||
| ANTIDIABETICS | RYBELSUS | PREFERRED | PA | |
| ANTIDIABETICS | SAXAGLIPTIN HYDROCHLORIDE | GENERIC | ||
| ANTIDIABETICS | SAXAGLIPTIN HYDROCHLORIDE /METFORMIN HYDROCHLORIDE ER | EXCLUDED | ||
| ANTIDIABETICS | SEGLUROMET | EXCLUDED | ||
| ANTIDIABETICS | SEMGLEE | EXCLUDED | ||
| ANTIDIABETICS | SITAGLIPTIN | EXCLUDED | ||
| ANTIDIABETICS | SITAGLIPTIN/METFORMIN HYD ROCHLORIDE | EXCLUDED | ||
| ANTIDIABETICS | SOLIQUA 100/33 | PREFERRED | PA | |
| ANTIDIABETICS | STEGLATRO | EXCLUDED | ||
| ANTIDIABETICS | STEGLUJAN | EXCLUDED | ||
| ANTIDIABETICS | SYNJARDY | PREFERRED | ||
| ANTIDIABETICS | SYNJARDY XR | PREFERRED | ||
| ANTIDIABETICS | TOUJEO MAX SOLOSTAR | EXCLUDED | ||
| ANTIDIABETICS | TOUJEO SOLOSTAR | EXCLUDED | ||
| ANTIDIABETICS | TRADJENTA | EXCLUDED | ||
| ANTIDIABETICS | TRESIBA | PREFERRED | ||
| ANTIDIABETICS | TRESIBA FLEXTOUCH | PREFERRED | ||
| ANTIDIABETICS | TRIJARDY XR | PREFERRED | ||
| ANTIDIABETICS | TRULICITY | PREFERRED | PA | |
| ANTIDIABETICS | TZIELD | EXCLUDED | SP | PA |
| ANTIDIABETICS | VICTOZA | EXCLUDED | PA | |
| ANTIDIABETICS | XIGDUO XR | EXCLUDED | ||
| ANTIDIABETICS | XULTOPHY 100/3.6 | PREFERRED | PA | |
| ANTIDIABETICS | ZITUVIMET | EXCLUDED | ||
| ANTIDIABETICS | ZITUVIMET XR | EXCLUDED | ||
| ANTIDIABETICS | ZITUVIO | EXCLUDED | ||
| ANTIDIARRHEAL/PROBIOTIC AGENTS | DIPHENOXYLATE HYDROCHLORI DE/ATROPINE SULFATE | GENERIC | ||
| ANTIDIARRHEAL/PROBIOTIC AGENTS | DIPHENOXYLATE/ATROPINE | PREFERRED | ||
| ANTIDIARRHEAL/PROBIOTIC AGENTS | LOMOTIL | EXCLUDED | ||
| ANTIDIARRHEAL/PROBIOTIC AGENTS | LOPERAMIDE HYDROCHLORIDE | GENERIC | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | ACETADOTE | EXCLUDED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | ACETYLCYSTEINE | GENERIC | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | BRIDION | EXCLUDED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | CHEMET | PREFERRED | PA | |
| ANTIDOTES AND SPECIFIC ANTAGONISTS | CYANOKIT | PREFERRED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | DEFERASIROX | GENERIC | SP | PA |
| ANTIDOTES AND SPECIFIC ANTAGONISTS | DEFERIPRONE | GENERIC | SP | PA |
| ANTIDOTES AND SPECIFIC ANTAGONISTS | DEFEROXAMINE MESYLATE | GENERIC | SP | PA |
| ANTIDOTES AND SPECIFIC ANTAGONISTS | DESFERAL | EXCLUDED | SP | PA |
| ANTIDOTES AND SPECIFIC ANTAGONISTS | DIGIFAB | EXCLUDED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | EDETATE CALCIUM DISODIUM | EXCLUDED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | EXJADE | EXCLUDED | SP | PA |
| ANTIDOTES AND SPECIFIC ANTAGONISTS | FERRIPROX | PREFERRED | SP | PA |
| ANTIDOTES AND SPECIFIC ANTAGONISTS | FERRIPROX | NON-PREFERRED | SP | PA |
| ANTIDOTES AND SPECIFIC ANTAGONISTS | FERRIPROX TWICE-A-DAY | NON-PREFERRED | SP | PA |
| ANTIDOTES AND SPECIFIC ANTAGONISTS | FLUMAZENIL | GENERIC | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | FOMEPIZOLE | EXCLUDED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | JADENU | EXCLUDED | SP | PA |
| ANTIDOTES AND SPECIFIC ANTAGONISTS | JADENU SPRINKLE | EXCLUDED | SP | PA |
| ANTIDOTES AND SPECIFIC ANTAGONISTS | KLOXXADO | PREFERRED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | METHYLENE BLUE | GENERIC | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | METHYLENE BLUE | EXCLUDED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | NALMEFENE HYDROCHLORIDE | EXCLUDED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | NALOXONE HCL | GENERIC | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | NALOXONE HYDROCHLORIDE | PREFERRED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | NALOXONE HYDROCHLORIDE | GENERIC | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | NALTREXONE HYDROCHLORIDE | GENERIC | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | NITHIODOTE | NON-PREFERRED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | OPVEE | PREFERRED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | PENTETATE CALCIUM TRISODI UM | PREFERRED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | PENTETATE ZINC TRISODIUM | PREFERRED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | PRAXBIND | NON-PREFERRED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | PREVDUO | EXCLUDED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | PROTOPAM CHLORIDE | EXCLUDED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | PROVAYBLUE | PREFERRED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | PROVAYBLUE | EXCLUDED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | PYRIDOSTIGMINE BROMIDE ER | NON-PREFERRED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | RADIOGARDASE | NON-PREFERRED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | REXTOVY | EXCLUDED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | SODIUM NITRITE | EXCLUDED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | SODIUM THIOSULFATE | PREFERRED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | SUGAMMADEX SODIUM | EXCLUDED | ||
| ANTIDOTES AND SPECIFIC ANTAGONISTS | VISTOGARD | PREFERRED | SP | PA |
| ANTIDOTES AND SPECIFIC ANTAGONISTS | VIVITROL | PREFERRED | SP | PA |
| ANTIDOTES AND SPECIFIC ANTAGONISTS | ZURNAI | PREFERRED | ||
| ANTIEMETICS | AKYNZEO | EXCLUDED | PA | |
| ANTIEMETICS | APONVIE | EXCLUDED | PA | |
| ANTIEMETICS | APREPITANT | GENERIC | PA | |
| ANTIEMETICS | BARHEMSYS | NON-PREFERRED | ||
| ANTIEMETICS | CINVANTI | NON-PREFERRED | PA | |
| ANTIEMETICS | DIMENHYDRINATE | PREFERRED | ||
| ANTIEMETICS | DRONABINOL | GENERIC | PA | |
| ANTIEMETICS | EMEND | EXCLUDED | ||
| ANTIEMETICS | EMEND | EXCLUDED | PA | |
| ANTIEMETICS | EMEND BIPACK | EXCLUDED | PA | |
| ANTIEMETICS | EMEND TRIPACK | EXCLUDED | PA | |
| ANTIEMETICS | FOCINVEZ | EXCLUDED | ||
| ANTIEMETICS | FOSAPREPITANT DIMEGLUMINE | GENERIC | ||
| ANTIEMETICS | FOSAPREPITANT DIMEGLUMINE | PREFERRED | ||
| ANTIEMETICS | GRANISETRON HCL | GENERIC | ||
| ANTIEMETICS | GRANISETRON HYDROCHLORIDE | GENERIC | ||
| ANTIEMETICS | MARINOL | EXCLUDED | PA | |
| ANTIEMETICS | MECLIZINE HCL | GENERIC | ||
| ANTIEMETICS | MECLIZINE HYDROCHLORIDE | GENERIC | ||
| ANTIEMETICS | MECLIZINE HYDROCHLORIDE | EXCLUDED | ||
| ANTIEMETICS | ONDANSETRON HCL | GENERIC | ||
| ANTIEMETICS | ONDANSETRON HYDROCHLORIDE | GENERIC | ||
| ANTIEMETICS | ONDANSETRON HYDROCHLORIDE | PREFERRED | ||
| ANTIEMETICS | ONDANSETRON ODT | GENERIC | ||
| ANTIEMETICS | ONDANSETRON ODT | EXCLUDED | ||
| ANTIEMETICS | PALONOSETRON HYDROCHLORID E | GENERIC | ||
| ANTIEMETICS | PALONOSETRON HYDROCHLORID E | PREFERRED | ||
| ANTIEMETICS | POSFREA | EXCLUDED | ||
| ANTIEMETICS | SANCUSO | PREFERRED | PA | |
| ANTIEMETICS | SCOPOLAMINE | GENERIC | ||
| ANTIEMETICS | TIGAN | EXCLUDED | ||
| ANTIEMETICS | TRIMETHOBENZAMIDE HYDROCH LORIDE | GENERIC | ||
| ANTIEMETICS | VARUBI | PREFERRED | PA | |
| ANTIFUNGALS | AMBISOME | EXCLUDED | ||
| ANTIFUNGALS | AMPHOTERICIN B | PREFERRED | ||
| ANTIFUNGALS | AMPHOTERICIN B LIPOSOME | EXCLUDED | ||
| ANTIFUNGALS | ANCOBON | EXCLUDED | PA | |
| ANTIFUNGALS | CASPOFUNGIN ACETATE | GENERIC | ||
| ANTIFUNGALS | CASPOFUNGIN ACETATE | PREFERRED | ||
| ANTIFUNGALS | CRESEMBA | PREFERRED | PA | |
| ANTIFUNGALS | DIFLUCAN | EXCLUDED | ||
| ANTIFUNGALS | ERAXIS | PREFERRED | ||
| ANTIFUNGALS | ERAXIS | NON-PREFERRED | ||
| ANTIFUNGALS | FLUCONAZOLE | GENERIC | ||
| ANTIFUNGALS | FLUCONAZOLE IN NACL | GENERIC | ||
| ANTIFUNGALS | FLUCONAZOLE IN SODIUM CHL ORIDE | GENERIC | ||
| ANTIFUNGALS | FLUCYTOSINE | GENERIC | PA | |
| ANTIFUNGALS | GRISEOFULVIN MICROSIZE | GENERIC | ||
| ANTIFUNGALS | GRISEOFULVIN ULTRAMICROSI ZE | GENERIC | ||
| ANTIFUNGALS | GRISEOFULVIN ULTRAMICROSI ZE | PREFERRED | ||
| ANTIFUNGALS | ITRACONAZOLE | GENERIC | ||
| ANTIFUNGALS | KETOCONAZOLE | GENERIC | ||
| ANTIFUNGALS | MICAFUNGIN | GENERIC | ||
| ANTIFUNGALS | MICAFUNGIN | PREFERRED | ||
| ANTIFUNGALS | MICAFUNGIN SODIUM/SODIUM CHLORIDE | EXCLUDED | ||
| ANTIFUNGALS | MICAFUNGIN/SODIUM CHLORID E | EXCLUDED | ||
| ANTIFUNGALS | NOXAFIL | PREFERRED | PA | |
| ANTIFUNGALS | NOXAFIL | EXCLUDED | PA | |
| ANTIFUNGALS | NYSTATIN | GENERIC | ||
| ANTIFUNGALS | POSACONAZOLE | GENERIC | PA | |
| ANTIFUNGALS | POSACONAZOLE DR | GENERIC | PA | |
| ANTIFUNGALS | REZZAYO | EXCLUDED | ||
| ANTIFUNGALS | SPORANOX | EXCLUDED | ||
| ANTIFUNGALS | TERBINAFINE HCL | GENERIC | ||
| ANTIFUNGALS | TERBINAFINE HYDROCHLORIDE | GENERIC | ||
| ANTIFUNGALS | VFEND | EXCLUDED | PA | |
| ANTIFUNGALS | VFEND IV | EXCLUDED | PA | |
| ANTIFUNGALS | VIVJOA | EXCLUDED | PA | |
| ANTIFUNGALS | VORICONAZOLE | GENERIC | PA | |
| ANTIFUNGALS | VORICONAZOLE | PREFERRED | PA | |
| ANTIHISTAMINES | CARBINOXAMINE MALEATE | GENERIC | ||
| ANTIHISTAMINES | CARBINOXAMINE MALEATE | PREFERRED | ||
| ANTIHISTAMINES | CARBINOXAMINE MALEATE ER | EXCLUDED | ||
| ANTIHISTAMINES | CARBZAH | PREFERRED | ||
| ANTIHISTAMINES | CETIRIZINE HYDROCHLORIDE | GENERIC | ||
| ANTIHISTAMINES | CLARINEX | EXCLUDED | ||
| ANTIHISTAMINES | CLEMASTINE FUMARATE | PREFERRED | ||
| ANTIHISTAMINES | CLEMSZA | PREFERRED | ||
| ANTIHISTAMINES | CYPROHEPTADINE HCL | GENERIC | ||
| ANTIHISTAMINES | CYPROHEPTADINE HYDROCHLOR IDE | GENERIC | ||
| ANTIHISTAMINES | DESLORATADINE | GENERIC | ||
| ANTIHISTAMINES | DESLORATADINE | EXCLUDED | ||
| ANTIHISTAMINES | DESLORATADINE ODT | PREFERRED | ||
| ANTIHISTAMINES | DIPHENHYDRAMINE HYDROCHLO RIDE | GENERIC | ||
| ANTIHISTAMINES | KARBINAL ER | EXCLUDED | ||
| ANTIHISTAMINES | LEVOCETIRIZINE DIHYDROCHL ORIDE | GENERIC | ||
| ANTIHISTAMINES | PHENERGAN | EXCLUDED | ||
| ANTIHISTAMINES | PROMETHAZINE HCL | GENERIC | ||
| ANTIHISTAMINES | PROMETHAZINE HYDROCHLORID E | GENERIC | ||
| ANTIHISTAMINES | PROMETHAZINE HYDROCHLORID E PLAIN | GENERIC | ||
| ANTIHISTAMINES | PROMETHEGAN | PREFERRED | ||
| ANTIHISTAMINES | PROMETHEGAN | GENERIC | ||
| ANTIHISTAMINES | RYCLORA | EXCLUDED | ||
| ANTIHYPERLIPIDEMICS | ATORVASTATIN CALCIUM | GENERIC | ||
| ANTIHYPERLIPIDEMICS | CHOLESTYRAMINE | GENERIC | ||
| ANTIHYPERLIPIDEMICS | CHOLESTYRAMINE LIGHT | GENERIC | ||
| ANTIHYPERLIPIDEMICS | COLESEVELAM HYDROCHLORIDE | GENERIC | ||
| ANTIHYPERLIPIDEMICS | COLESEVELAM HYDROCHLORIDE | EXCLUDED | ||
| ANTIHYPERLIPIDEMICS | COLESTID | EXCLUDED | ||
| ANTIHYPERLIPIDEMICS | COLESTIPOL HYDROCHLORIDE | GENERIC | ||
| ANTIHYPERLIPIDEMICS | CRESTOR | EXCLUDED | ||
| ANTIHYPERLIPIDEMICS | EVKEEZA | EXCLUDED | SP | PA |
| ANTIHYPERLIPIDEMICS | EZETIMIBE | GENERIC | ||
| ANTIHYPERLIPIDEMICS | FENOFIBRATE | GENERIC | ||
| ANTIHYPERLIPIDEMICS | FENOFIBRATE | EXCLUDED | ||
| ANTIHYPERLIPIDEMICS | FENOFIBRATE MICRONIZED | GENERIC | ||
| ANTIHYPERLIPIDEMICS | FENOFIBRIC ACID DR | GENERIC | ||
| ANTIHYPERLIPIDEMICS | FLUVASTATIN | GENERIC | ||
| ANTIHYPERLIPIDEMICS | FLUVASTATIN SODIUM ER | GENERIC | ||
| ANTIHYPERLIPIDEMICS | GEMFIBROZIL | GENERIC | ||
| ANTIHYPERLIPIDEMICS | ICOSAPENT ETHYL | EXCLUDED | ||
| ANTIHYPERLIPIDEMICS | JUXTAPID | PREFERRED | SP | PA |
| ANTIHYPERLIPIDEMICS | LEQVIO | EXCLUDED | PA | |
| ANTIHYPERLIPIDEMICS | LIPITOR | EXCLUDED | ||
| ANTIHYPERLIPIDEMICS | LIPOFEN | EXCLUDED | ||
| ANTIHYPERLIPIDEMICS | LIVALO | EXCLUDED | ||
| ANTIHYPERLIPIDEMICS | LOPID | EXCLUDED | ||
| ANTIHYPERLIPIDEMICS | LOVASTATIN | GENERIC | ||
| ANTIHYPERLIPIDEMICS | LOVAZA | EXCLUDED | ||
| ANTIHYPERLIPIDEMICS | NEXLIZET | PREFERRED | ||
| ANTIHYPERLIPIDEMICS | NIACIN ER | GENERIC | ||
| ANTIHYPERLIPIDEMICS | NIACOR | EXCLUDED | ||
| ANTIHYPERLIPIDEMICS | OMEGA-3-ACID ETHYL ESTERS | GENERIC | ||
| ANTIHYPERLIPIDEMICS | PITAVASTATIN CALCIUM | GENERIC | ||
| ANTIHYPERLIPIDEMICS | PRALUENT | EXCLUDED | PA | |
| ANTIHYPERLIPIDEMICS | PRAVASTATIN SODIUM | GENERIC | ||
| ANTIHYPERLIPIDEMICS | PREVALITE | GENERIC | ||
| ANTIHYPERLIPIDEMICS | QUESTRAN | EXCLUDED | ||
| ANTIHYPERLIPIDEMICS | QUESTRAN LIGHT | EXCLUDED | ||
| ANTIHYPERLIPIDEMICS | REPATHA | PREFERRED | PA | |
| ANTIHYPERLIPIDEMICS | REPATHA SURECLICK | PREFERRED | PA | |
| ANTIHYPERLIPIDEMICS | ROSUVASTATIN CALCIUM | GENERIC | ||
| ANTIHYPERLIPIDEMICS | SIMVASTATIN | GENERIC | ||
| ANTIHYPERLIPIDEMICS | TRICOR | EXCLUDED | ||
| ANTIHYPERLIPIDEMICS | VASCEPA | PREFERRED | ||
| ANTIHYPERLIPIDEMICS | WELCHOL | EXCLUDED | ||
| ANTIHYPERLIPIDEMICS | ZETIA | EXCLUDED | ||
| ANTIHYPERLIPIDEMICS | ZOCOR | EXCLUDED | ||
| ANTIHYPERTENSIVES | ALISKIREN | EXCLUDED | ||
| ANTIHYPERTENSIVES | AMLODIPINE BESYLATE/BENAZ EPRIL HCL | GENERIC | ||
| ANTIHYPERTENSIVES | AMLODIPINE BESYLATE/BENAZ EPRIL HYDROCHLORIDE | GENERIC | ||
| ANTIHYPERTENSIVES | AMLODIPINE BESYLATE/VALSA RTAN | EXCLUDED | ||
| ANTIHYPERTENSIVES | AMLODIPINE/OLMESARTAN MED OXOMIL | GENERIC | ||
| ANTIHYPERTENSIVES | AMLODIPINE/VALSARTAN/HYDR OCHLOROTHIAZIDE | EXCLUDED | ||
| ANTIHYPERTENSIVES | ARBLI | EXCLUDED | ||
| ANTIHYPERTENSIVES | ATACAND | EXCLUDED | ||
| ANTIHYPERTENSIVES | ATACAND HCT | EXCLUDED | ||
| ANTIHYPERTENSIVES | ATENOLOL/CHLORTHALIDONE | GENERIC | ||
| ANTIHYPERTENSIVES | AVALIDE | EXCLUDED | ||
| ANTIHYPERTENSIVES | AVAPRO | EXCLUDED | ||
| ANTIHYPERTENSIVES | AZOR | EXCLUDED | ||
| ANTIHYPERTENSIVES | BENAZEPRIL HYDROCHLORIDE | GENERIC | ||
| ANTIHYPERTENSIVES | BENAZEPRIL HYDROCHLORIDE/ HYDROCHLOROTHIAZIDE | GENERIC | ||
| ANTIHYPERTENSIVES | BENICAR | EXCLUDED | ||
| ANTIHYPERTENSIVES | BENICAR HCT | EXCLUDED | ||
| ANTIHYPERTENSIVES | BISOPROLOL FUMARATE/HYDRO CHLOROTHIAZIDE | GENERIC | ||
| ANTIHYPERTENSIVES | CANDESARTAN CILEXETIL | GENERIC | ||
| ANTIHYPERTENSIVES | CANDESARTAN CILEXETIL/HYD ROCHLOROTHIAZIDE | GENERIC | ||
| ANTIHYPERTENSIVES | CAPTOPRIL | GENERIC | ||
| ANTIHYPERTENSIVES | CAPTOPRIL/HYDROCHLOROTHIA ZIDE | PREFERRED | ||
| ANTIHYPERTENSIVES | CARDURA | EXCLUDED | ||
| ANTIHYPERTENSIVES | CLONIDINE HYDROCHLORIDE | GENERIC | ||
| ANTIHYPERTENSIVES | CLONIDINE HYDROCHLORIDE E R | EXCLUDED | ||
| ANTIHYPERTENSIVES | COZAAR | EXCLUDED | ||
| ANTIHYPERTENSIVES | DEMSER | NON-PREFERRED | SP | PA |
| ANTIHYPERTENSIVES | DIOVAN | EXCLUDED | ||
| ANTIHYPERTENSIVES | DIOVAN HCT | EXCLUDED | ||
| ANTIHYPERTENSIVES | DOXAZOSIN | GENERIC | ||
| ANTIHYPERTENSIVES | DOXAZOSIN MESYLATE | GENERIC | ||
| ANTIHYPERTENSIVES | EDARBI | EXCLUDED | ||
| ANTIHYPERTENSIVES | EDARBYCLOR | EXCLUDED | ||
| ANTIHYPERTENSIVES | ENALAPRIL MALEATE | GENERIC | ||
| ANTIHYPERTENSIVES | ENALAPRIL MALEATE | EXCLUDED | ||
| ANTIHYPERTENSIVES | ENALAPRIL MALEATE/HYDROCH LOROTHIAZIDE | GENERIC | ||
| ANTIHYPERTENSIVES | ENALAPRILAT | GENERIC | ||
| ANTIHYPERTENSIVES | EPLERENONE | GENERIC | ||
| ANTIHYPERTENSIVES | EXFORGE | EXCLUDED | ||
| ANTIHYPERTENSIVES | EXFORGE HCT | EXCLUDED | ||
| ANTIHYPERTENSIVES | FOSINOPRIL SODIUM | GENERIC | ||
| ANTIHYPERTENSIVES | FOSINOPRIL SODIUM/HYDROCH LOROTHIAZIDE | GENERIC | ||
| ANTIHYPERTENSIVES | GUANFACINE HYDROCHLORIDE | GENERIC | ||
| ANTIHYPERTENSIVES | HYDRALAZINE HYDROCHLORIDE | GENERIC | ||
| ANTIHYPERTENSIVES | HYZAAR | EXCLUDED | ||
| ANTIHYPERTENSIVES | INSPRA | EXCLUDED | ||
| ANTIHYPERTENSIVES | IRBESARTAN | GENERIC | ||
| ANTIHYPERTENSIVES | IRBESARTAN/HYDROCHLOROTHI AZIDE | GENERIC | ||
| ANTIHYPERTENSIVES | JAVADIN | EXCLUDED | ||
| ANTIHYPERTENSIVES | LISINOPRIL | GENERIC | ||
| ANTIHYPERTENSIVES | LISINOPRIL/HYDROCHLOROTHI AZIDE | GENERIC | ||
| ANTIHYPERTENSIVES | LOSARTAN POTASSIUM | GENERIC | ||
| ANTIHYPERTENSIVES | LOSARTAN POTASSIUM/HYDROC HLOROTHIAZIDE | GENERIC | ||
| ANTIHYPERTENSIVES | LOTENSIN | EXCLUDED | ||
| ANTIHYPERTENSIVES | LOTENSIN HCT | EXCLUDED | ||
| ANTIHYPERTENSIVES | LOTREL | EXCLUDED | ||
| ANTIHYPERTENSIVES | METHYLDOPA | GENERIC | ||
| ANTIHYPERTENSIVES | METHYLDOPA | PREFERRED | ||
| ANTIHYPERTENSIVES | METOPROLOL/HYDROCHLOROTHI AZIDE | GENERIC | ||
| ANTIHYPERTENSIVES | METYROSINE | GENERIC | SP | PA |
| ANTIHYPERTENSIVES | MICARDIS | EXCLUDED | ||
| ANTIHYPERTENSIVES | MICARDIS HCT | EXCLUDED | ||
| ANTIHYPERTENSIVES | MINOXIDIL | GENERIC | ||
| ANTIHYPERTENSIVES | MOEXIPRIL HYDROCHLORIDE | GENERIC | ||
| ANTIHYPERTENSIVES | NEXICLON XR | EXCLUDED | ||
| ANTIHYPERTENSIVES | NIPRIDE RTU | NON-PREFERRED | ||
| ANTIHYPERTENSIVES | OLMESARTAN MEDOXOMIL | GENERIC | ||
| ANTIHYPERTENSIVES | OLMESARTAN MEDOXOMIL/AMLO DIPINE/HYDROCHLOROTHIAZIDE | GENERIC | ||
| ANTIHYPERTENSIVES | OLMESARTAN MEDOXOMIL/HYDR OCHLOROTHIAZIDE | GENERIC | ||
| ANTIHYPERTENSIVES | PERINDOPRIL ERBUMINE | PREFERRED | ||
| ANTIHYPERTENSIVES | PERINDOPRIL ERBUMINE | GENERIC | ||
| ANTIHYPERTENSIVES | PHENOXYBENZAMINE HYDROCHL ORIDE | GENERIC | PA | |
| ANTIHYPERTENSIVES | PHENTOLAMINE MESYLATE | GENERIC | ||
| ANTIHYPERTENSIVES | PRAZOSIN HYDROCHLORIDE | GENERIC | ||
| ANTIHYPERTENSIVES | PRESTALIA | EXCLUDED | ||
| ANTIHYPERTENSIVES | QUINAPRIL HYDROCHLORIDE | GENERIC | ||
| ANTIHYPERTENSIVES | QUINAPRIL/HYDROCHLOROTHIA ZIDE | PREFERRED | ||
| ANTIHYPERTENSIVES | RAMIPRIL | GENERIC | ||
| ANTIHYPERTENSIVES | SODIUM NITROPRUSSIDE | GENERIC | ||
| ANTIHYPERTENSIVES | SODIUM NITROPRUSSIDE/SODI UM CHLORIDE | EXCLUDED | ||
| ANTIHYPERTENSIVES | TEKTURNA | EXCLUDED | ||
| ANTIHYPERTENSIVES | TELMISARTAN | GENERIC | ||
| ANTIHYPERTENSIVES | TELMISARTAN/AMLODIPINE | PREFERRED | ||
| ANTIHYPERTENSIVES | TELMISARTAN/HYDROCHLOROTH IAZIDE | GENERIC | ||
| ANTIHYPERTENSIVES | TENORETIC 100 | EXCLUDED | ||
| ANTIHYPERTENSIVES | TENORETIC 50 | EXCLUDED | ||
| ANTIHYPERTENSIVES | TERAZOSIN HCL | GENERIC | ||
| ANTIHYPERTENSIVES | TERAZOSIN HYDROCHLORIDE | GENERIC | ||
| ANTIHYPERTENSIVES | TEZRULY | EXCLUDED | ||
| ANTIHYPERTENSIVES | TRANDOLAPRIL | GENERIC | ||
| ANTIHYPERTENSIVES | TRANDOLAPRIL/VERAPAMIL HC L ER | PREFERRED | ||
| ANTIHYPERTENSIVES | TRIBENZOR | EXCLUDED | ||
| ANTIHYPERTENSIVES | TRYVIO | EXCLUDED | ||
| ANTIHYPERTENSIVES | VALSARTAN | GENERIC | ||
| ANTIHYPERTENSIVES | VALSARTAN | EXCLUDED | ||
| ANTIHYPERTENSIVES | VALSARTAN/HYDROCHLOROTHIA ZIDE | GENERIC | ||
| ANTIHYPERTENSIVES | VASERETIC | EXCLUDED | ||
| ANTIHYPERTENSIVES | ZESTORETIC | EXCLUDED | ||
| ANTIHYPERTENSIVES | ZESTRIL | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | ATOVAQUONE | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | AZACTAM | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | AZTREONAM | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | BACTRIM | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | BACTRIM DS | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | CAYSTON | PREFERRED | SP | PA |
| ANTI-INFECTIVE AGENTS - MISC. | CHLORAMPHENICOL SODIUM SU CCINATE | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | CLEOCIN | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | CLEOCIN PHOSPHATE | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | CLINDAMYCIN HCL | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | CLINDAMYCIN HYDROCHLORIDE | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | CLINDAMYCIN PALMITATE HYD ROCHLORIDE | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | CLINDAMYCIN PHOSPHATE | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | CLINDAMYCIN PHOSPHATE IN D5W | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | CLINDAMYCIN PHOSPHATE IN D5W | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | CLINDAMYCIN PHOSPHATE/DEX TROSE | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | CLINDAMYCIN/SODIUM CHLORI DE | NON-PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | COLISTIMETHATE SODIUM | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | COLY-MYCIN M | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | DALVANCE | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | DAPSONE | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | DAPTOMYCIN | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | DAPTOMYCIN | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | DAPTOMYCIN | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | DAPTOMYCIN/SODIUM CHLORID E | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | EMBLAVEO | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | ERTAPENEM SODIUM | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | FIRVANQ | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | FOSFOMYCIN TROMETHAMINE | GENERIC | PA | |
| ANTI-INFECTIVE AGENTS - MISC. | IMIPENEM/CILASTATIN | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | IMIPENEM/CILASTATIN | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | IMPAVIDO | PREFERRED | PA | |
| ANTI-INFECTIVE AGENTS - MISC. | KIMYRSA | NON-PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | LAMPIT | NON-PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | LIKMEZ | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | LINCOCIN | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | LINCOMYCIN HYDROCHLORIDE | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | LINEZOLID | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | LINEZOLID | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | MACROBID | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | ME/NAPHOS/MB/HYO 1 | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | MEPRON | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | MEROPENEM | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | MEROPENEM | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | MEROPENEM/SODIUM CHLORIDE | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | METHENAMINE HIPPURATE | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | METHENAMINE MANDELATE | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | METRONIDAZOLE | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | METRONIDAZOLE | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | NEBUPENT | NON-PREFERRED | PA | |
| ANTI-INFECTIVE AGENTS - MISC. | NITAZOXANIDE | GENERIC | PA | |
| ANTI-INFECTIVE AGENTS - MISC. | NITROFURANTOIN | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | NITROFURANTOIN | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | NITROFURANTOIN MACROCRYST ALS | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | NITROFURANTOIN MONOHYDRAT E | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | NITROFURANTOIN MONOHYDRAT E/MACROCRYSTALS | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | ORBACTIV | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | ORLYNVAH | NON-PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | PENTAM 300 | EXCLUDED | PA | |
| ANTI-INFECTIVE AGENTS - MISC. | PENTAMIDINE ISETHIONATE | GENERIC | PA | |
| ANTI-INFECTIVE AGENTS - MISC. | PENTAMIDINE ISETHIONATE | EXCLUDED | PA | |
| ANTI-INFECTIVE AGENTS - MISC. | POLYMYXIN B SULFATE | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | PRIMAXIN IV | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | RECARBRIO | NON-PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | SIVEXTRO | NON-PREFERRED | PA | |
| ANTI-INFECTIVE AGENTS - MISC. | SULFAMETHOXAZOLE/TRIMETHO PRIM | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | SULFAMETHOXAZOLE/TRIMETHO PRIM DS | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | SULFATRIM PEDIATRIC | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | TINIDAZOLE | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | TRIMETHOPRIM | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | TRIMETHOPRIM | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | TYZAVAN | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | URELLE | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | URETRON D/S | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | URIBEL | NON-PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | UROGESIC-BLUE | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | URO-MP | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | VABOMERE | NON-PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | VANCOCIN | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | VANCOMYCIN | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | VANCOMYCIN HCL | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | VANCOMYCIN HCL | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | VANCOMYCIN HYDROCHLORIDE | GENERIC | ||
| ANTI-INFECTIVE AGENTS - MISC. | VANCOMYCIN HYDROCHLORIDE | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | VANCOMYCIN HYDROCHLORIDE | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | VANCOMYCIN HYDROCHLORIDE/ SODIUM CHLORIDE | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | VANCOMYCIN HYDROCHLORIDE/ DEXTROSE | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | VANCOMYCIN HYDROCHLORIDE/ DEXTROSE | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | VANCOMYCIN HYDROCHLORIDE/ SODIUM CHLORIDE | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | VIBATIV | PREFERRED | ||
| ANTI-INFECTIVE AGENTS - MISC. | XACDURO | EXCLUDED | ||
| ANTI-INFECTIVE AGENTS - MISC. | XIFAXAN | PREFERRED | PA | |
| ANTI-INFECTIVE AGENTS - MISC. | XIFAXAN | EXCLUDED | PA | |
| ANTI-INFECTIVE AGENTS - MISC. | ZYVOX | EXCLUDED | ||
| ANTIMALARIALS | ARAKODA | NON-PREFERRED | ||
| ANTIMALARIALS | ATOVAQUONE/PROGUANIL HCL | GENERIC | ||
| ANTIMALARIALS | ATOVAQUONE/PROGUANIL HYDR OCHLORIDE | GENERIC | ||
| ANTIMALARIALS | CHLOROQUINE PHOSPHATE | GENERIC | ||
| ANTIMALARIALS | CHLOROQUINE PHOSPHATE | PREFERRED | ||
| ANTIMALARIALS | COARTEM | PREFERRED | ||
| ANTIMALARIALS | DARAPRIM | EXCLUDED | PA | |
| ANTIMALARIALS | HYDROXYCHLOROQUINE SULFAT E | GENERIC | ||
| ANTIMALARIALS | HYDROXYCHLOROQUINE SULFAT E | EXCLUDED | ||
| ANTIMALARIALS | KRINTAFEL | PREFERRED | ||
| ANTIMALARIALS | MALARONE | EXCLUDED | ||
| ANTIMALARIALS | MEFLOQUINE HYDROCHLORIDE | GENERIC | ||
| ANTIMALARIALS | PLAQUENIL | EXCLUDED | ||
| ANTIMALARIALS | PRIMAQUINE PHOSPHATE | PREFERRED | ||
| ANTIMALARIALS | PRIMAQUINE PHOSPHATE | GENERIC | ||
| ANTIMALARIALS | PYRIMETHAMINE | GENERIC | PA | |
| ANTIMALARIALS | QUININE SULFATE | GENERIC | ||
| ANTIMALARIALS | SOVUNA | EXCLUDED | ||
| ANTIMYASTHENIC/CHOLINERGIC AGENTS | BLOXIVERZ | NON-PREFERRED | ||
| ANTIMYASTHENIC/CHOLINERGIC AGENTS | BLOXIVERZ | EXCLUDED | ||
| ANTIMYASTHENIC/CHOLINERGIC AGENTS | FIRDAPSE | EXCLUDED | SP | PA |
| ANTIMYASTHENIC/CHOLINERGIC AGENTS | MESTINON | EXCLUDED | ||
| ANTIMYASTHENIC/CHOLINERGIC AGENTS | NEOSTIGMINE METHYLSULFATE | GENERIC | ||
| ANTIMYASTHENIC/CHOLINERGIC AGENTS | NEOSTIGMINE METHYLSULFATE | NON-PREFERRED | ||
| ANTIMYASTHENIC/CHOLINERGIC AGENTS | NEOSTIGMINE METHYLSULFATE | PREFERRED | ||
| ANTIMYASTHENIC/CHOLINERGIC AGENTS | PYRIDOSTIGMINE BROMIDE | GENERIC | ||
| ANTIMYASTHENIC/CHOLINERGIC AGENTS | PYRIDOSTIGMINE BROMIDE | PREFERRED | ||
| ANTIMYASTHENIC/CHOLINERGIC AGENTS | REGONOL | NON-PREFERRED | ||
| ANTIMYCOBACTERIAL AGENTS | CYCLOSERINE | PREFERRED | PA | |
| ANTIMYCOBACTERIAL AGENTS | ETHAMBUTOL HYDROCHLORIDE | GENERIC | ||
| ANTIMYCOBACTERIAL AGENTS | ISONIAZID | GENERIC | ||
| ANTIMYCOBACTERIAL AGENTS | ISONIAZID | PREFERRED | ||
| ANTIMYCOBACTERIAL AGENTS | PRETOMANID | NON-PREFERRED | PA | |
| ANTIMYCOBACTERIAL AGENTS | PRIFTIN | PREFERRED | ||
| ANTIMYCOBACTERIAL AGENTS | PYRAZINAMIDE | GENERIC | ||
| ANTIMYCOBACTERIAL AGENTS | RIFABUTIN | GENERIC | ||
| ANTIMYCOBACTERIAL AGENTS | RIFAMPIN | GENERIC | ||
| ANTIMYCOBACTERIAL AGENTS | SIRTURO | PREFERRED | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ABIRATERONE ACETATE | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ABIRATERONE ACETATE | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ABIRTEGA | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ABRAXANE | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ACTIMMUNE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ADCETRIS | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ADRIAMYCIN | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ADSTILADRIN | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | AFINITOR | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | AFINITOR DISPERZ | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | AKEEGA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ALECENSA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ALIMTA | EXCLUDED | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ALUNBRIG | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ALYMSYS | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ANASTROZOLE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ANKTIVA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ARIMIDEX | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | AROMASIN | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ARRANON | NON-PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ARSENIC TRIOXIDE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ASPARLAS | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | AUGTYRO | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | AVASTIN | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | AVGEMSI | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | AVMAPKI FAKZYNJA CO-PACK | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | AXTLE | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | AYVAKIT | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | AZACITIDINE | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BALVERSA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BAVENCIO | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BELEODAQ | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BELRAPZO | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BENDAMUSTINE HYDROCHLORID E | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BENDAMUSTINE HYDROCHLORID E | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BENDEKA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BESPONSA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BESREMI | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BEXAROTENE | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BICALUTAMIDE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BIZENGRI | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BLEOMYCIN SULFATE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BLINCYTO | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BORTEZOMIB | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BORUZU | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BOSULIF | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BRAFTOVI | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BRUKINSA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BUSULFAN | GENERIC | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | BUSULFEX | EXCLUDED | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CABOMETYX | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CALQUENCE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CAMCEVI | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CAMPTOSAR | NON-PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CAMPTOSAR | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CAPECITABINE | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CAPRELSA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CARBOPLATIN | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CARMUSTINE | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CASODEX | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CISPLATIN | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CISPLATIN | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CLADRIBINE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CLOFARABINE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | COLUMVI | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | COMETRIQ | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | COPIKTRA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | COSELA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | COTELLIC | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CYCLOPHOSPHAMIDE | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CYCLOPHOSPHAMIDE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CYCLOPHOSPHAMIDE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CYCLOPHOSPHAMIDE MONOHYDR ATE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CYRAMZA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CYTARABINE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CYTARABINE AQUEOUS | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | CYTARABINE AQUEOUS | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DACARBAZINE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DACARBAZINE | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DACTINOMYCIN | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DANYELZA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DANZITEN | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DARZALEX | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DARZALEX FASPRO | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DASATINIB | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DATROWAY | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DAUNORUBICIN HYDROCHLORID E | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DAUNORUBICIN HYDROCHLORID E | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DAURISMO | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DECITABINE | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DEXRAZOXANE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DEXRAZOXANE HYDROCHLORIDE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DOCETAXEL | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DOCETAXEL | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DOCIVYX | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DOXIL | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DOXORUBICIN HCL | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DOXORUBICIN HYDROCHLORIDE | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DOXORUBICIN HYDROCHLORIDE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | DOXORUBICIN HYDROCHLORIDE LIPOSOMAL | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ELAHERE | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ELIGARD | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ELITEK | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ELLENCE | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ELREXFIO | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ELZONRIS | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | EMPLICITI | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | EMRELIS | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ENHERTU | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ENSACOVE | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | EPKINLY | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ERBITUX | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ERIBULIN MESYLATE | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ERIVEDGE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ERLEADA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ERLOTINIB HYDROCHLORIDE | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ETOPOPHOS | NON-PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ETOPOSIDE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ETOPOSIDE | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | EULEXIN | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | EVEROLIMUS | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | EVOMELA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | EXEMESTANE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | FARESTON | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | FASLODEX | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | FEMARA | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | FIRMAGON | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | FLOXURIDINE | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | FLUDARABINE PHOSPHATE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | FLUDARABINE PHOSPHATE | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | FLUOROURACIL | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | FOLOTYN | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | FOTIVDA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | FRINDOVYX | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | FRUZAQLA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | FULVESTRANT | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | FULVESTRANT | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | FYARRO | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | GAVRETO | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | GAZYVA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | GEFITINIB | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | GEMCITABINE HCL | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | GEMCITABINE HYDROCHLORIDE | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | GEMCITABINE HYDROCHLORIDE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | GEMCITABINE HYDROCHLORIDE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | GILOTRIF | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | GLEEVEC | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | GLEOSTINE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | GLIADEL WAFER | NON-PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | GOMEKLI | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | GRAFAPEX | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | HALAVEN | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | HEPZATO/50MM DOUBLE BALLO ON CATHETER | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | HEPZATO/62MM DOUBLE BALLO ON CATHETER | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | HERCEPTIN | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | HERCEPTIN HYLECTA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | HERCESSI | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | HERNEXEOS | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | HERZUMA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | HYCAMTIN | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | HYDROXYUREA | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | HYRNUO | EXCLUDED | SP | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IBRANCE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IBTROZI | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ICLUSIG | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IDAMYCIN PFS | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IDARUBICIN HCL | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IDARUBICIN HYDROCHLORIDE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IDHIFA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IFEX | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IFOSFAMIDE | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IFOSFAMIDE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IMATINIB MESYLATE | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IMBRUVICA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IMDELLTRA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IMFINZI | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IMJUDO | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IMKELDI | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | INLYTA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | INQOVI | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | INREBIC | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IRESSA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IRINOTECAN | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IRINOTECAN HYDROCHLORIDE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ISTODAX | EXCLUDED | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ITOVEBI | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IVRA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IWILFIN | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | IXEMPRA KIT | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | JAKAFI | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | JAYPIRCA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | JELMYTO | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | JEMPERLI | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | JEVTANA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | JYLAMVO | PREFERRED | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KADCYLA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KANJINTI | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KEPIVANCE | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KEYTRUDA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KHAPZORY | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KIMMTRAK | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KISQALI | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KOMZIFTI | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KOSELUGO | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KRAZATI | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KYPROLIS | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | KYXATA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LAPATINIB DITOSYLATE | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LAZCLUZE | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LENVIMA 10 MG DAILY DOSE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LENVIMA 12MG DAILY DOSE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LENVIMA 14 MG DAILY DOSE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LENVIMA 18 MG DAILY DOSE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LENVIMA 20 MG DAILY DOSE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LENVIMA 24 MG DAILY DOSE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LENVIMA 4 MG DAILY DOSE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LENVIMA 8 MG DAILY DOSE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LETROZOLE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LEUCOVORIN CALCIUM | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LEUCOVORIN CALCIUM | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LEUKERAN | PREFERRED | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LEUPROLIDE ACETATE | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LEVOLEUCOVORIN | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LEVOLEUCOVORIN CALCIUM | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LIBTAYO | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LOMUSTINE | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LONSURF | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LOQTORZI | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LORBRENA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LUMAKRAS | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LUNSUMIO | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LUPRON DEPOT (1-MONTH) | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LUPRON DEPOT (3-MONTH) | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LUPRON DEPOT (4-MONTH) | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LUPRON DEPOT (6-MONTH) | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LUTATHERA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LUTRATE DEPOT | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LYMPHIR | EXCLUDED | SP | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LYNOZYFIC | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LYNOZYFIC | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LYNPARZA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LYSODREN | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | LYTGOBI | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MARGENZA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MATULANE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MEGESTROL ACETATE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MEKINIST | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MEKTOVI | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MELPHALAN HYDROCHLORIDE | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MERCAPTOPURINE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MERCAPTOPURINE | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MESNA | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MESNA | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MESNEX | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | METHOTREXATE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | METHOTREXATE | PREFERRED | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | METHOTREXATE SODIUM | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | METHOTREXATE SODIUM | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MITOMYCIN | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MITOMYCIN | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MITOXANTRONE HCL | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MITOXANTRONE HYDROCHLORID E | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MODEYSO | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MONJUVI | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MUTAMYCIN | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MVASI | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MYLERAN | PREFERRED | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | MYLOTARG | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | NELARABINE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | NERLYNX | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | NEXAVAR | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | NILOTINIB | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | NILOTINIB HYDROCHLORIDE | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | NILUTAMIDE | GENERIC | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | NINLARO | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | NIPENT | NON-PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | NUBEQA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ODOMZO | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | OGIVRI | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | OGSIVEO | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | OJEMDA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | OJJAARA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | OMISIRGE | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ONCASPAR | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ONIVYDE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ONTRUZANT | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ONUREG | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | OPDIVO | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | OPDIVO QVANTIG | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | OPDUALAG | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ORGOVYX | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ORSERDU | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | OXALIPLATIN | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | OXALIPLATIN | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PACLITAXEL | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PACLITAXEL | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PACLITAXEL PROTEIN-BOUND PARTICLES | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PACLITAXEL PROTEIN-BOUND PARTICLES | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PADCEV | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PAZOPANIB HYDROCHLORIDE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PAZOPANIB HYDROCHLORIDE | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PEDMARK | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PEMAZYRE | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PEMETREXED | EXCLUDED | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PEMETREXED | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PEMETREXED | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PEMETREXED DISODIUM | EXCLUDED | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PEMFEXY | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PEMRYDI RTU | EXCLUDED | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PERJETA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PHESGO | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PHOTOFRIN | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PIQRAY 200MG DAILY DOSE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PIQRAY 250MG DAILY DOSE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PIQRAY 300MG DAILY DOSE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | POLIVY | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | POMALYST | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | POTELIGEO | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PROLEUKIN | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | PURIXAN | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | QINLOCK | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | RETEVMO | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | REVUFORJ | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | REZLIDHIA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | RIABNI | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | RITUXAN | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | RITUXAN HYCELA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ROMIDEPSIN | EXCLUDED | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ROMVIMZA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ROZLYTREK | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | RUBRACA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | RUXIENCE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | RYBREVANT | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | RYDAPT | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | RYLAZE | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | RYTELO | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | SARCLISA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | SCEMBLIX | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | SOLTAMOX | EXCLUDED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | SORAFENIB | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | SORAFENIB TOSYLATE | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | SPRYCEL | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | STIVARGA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | STRONTIUM CHLORIDE SR-89 | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | SUNITINIB MALATE | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | SUTENT | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TABLOID | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TABRECTA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TAFINLAR | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TAGRISSO | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TALVEY | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TALZENNA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TAMOXIFEN CITRATE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TARGRETIN | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TASIGNA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TAZVERIK | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TECENTRIQ | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TECENTRIQ HYBREZA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TECVAYLI | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TEMODAR | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TEMOZOLOMIDE | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TEMSIROLIMUS | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TEPADINA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TEPADINA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TEPMETKO | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TEPYLUTE | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TEVIMBRA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | THIOTEPA | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TIBSOVO | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TICE BCG | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TIVDAK | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TOPOTECAN HCL | PREFERRED | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TOPOTECAN HCL | GENERIC | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TOPOTECAN HYDROCHLORIDE | GENERIC | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TOREMIFENE CITRATE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TORISEL | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TORPENZ | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TRAZIMERA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TREANDA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TRELSTAR MIXJECT | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TRETINOIN | GENERIC | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TRISENOX | NON-PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TRODELVY | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TRUQAP | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TRUXIMA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TUKYSA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TURALIO | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | TYKERB | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | UNITUXIN | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | UVADEX | NON-PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VABRINTY | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VALRUBICIN | GENERIC | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VALSTAR | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VANFLYTA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VECTIBIX | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VEGZELMA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VELCADE | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VENCLEXTA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VENCLEXTA STARTING PACK | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VERZENIO | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VIDAZA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VINBLASTINE SULFATE | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VINCRISTINE SULFATE | PREFERRED | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VINORELBINE TARTRATE | GENERIC | ||
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VITRAKVI | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VIVIMUSTA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VIZIMPRO | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VONJO | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VORANIGO | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VORAXAZE | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VOTRIENT | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VYLOY | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | VYXEOS | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | WELIREG | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | XALKORI | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | XATMEP | EXCLUDED | PA | |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | XOFIGO | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | XOSPATA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | XPOVIO | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | XPOVIO 60 MG TWICE WEEKLY | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | XPOVIO 80 MG TWICE WEEKLY | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | XTANDI | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | YERVOY | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | YONDELIS | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | YONSA | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ZALTRAP | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ZEJULA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ZELBORAF | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ZEPZELCA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ZEVALIN Y-90 | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ZIIHERA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ZIRABEV | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ZOLADEX | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ZOLINZA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ZUSDURI | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ZYDELIG | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ZYKADIA | PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ZYNLONTA | NON-PREFERRED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ZYNYZ | EXCLUDED | SP | PA |
| ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES | ZYTIGA | EXCLUDED | SP | PA |
| ANTIPARKINSON AND RELATED THERAPY AGENTS | AMANTADINE HCL | GENERIC | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | AMANTADINE HYDROCHLORIDE | GENERIC | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | APOKYN | NON-PREFERRED | SP | PA |
| ANTIPARKINSON AND RELATED THERAPY AGENTS | APOMORPHINE HYDROCHLORIDE | GENERIC | SP | PA |
| ANTIPARKINSON AND RELATED THERAPY AGENTS | AZILECT | EXCLUDED | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | BENZTROPINE MESYLATE | GENERIC | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | BENZTROPINE MESYLATE | EXCLUDED | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | BROMOCRIPTINE MESYLATE | GENERIC | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | CARBIDOPA | GENERIC | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | CARBIDOPA/LEVODOPA | GENERIC | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | CARBIDOPA/LEVODOPA ER | GENERIC | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | CARBIDOPA/LEVODOPA ODT | GENERIC | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | CARBIDOPA/LEVODOPA/ENTACA PONE | GENERIC | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | CREXONT | NON-PREFERRED | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | DHIVY | EXCLUDED | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | DUOPA | EXCLUDED | SP | PA |
| ANTIPARKINSON AND RELATED THERAPY AGENTS | ENTACAPONE | GENERIC | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | INBRIJA | EXCLUDED | SP | PA |
| ANTIPARKINSON AND RELATED THERAPY AGENTS | LODOSYN | EXCLUDED | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | NEUPRO | EXCLUDED | PA | |
| ANTIPARKINSON AND RELATED THERAPY AGENTS | NOURIANZ | EXCLUDED | PA | |
| ANTIPARKINSON AND RELATED THERAPY AGENTS | ONAPGO | EXCLUDED | SP | PA |
| ANTIPARKINSON AND RELATED THERAPY AGENTS | ONGENTYS | EXCLUDED | PA | |
| ANTIPARKINSON AND RELATED THERAPY AGENTS | PRAMIPEXOLE DIHYDROCHLORI DE | GENERIC | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | RASAGILINE MESYLATE | GENERIC | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | ROPINIROLE ER | GENERIC | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | ROPINIROLE HCL | GENERIC | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | ROPINIROLE HYDROCHLORIDE | GENERIC | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | RYTARY | PREFERRED | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | SELEGILINE HCL | GENERIC | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | SELEGILINE HYDROCHLORIDE | GENERIC | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | SINEMET | EXCLUDED | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | TASMAR | EXCLUDED | PA | |
| ANTIPARKINSON AND RELATED THERAPY AGENTS | TOLCAPONE | GENERIC | PA | |
| ANTIPARKINSON AND RELATED THERAPY AGENTS | TRIHEXYPHENIDYL HCL | PREFERRED | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | TRIHEXYPHENIDYL HYDROCHLO RIDE | GENERIC | ||
| ANTIPARKINSON AND RELATED THERAPY AGENTS | VYALEV | EXCLUDED | SP | PA |
| ANTIPARKINSON AND RELATED THERAPY AGENTS | XADAGO | EXCLUDED | PA | |
| ANTIPARKINSON AND RELATED THERAPY AGENTS | ZELAPAR | EXCLUDED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | ABILIFY | EXCLUDED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | ABILIFY ASIMTUFII | PREFERRED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | ABILIFY MAINTENA | PREFERRED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | ARIPIPRAZOLE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | ARISTADA | PREFERRED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | ARISTADA INITIO | PREFERRED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | ASENAPINE MALEATE SL | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | CAPLYTA | NON-PREFERRED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | CHLORPROMAZINE HCL | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | CHLORPROMAZINE HYDROCHLOR IDE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | CHLORPROMAZINE HYDROCHLOR IDE | EXCLUDED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | CLOZAPINE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | CLOZAPINE ODT | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | CLOZAPINE ODT | EXCLUDED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | CLOZARIL | EXCLUDED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | COBENFY | NON-PREFERRED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | COBENFY STARTER PACK | NON-PREFERRED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | COMPRO | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | EQUETRO | EXCLUDED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | ERZOFRI | PREFERRED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | ERZOFRI | NON-PREFERRED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | FANAPT | NON-PREFERRED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | FANAPT TITRATION PACK A | NON-PREFERRED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | FANAPT TITRATION PACK B | NON-PREFERRED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | FANAPT TITRATION PACK C | NON-PREFERRED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | FLUPHENAZINE DECANOATE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | FLUPHENAZINE HCL | PREFERRED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | FLUPHENAZINE HYDROCHLORID E | PREFERRED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | FLUPHENAZINE HYDROCHLORID E | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | GEODON | EXCLUDED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | HALOPERIDOL | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | HALOPERIDOL DECANOATE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | HALOPERIDOL LACTATE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | INVEGA | EXCLUDED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | INVEGA HAFYERA | NON-PREFERRED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | INVEGA SUSTENNA | NON-PREFERRED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | INVEGA TRINZA | NON-PREFERRED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | LATUDA | EXCLUDED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | LITHIUM | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | LITHIUM CARBONATE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | LITHIUM CARBONATE | PREFERRED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | LITHIUM CARBONATE ER | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | LITHOBID | EXCLUDED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | LOXAPINE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | LOXAPINE SUCCINATE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | LURASIDONE HYDROCHLORIDE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | MOLINDONE HYDROCHLORIDE | PREFERRED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | NUPLAZID | NON-PREFERRED | SP | PA |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | OLANZAPINE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | OPIPZA | EXCLUDED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | PALIPERIDONE ER | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | PERPHENAZINE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | PROCHLORPERAZINE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | PROCHLORPERAZINE EDISYLAT E | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | PROCHLORPERAZINE MALEATE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | QUETIAPINE FUMARATE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | QUETIAPINE FUMARATE | EXCLUDED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | QUETIAPINE FUMARATE ER | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | REXULTI | NON-PREFERRED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | RISPERDAL | EXCLUDED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | RISPERDAL CONSTA | EXCLUDED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | RISPERIDONE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | RISPERIDONE ER | GENERIC | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | RISPERIDONE ODT | PREFERRED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | RISPERIDONE ODT | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | RYKINDO | PREFERRED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | SAPHRIS | EXCLUDED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | SECUADO | EXCLUDED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | SEROQUEL | EXCLUDED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | SEROQUEL XR | EXCLUDED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | THIORIDAZINE HYDROCHLORID E | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | THIOTHIXENE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | TRIFLUOPERAZINE HCL | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | TRIFLUOPERAZINE HYDROCHLO RIDE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | VERSACLOZ | EXCLUDED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | VRAYLAR | NON-PREFERRED | PA | |
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | ZIPRASIDONE HCL | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | ZIPRASIDONE HYDROCHLORIDE | GENERIC | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | ZIPRASIDONE MESYLATE | EXCLUDED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | ZYPREXA | EXCLUDED | ||
| ANTIPSYCHOTICS/ANTIMANIC AGENTS | ZYPREXA RELPREVV | NON-PREFERRED | PA | |
| ANTIVIRALS | ABACAVIR | GENERIC | ||
| ANTIVIRALS | ABACAVIR SULFATE | GENERIC | ||
| ANTIVIRALS | ABACAVIR SULFATE/LAMIVUDI NE | GENERIC | ||
| ANTIVIRALS | ACYCLOVIR | GENERIC | ||
| ANTIVIRALS | ACYCLOVIR SODIUM | GENERIC | ||
| ANTIVIRALS | ACYCLOVIR SODIUM/SODIUM C HLORIDE | PREFERRED | ||
| ANTIVIRALS | ADEFOVIR DIPIVOXIL | GENERIC | PA | |
| ANTIVIRALS | APRETUDE | PREFERRED | PA | |
| ANTIVIRALS | APTIVUS | PREFERRED | ||
| ANTIVIRALS | ATAZANAVIR | GENERIC | ||
| ANTIVIRALS | ATAZANAVIR SULFATE | GENERIC | ||
| ANTIVIRALS | BARACLUDE | PREFERRED | PA | |
| ANTIVIRALS | BARACLUDE | EXCLUDED | PA | |
| ANTIVIRALS | BIKTARVY | PREFERRED | ||
| ANTIVIRALS | CABENUVA | PREFERRED | PA | |
| ANTIVIRALS | CIDOFOVIR | GENERIC | ||
| ANTIVIRALS | CIMDUO | PREFERRED | ||
| ANTIVIRALS | COMPLERA | EXCLUDED | ||
| ANTIVIRALS | DARUNAVIR | GENERIC | ||
| ANTIVIRALS | DARUNAVIR | EXCLUDED | ||
| ANTIVIRALS | DELSTRIGO | EXCLUDED | ||
| ANTIVIRALS | DESCOVY | PREFERRED | ||
| ANTIVIRALS | DOVATO | PREFERRED | ||
| ANTIVIRALS | EDURANT | PREFERRED | ||
| ANTIVIRALS | EDURANT PED | PREFERRED | ||
| ANTIVIRALS | EFAVIRENZ | GENERIC | ||
| ANTIVIRALS | EFAVIRENZ/EMTRICITABINE/T ENOFOVIR DISOPROXIL FUMARATE | EXCLUDED | ||
| ANTIVIRALS | EFAVIRENZ/LAMIVUDINE/TENO FOVIR DISOPROXIL FUMARATE | GENERIC | ||
| ANTIVIRALS | EFAVIRENZ/LAMIVUDINE/TENO FOVIR DISOPROXIL FUMARATE | PREFERRED | ||
| ANTIVIRALS | EMTRICITABINE | GENERIC | ||
| ANTIVIRALS | EMTRICITABINE/RILPIVIRINE /TENOFOVIR DISOPROXIL FUMARATE | EXCLUDED | ||
| ANTIVIRALS | EMTRICITABINE/TENOFOVIR D ISOPROXIL | GENERIC | ||
| ANTIVIRALS | EMTRICITABINE/TENOFOVIR D ISOPROXIL FUMARATE | GENERIC | ||
| ANTIVIRALS | EMTRIVA | PREFERRED | ||
| ANTIVIRALS | EMTRIVA | EXCLUDED | ||
| ANTIVIRALS | ENTECAVIR | GENERIC | PA | |
| ANTIVIRALS | EPCLUSA | PREFERRED | SP | PA |
| ANTIVIRALS | EPIVIR | EXCLUDED | ||
| ANTIVIRALS | ETRAVIRINE | GENERIC | ||
| ANTIVIRALS | EVOTAZ | EXCLUDED | ||
| ANTIVIRALS | FAMCICLOVIR | GENERIC | ||
| ANTIVIRALS | FOSAMPRENAVIR CALCIUM | GENERIC | ||
| ANTIVIRALS | FOSCARNET SODIUM | EXCLUDED | ||
| ANTIVIRALS | FOSCAVIR | EXCLUDED | ||
| ANTIVIRALS | GANCICLOVIR | GENERIC | ||
| ANTIVIRALS | GANCICLOVIR | PREFERRED | ||
| ANTIVIRALS | GENVOYA | PREFERRED | ||
| ANTIVIRALS | HARVONI | PREFERRED | SP | PA |
| ANTIVIRALS | INTELENCE | PREFERRED | ||
| ANTIVIRALS | INTELENCE | EXCLUDED | ||
| ANTIVIRALS | ISENTRESS | PREFERRED | ||
| ANTIVIRALS | ISENTRESS HD | PREFERRED | ||
| ANTIVIRALS | JULUCA | PREFERRED | ||
| ANTIVIRALS | KALETRA | NON-PREFERRED | ||
| ANTIVIRALS | KALETRA | EXCLUDED | ||
| ANTIVIRALS | LAGEVRIO | PREFERRED | ||
| ANTIVIRALS | LAMIVUDINE | GENERIC | ||
| ANTIVIRALS | LAMIVUDINE | GENERIC | PA | |
| ANTIVIRALS | LAMIVUDINE/ZIDOVUDINE | GENERIC | ||
| ANTIVIRALS | LIVTENCITY | PREFERRED | SP | PA |
| ANTIVIRALS | LOPINAVIR/RITONAVIR | GENERIC | ||
| ANTIVIRALS | MARAVIROC | GENERIC | ||
| ANTIVIRALS | MAVYRET | PREFERRED | SP | PA |
| ANTIVIRALS | NEVIRAPINE | GENERIC | ||
| ANTIVIRALS | NEVIRAPINE | PREFERRED | ||
| ANTIVIRALS | NEVIRAPINE ER | GENERIC | ||
| ANTIVIRALS | NORVIR | NON-PREFERRED | ||
| ANTIVIRALS | NORVIR | EXCLUDED | ||
| ANTIVIRALS | ODEFSEY | PREFERRED | ||
| ANTIVIRALS | OSELTAMIVIR PHOSPHATE | GENERIC | ||
| ANTIVIRALS | PAPZIMEOS | NON-PREFERRED | SP | PA |
| ANTIVIRALS | PAXLOVID | NON-PREFERRED | ||
| ANTIVIRALS | PAXLOVID | PREFERRED | ||
| ANTIVIRALS | PEGASYS | EXCLUDED | SP | PA |
| ANTIVIRALS | PIFELTRO | EXCLUDED | ||
| ANTIVIRALS | PREVYMIS | NON-PREFERRED | PA | |
| ANTIVIRALS | PREZCOBIX | NON-PREFERRED | ||
| ANTIVIRALS | PREZCOBIX | EXCLUDED | ||
| ANTIVIRALS | PREZISTA | EXCLUDED | ||
| ANTIVIRALS | RAPIVAB | PREFERRED | ||
| ANTIVIRALS | RELENZA DISKHALER | PREFERRED | ||
| ANTIVIRALS | RETROVIR | EXCLUDED | ||
| ANTIVIRALS | RETROVIR IV INFUSION | PREFERRED | ||
| ANTIVIRALS | REYATAZ | NON-PREFERRED | ||
| ANTIVIRALS | REYATAZ | EXCLUDED | ||
| ANTIVIRALS | RIBAVIRIN | GENERIC | PA | |
| ANTIVIRALS | RIBAVIRIN | PREFERRED | SP | PA |
| ANTIVIRALS | RIMANTADINE HYDROCHLORIDE | PREFERRED | ||
| ANTIVIRALS | RITONAVIR | GENERIC | ||
| ANTIVIRALS | RUKOBIA | PREFERRED | ||
| ANTIVIRALS | SELZENTRY | EXCLUDED | ||
| ANTIVIRALS | SOVALDI | EXCLUDED | SP | PA |
| ANTIVIRALS | STRIBILD | EXCLUDED | ||
| ANTIVIRALS | SUNLENCA | PREFERRED | ||
| ANTIVIRALS | SUNLENCA | PREFERRED | PA | |
| ANTIVIRALS | SYMFI | EXCLUDED | ||
| ANTIVIRALS | SYMTUZA | PREFERRED | ||
| ANTIVIRALS | TAMIFLU | EXCLUDED | ||
| ANTIVIRALS | TEMBEXA | PREFERRED | ||
| ANTIVIRALS | TENOFOVIR DISOPROXIL FUMA RATE | GENERIC | ||
| ANTIVIRALS | TIVICAY | PREFERRED | ||
| ANTIVIRALS | TIVICAY PD | PREFERRED | ||
| ANTIVIRALS | TPOXX | PREFERRED | ||
| ANTIVIRALS | TPOXX | EXCLUDED | ||
| ANTIVIRALS | TRIUMEQ | PREFERRED | ||
| ANTIVIRALS | TRIUMEQ PD | PREFERRED | ||
| ANTIVIRALS | TROGARZO | NON-PREFERRED | PA | |
| ANTIVIRALS | TRUVADA | EXCLUDED | ||
| ANTIVIRALS | TYBOST | NON-PREFERRED | ||
| ANTIVIRALS | VALACYCLOVIR HYDROCHLORID E | GENERIC | ||
| ANTIVIRALS | VALCYTE | EXCLUDED | ||
| ANTIVIRALS | VALGANCICLOVIR | GENERIC | ||
| ANTIVIRALS | VALGANCICLOVIR HYDROCHLOR IDE | GENERIC | ||
| ANTIVIRALS | VALTREX | EXCLUDED | ||
| ANTIVIRALS | VEKLURY | NON-PREFERRED | PA | |
| ANTIVIRALS | VEMLIDY | PREFERRED | PA | |
| ANTIVIRALS | VIRACEPT | PREFERRED | ||
| ANTIVIRALS | VIREAD | NON-PREFERRED | ||
| ANTIVIRALS | VIREAD | EXCLUDED | ||
| ANTIVIRALS | VOSEVI | PREFERRED | SP | PA |
| ANTIVIRALS | XOFLUZA | EXCLUDED | ||
| ANTIVIRALS | YEZTUGO | PREFERRED | ||
| ANTIVIRALS | YEZTUGO | PREFERRED | PA | |
| ANTIVIRALS | ZEPATIER | EXCLUDED | SP | PA |
| ANTIVIRALS | ZIAGEN | EXCLUDED | ||
| ANTIVIRALS | ZIDOVUDINE | GENERIC | ||
| BETA BLOCKERS | ACEBUTOLOL HYDROCHLORIDE | GENERIC | ||
| BETA BLOCKERS | ATENOLOL | GENERIC | ||
| BETA BLOCKERS | BETAPACE AF | EXCLUDED | ||
| BETA BLOCKERS | BETAXOLOL HCL | GENERIC | ||
| BETA BLOCKERS | BISOPROLOL FUMARATE | GENERIC | ||
| BETA BLOCKERS | BISOPROLOL FUMARATE | PREFERRED | ||
| BETA BLOCKERS | BREVIBLOC | EXCLUDED | ||
| BETA BLOCKERS | BREVIBLOC PREMIXED | EXCLUDED | ||
| BETA BLOCKERS | BREVIBLOC PREMIXED DOUBLE STRENGTH | EXCLUDED | ||
| BETA BLOCKERS | BYSTOLIC | EXCLUDED | ||
| BETA BLOCKERS | CARVEDILOL | GENERIC | ||
| BETA BLOCKERS | COREG | EXCLUDED | ||
| BETA BLOCKERS | ESMOLOL HCL | GENERIC | ||
| BETA BLOCKERS | ESMOLOL HYDROCHLORIDE | PREFERRED | ||
| BETA BLOCKERS | ESMOLOL HYDROCHLORIDE IN SODIUM CHLORIDE | GENERIC | ||
| BETA BLOCKERS | ESMOLOL HYDROCHLORIDE IN SODIUM CHLORIDE DOUBLE STRENGTH | GENERIC | ||
| BETA BLOCKERS | ESMOLOL HYDROCHLORIDE IN WATER | PREFERRED | ||
| BETA BLOCKERS | ESMOLOL HYDROCHLORIDE IN WATER DOUBLE STRENGTH | PREFERRED | ||
| BETA BLOCKERS | ESMOLOL HYDROCHLORIDE/SOD IUM CHLORIDE | GENERIC | ||
| BETA BLOCKERS | HEMANGEOL | EXCLUDED | PA | |
| BETA BLOCKERS | INDERAL LA | EXCLUDED | ||
| BETA BLOCKERS | KAPSPARGO SPRINKLE | EXCLUDED | ||
| BETA BLOCKERS | LABETALOL HYDROCHLORIDE | GENERIC | ||
| BETA BLOCKERS | LABETALOL HYDROCHLORIDE | PREFERRED | ||
| BETA BLOCKERS | LABETALOL HYDROCHLORIDE | EXCLUDED | ||
| BETA BLOCKERS | LOPRESSOR | EXCLUDED | ||
| BETA BLOCKERS | METOPROLOL SUCCINATE ER | GENERIC | ||
| BETA BLOCKERS | METOPROLOL TARTRATE | GENERIC | ||
| BETA BLOCKERS | NADOLOL | GENERIC | ||
| BETA BLOCKERS | NEBIVOLOL HYDROCHLORIDE | GENERIC | ||
| BETA BLOCKERS | PINDOLOL | GENERIC | ||
| BETA BLOCKERS | PROPRANOLOL HCL | PREFERRED | ||
| BETA BLOCKERS | PROPRANOLOL HCL | GENERIC | ||
| BETA BLOCKERS | PROPRANOLOL HYDROCHLORIDE | PREFERRED | ||
| BETA BLOCKERS | PROPRANOLOL HYDROCHLORIDE | GENERIC | ||
| BETA BLOCKERS | PROPRANOLOL HYDROCHLORIDE ER | GENERIC | ||
| BETA BLOCKERS | RAPIBLYK | EXCLUDED | ||
| BETA BLOCKERS | SOTALOL HCL | GENERIC | ||
| BETA BLOCKERS | SOTALOL HCL (AF) | GENERIC | ||
| BETA BLOCKERS | SOTALOL HCL AF | GENERIC | ||
| BETA BLOCKERS | SOTALOL HYDROCHLORIDE | GENERIC | ||
| BETA BLOCKERS | SOTALOL HYDROCHLORIDE | NON-PREFERRED | ||
| BETA BLOCKERS | SOTALOL HYDROCHLORIDE (AF ) | GENERIC | ||
| BETA BLOCKERS | SOTALOL HYDROCHLORIDE AF | GENERIC | ||
| BETA BLOCKERS | SOTYLIZE | PREFERRED | ||
| BETA BLOCKERS | TENORMIN | EXCLUDED | ||
| BETA BLOCKERS | TIMOLOL MALEATE | GENERIC | ||
| BETA BLOCKERS | TIMOLOL MALEATE | PREFERRED | ||
| BETA BLOCKERS | TOPROL XL | EXCLUDED | ||
| CALCIUM CHANNEL BLOCKERS | AMLODIPINE BESYLATE | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | CARDENE IV | NON-PREFERRED | ||
| CALCIUM CHANNEL BLOCKERS | CARDIZEM | EXCLUDED | ||
| CALCIUM CHANNEL BLOCKERS | CARDIZEM LA | EXCLUDED | ||
| CALCIUM CHANNEL BLOCKERS | CARTIA XT | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | CLEVIPREX | NON-PREFERRED | ||
| CALCIUM CHANNEL BLOCKERS | CONJUPRI | EXCLUDED | ||
| CALCIUM CHANNEL BLOCKERS | DILTIAZEM HCL | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | DILTIAZEM HCL | PREFERRED | ||
| CALCIUM CHANNEL BLOCKERS | DILTIAZEM HCL ER | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | DILTIAZEM HYDROCHLORIDE | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | DILTIAZEM HYDROCHLORIDE E R | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | DILTIAZEM HYDROCHLORIDE/D EXTROSE | PREFERRED | ||
| CALCIUM CHANNEL BLOCKERS | DILTIAZEM HYDROCHLORIDE/S ODIUM CHLORIDE | PREFERRED | ||
| CALCIUM CHANNEL BLOCKERS | DILTIAZEM HYDROCHLORIDE/S ODIUM CHLORIDE | EXCLUDED | ||
| CALCIUM CHANNEL BLOCKERS | DILT-XR | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | FELODIPINE ER | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | ISRADIPINE | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | KATERZIA | EXCLUDED | ||
| CALCIUM CHANNEL BLOCKERS | LEVAMLODIPINE | EXCLUDED | ||
| CALCIUM CHANNEL BLOCKERS | MATZIM LA | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | NICARDIPINE HCL | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | NICARDIPINE HYDROCHLORIDE | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | NICARDIPINE HYDROCHLORIDE | PREFERRED | ||
| CALCIUM CHANNEL BLOCKERS | NICARDIPINE HYDROCHLORIDE /SODIUM CHLORIDE | PREFERRED | ||
| CALCIUM CHANNEL BLOCKERS | NICARDIPINE HYDROCHLORIDE /SODIUM CHLORIDE | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | NIFEDIPINE | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | NIFEDIPINE ER | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | NIMODIPINE | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | NIMODIPINE | EXCLUDED | ||
| CALCIUM CHANNEL BLOCKERS | NISOLDIPINE ER | EXCLUDED | ||
| CALCIUM CHANNEL BLOCKERS | NORLIQVA | EXCLUDED | ||
| CALCIUM CHANNEL BLOCKERS | NORVASC | EXCLUDED | ||
| CALCIUM CHANNEL BLOCKERS | PROCARDIA XL | EXCLUDED | ||
| CALCIUM CHANNEL BLOCKERS | SULAR | EXCLUDED | ||
| CALCIUM CHANNEL BLOCKERS | TIADYLT ER | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | TIAZAC | EXCLUDED | ||
| CALCIUM CHANNEL BLOCKERS | VERAPAMIL HCL | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | VERAPAMIL HCL ER | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | VERAPAMIL HYDROCHLORIDE | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | VERAPAMIL HYDROCHLORIDE E R | PREFERRED | ||
| CALCIUM CHANNEL BLOCKERS | VERAPAMIL HYDROCHLORIDE E R | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | VERAPAMIL HYDROCHLORIDE S R | GENERIC | ||
| CALCIUM CHANNEL BLOCKERS | VERAPAMIL HYDROCHLORIDE S R | PREFERRED | ||
| CARDIOTONICS | DIGOXIN | NON-PREFERRED | ||
| CARDIOTONICS | DIGOXIN | GENERIC | ||
| CARDIOTONICS | DOBUTAMINE HCL | GENERIC | ||
| CARDIOTONICS | DOBUTAMINE HCL/D5W | EXCLUDED | ||
| CARDIOTONICS | DOBUTAMINE HYDROCHLORIDE | GENERIC | ||
| CARDIOTONICS | DOBUTAMINE HYDROCHLORIDE/ DEXTROSE 5% | EXCLUDED | ||
| CARDIOTONICS | DOPAMINE HYDROCHLORIDE | GENERIC | ||
| CARDIOTONICS | DOPAMINE HYDROCHLORIDE | PREFERRED | ||
| CARDIOTONICS | DOPAMINE HYDROCHLORIDE/DE XTROSE | PREFERRED | ||
| CARDIOTONICS | DOPAMINE/D5W | PREFERRED | ||
| CARDIOTONICS | LANOXIN | NON-PREFERRED | ||
| CARDIOTONICS | LANOXIN | EXCLUDED | ||
| CARDIOTONICS | LANOXIN PEDIATRIC | NON-PREFERRED | ||
| CARDIOTONICS | MILRINONE LACTATE | EXCLUDED | ||
| CARDIOTONICS | MILRINONE LACTATE IN DEXT ROSE | EXCLUDED | ||
| CARDIOVASCULAR AGENTS - MISC. | ABLYSINOL | EXCLUDED | ||
| CARDIOVASCULAR AGENTS - MISC. | ADCIRCA | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | ADEMPAS | PREFERRED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | ALPROSTADIL | GENERIC | ||
| CARDIOVASCULAR AGENTS - MISC. | ALYQ | GENERIC | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | AMBRISENTAN | GENERIC | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | AMLODIPINE BESYLATE/ATORV ASTATIN CALCIUM | EXCLUDED | ||
| CARDIOVASCULAR AGENTS - MISC. | ATTRUBY | PREFERRED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | BOSENTAN | GENERIC | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | CAMZYOS | NON-PREFERRED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | CARDIOPLEGIA DEL NIDO FOR MULA | PREFERRED | ||
| CARDIOVASCULAR AGENTS - MISC. | CARDIOPLEGIA DEL NIDO FOR MULA | EXCLUDED | ||
| CARDIOVASCULAR AGENTS - MISC. | CARDIOPLEGIA INDUCTION HI GH POTASSIUM | PREFERRED | ||
| CARDIOVASCULAR AGENTS - MISC. | CARDIOPLEGIA INDUCTION HI GH POTASSIUM | EXCLUDED | ||
| CARDIOVASCULAR AGENTS - MISC. | CARDIOPLEGIA INDUCTION HI GH POTASSIUM/NON-ENRICHED | PREFERRED | ||
| CARDIOVASCULAR AGENTS - MISC. | CARDIOPLEGIA INDUCTION PL ASMALYTE/HIGH POTASSIUM | PREFERRED | ||
| CARDIOVASCULAR AGENTS - MISC. | CARDIOPLEGIA INDUCTION PL ASMALYTE/TROMETHAMINE HIGH POTASSIU | PREFERRED | ||
| CARDIOVASCULAR AGENTS - MISC. | CARDIOPLEGIA MAINTENANCE LOW POTASSIUM | PREFERRED | ||
| CARDIOVASCULAR AGENTS - MISC. | CARDIOPLEGIA MAINTENANCE LOW TROMETHAMINE/LOW POTASSIUM | PREFERRED | ||
| CARDIOVASCULAR AGENTS - MISC. | CARDIOPLEGIA MAINTENANCE PLASMALYTE/TROMETHAMINE LOW POTASSI | PREFERRED | ||
| CARDIOVASCULAR AGENTS - MISC. | CARDIOPLEGIA REPERFUSATE/ LOW POTASSIUM | PREFERRED | ||
| CARDIOVASCULAR AGENTS - MISC. | CARDIOPLEGIC | GENERIC | ||
| CARDIOVASCULAR AGENTS - MISC. | CARDIOPLEGIC | PREFERRED | ||
| CARDIOVASCULAR AGENTS - MISC. | CORLANOR | EXCLUDED | ||
| CARDIOVASCULAR AGENTS - MISC. | DEHYDRATED ALCOHOL | EXCLUDED | ||
| CARDIOVASCULAR AGENTS - MISC. | ENTRESTO | EXCLUDED | PA | |
| CARDIOVASCULAR AGENTS - MISC. | EPOPROSTENOL SODIUM | GENERIC | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | FLOLAN | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | INPEFA | EXCLUDED | PA | |
| CARDIOVASCULAR AGENTS - MISC. | IVABRADINE HYDROCHLORIDE | GENERIC | ||
| CARDIOVASCULAR AGENTS - MISC. | LETAIRIS | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | LODOCO | EXCLUDED | ||
| CARDIOVASCULAR AGENTS - MISC. | MICROPLEGIA MSA/MSG | EXCLUDED | ||
| CARDIOVASCULAR AGENTS - MISC. | OPSUMIT | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | OPSYNVI | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | ORENITRAM | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | ORENITRAM TITRATION KIT M ONTH 1 | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | ORENITRAM TITRATION KIT M ONTH 2 | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | ORENITRAM TITRATION KIT M ONTH 3 | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | PAPAVERINE HYDROCHLORIDE | PREFERRED | ||
| CARDIOVASCULAR AGENTS - MISC. | PLEGISOL | EXCLUDED | ||
| CARDIOVASCULAR AGENTS - MISC. | PROSTIN VR PEDIATRIC | EXCLUDED | ||
| CARDIOVASCULAR AGENTS - MISC. | REMODULIN | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | REVATIO | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | SACUBITRIL/VALSARTAN | GENERIC | PA | |
| CARDIOVASCULAR AGENTS - MISC. | SILDENAFIL | GENERIC | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | SILDENAFIL CITRATE | GENERIC | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | TADALAFIL | GENERIC | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | TADLIQ | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | TRACLEER | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | TREPROSTINIL | GENERIC | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | TYVASO | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | TYVASO DPI MAINTENANCE KI T | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | TYVASO DPI TITRATION KIT | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | TYVASO REFILL KIT | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | TYVASO STARTER KIT | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | UPTRAVI | PREFERRED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | UPTRAVI TITRATION PACK | PREFERRED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | VELETRI | NON-PREFERRED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | VERQUVO | NON-PREFERRED | PA | |
| CARDIOVASCULAR AGENTS - MISC. | VYNDAMAX | NON-PREFERRED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | WINREVAIR | NON-PREFERRED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | WINREVAIR | EXCLUDED | SP | PA |
| CARDIOVASCULAR AGENTS - MISC. | YUTREPIA | PREFERRED | SP | PA |
| CEPHALOSPORINS | AVYCAZ | PREFERRED | ||
| CEPHALOSPORINS | CEFACLOR | PREFERRED | ||
| CEPHALOSPORINS | CEFACLOR ER | PREFERRED | ||
| CEPHALOSPORINS | CEFADROXIL | GENERIC | ||
| CEPHALOSPORINS | CEFADROXIL | PREFERRED | ||
| CEPHALOSPORINS | CEFAZOLIN | PREFERRED | ||
| CEPHALOSPORINS | CEFAZOLIN | EXCLUDED | ||
| CEPHALOSPORINS | CEFAZOLIN SODIUM | GENERIC | ||
| CEPHALOSPORINS | CEFAZOLIN SODIUM | PREFERRED | ||
| CEPHALOSPORINS | CEFAZOLIN SODIUM | EXCLUDED | ||
| CEPHALOSPORINS | CEFAZOLIN SODIUM/DEXTROSE | PREFERRED | ||
| CEPHALOSPORINS | CEFAZOLIN SODIUM/DEXTROSE | EXCLUDED | ||
| CEPHALOSPORINS | CEFAZOLIN SODIUM/SODIUM C HLORIDE | PREFERRED | ||
| CEPHALOSPORINS | CEFAZOLIN/DEXTROSE | EXCLUDED | ||
| CEPHALOSPORINS | CEFAZOLIN/SODIUM CHLORIDE | PREFERRED | ||
| CEPHALOSPORINS | CEFDINIR | GENERIC | ||
| CEPHALOSPORINS | CEFEPIME | NON-PREFERRED | ||
| CEPHALOSPORINS | CEFEPIME | GENERIC | ||
| CEPHALOSPORINS | CEFEPIME HYDROCHLORIDE | GENERIC | ||
| CEPHALOSPORINS | CEFEPIME HYDROCHLORIDE | PREFERRED | ||
| CEPHALOSPORINS | CEFEPIME/DEXTROSE | NON-PREFERRED | ||
| CEPHALOSPORINS | CEFIXIME | GENERIC | ||
| CEPHALOSPORINS | CEFOTAN | EXCLUDED | ||
| CEPHALOSPORINS | CEFOTAXIME SODIUM | PREFERRED | ||
| CEPHALOSPORINS | CEFOTAXIME SODIUM | EXCLUDED | ||
| CEPHALOSPORINS | CEFOTETAN | GENERIC | ||
| CEPHALOSPORINS | CEFOXITIN SODIUM | GENERIC | ||
| CEPHALOSPORINS | CEFOXITIN SODIUM | PREFERRED | ||
| CEPHALOSPORINS | CEFPODOXIME PROXETIL | GENERIC | ||
| CEPHALOSPORINS | CEFPODOXIME PROXETIL | PREFERRED | ||
| CEPHALOSPORINS | CEFPROZIL | GENERIC | ||
| CEPHALOSPORINS | CEFTAZIDIME | GENERIC | ||
| CEPHALOSPORINS | CEFTAZIDIME | PREFERRED | ||
| CEPHALOSPORINS | CEFTRIAXONE IN ISO-OSMOTI C DEXTROSE | PREFERRED | ||
| CEPHALOSPORINS | CEFTRIAXONE SODIUM | GENERIC | ||
| CEPHALOSPORINS | CEFTRIAXONE SODIUM | PREFERRED | ||
| CEPHALOSPORINS | CEFTRIAXONE/DEXTROSE | NON-PREFERRED | ||
| CEPHALOSPORINS | CEFUROXIME AXETIL | GENERIC | ||
| CEPHALOSPORINS | CEFUROXIME SODIUM | GENERIC | ||
| CEPHALOSPORINS | CEPHALEXIN | GENERIC | ||
| CEPHALOSPORINS | FETROJA | NON-PREFERRED | ||
| CEPHALOSPORINS | TAZICEF | GENERIC | ||
| CEPHALOSPORINS | TAZICEF | PREFERRED | ||
| CEPHALOSPORINS | TAZICEF | EXCLUDED | ||
| CEPHALOSPORINS | TEFLARO | PREFERRED | ||
| CEPHALOSPORINS | ZERBAXA | PREFERRED | ||
| CEPHALOSPORINS | ZEVTERA | EXCLUDED | ||
| CONTRACEPTIVES | AFIRMELLE | GENERIC | ||
| CONTRACEPTIVES | ALTAVERA | GENERIC | ||
| CONTRACEPTIVES | ALYACEN 1/35 | GENERIC | ||
| CONTRACEPTIVES | ALYACEN 7/7/7 | GENERIC | ||
| CONTRACEPTIVES | AMETHYST | GENERIC | ||
| CONTRACEPTIVES | APRI | GENERIC | ||
| CONTRACEPTIVES | ARANELLE | PREFERRED | ||
| CONTRACEPTIVES | ASHLYNA | GENERIC | ||
| CONTRACEPTIVES | AUBRA EQ | GENERIC | ||
| CONTRACEPTIVES | AUROVELA 1.5/30 | GENERIC | ||
| CONTRACEPTIVES | AUROVELA 1/20 | GENERIC | ||
| CONTRACEPTIVES | AUROVELA 24 FE | GENERIC | ||
| CONTRACEPTIVES | AUROVELA FE 1.5/30 | GENERIC | ||
| CONTRACEPTIVES | AUROVELA FE 1/20 | GENERIC | ||
| CONTRACEPTIVES | AVERI | EXCLUDED | ||
| CONTRACEPTIVES | AVIANE | GENERIC | ||
| CONTRACEPTIVES | AYUNA | GENERIC | ||
| CONTRACEPTIVES | AZURETTE | GENERIC | ||
| CONTRACEPTIVES | BALCOLTRA | EXCLUDED | ||
| CONTRACEPTIVES | BALZIVA | GENERIC | ||
| CONTRACEPTIVES | BEYAZ | EXCLUDED | ||
| CONTRACEPTIVES | BLISOVI 24 FE | GENERIC | ||
| CONTRACEPTIVES | BLISOVI FE 1.5/30 | GENERIC | ||
| CONTRACEPTIVES | BLISOVI FE 1/20 | GENERIC | ||
| CONTRACEPTIVES | BRIELLYN | GENERIC | ||
| CONTRACEPTIVES | CAMILA | GENERIC | ||
| CONTRACEPTIVES | CAMRESE | GENERIC | ||
| CONTRACEPTIVES | CAMRESE LO | GENERIC | ||
| CONTRACEPTIVES | CHARLOTTE 24 FE | GENERIC | ||
| CONTRACEPTIVES | CHATEAL EQ | GENERIC | ||
| CONTRACEPTIVES | CYRED EQ | GENERIC | ||
| CONTRACEPTIVES | DASETTA 1/35 | GENERIC | ||
| CONTRACEPTIVES | DASETTA 7/7/7 | GENERIC | ||
| CONTRACEPTIVES | DAYSEE | GENERIC | ||
| CONTRACEPTIVES | DEBLITANE | GENERIC | ||
| CONTRACEPTIVES | DEPO-PROVERA CONTRACEPTIV E | EXCLUDED | ||
| CONTRACEPTIVES | DEPO-SUBQ PROVERA 104 | NON-PREFERRED | ||
| CONTRACEPTIVES | DESOGESTREL/ETHINYL ESTRA DIOL | GENERIC | ||
| CONTRACEPTIVES | DOLISHALE | GENERIC | ||
| CONTRACEPTIVES | DROSPIRENONE/ETHINYL ESTR ADIOL | GENERIC | ||
| CONTRACEPTIVES | DROSPIRENONE/ETHINYL ESTR ADIOL/LEVOMEFOLATE CALCIUM | GENERIC | ||
| CONTRACEPTIVES | ELINEST | GENERIC | ||
| CONTRACEPTIVES | ELLA | NON-PREFERRED | ||
| CONTRACEPTIVES | ELURYNG | GENERIC | ||
| CONTRACEPTIVES | EMZAHH | GENERIC | ||
| CONTRACEPTIVES | ENILLORING | GENERIC | ||
| CONTRACEPTIVES | ENSKYCE | GENERIC | ||
| CONTRACEPTIVES | ERRIN | GENERIC | ||
| CONTRACEPTIVES | ESTARYLLA | GENERIC | ||
| CONTRACEPTIVES | ETHYNODIOL DIACETATE/ETHI NYL ESTRADIOL | GENERIC | ||
| CONTRACEPTIVES | ETONOGESTREL/ETHINYL ESTR ADIOL | GENERIC | ||
| CONTRACEPTIVES | FALMINA | GENERIC | ||
| CONTRACEPTIVES | FEIRZA 1.5/30 | GENERIC | ||
| CONTRACEPTIVES | FEIRZA 1/20 | GENERIC | ||
| CONTRACEPTIVES | FEMLYV | EXCLUDED | ||
| CONTRACEPTIVES | FINZALA | GENERIC | ||
| CONTRACEPTIVES | GALBRIELA | GENERIC | ||
| CONTRACEPTIVES | GEMMILY | GENERIC | ||
| CONTRACEPTIVES | HAILEY 1.5/30 | GENERIC | ||
| CONTRACEPTIVES | HAILEY 24 FE | GENERIC | ||
| CONTRACEPTIVES | HAILEY FE 1.5/30 | GENERIC | ||
| CONTRACEPTIVES | HAILEY FE 1/20 | GENERIC | ||
| CONTRACEPTIVES | HALOETTE | GENERIC | ||
| CONTRACEPTIVES | HEATHER | GENERIC | ||
| CONTRACEPTIVES | ICLEVIA | GENERIC | ||
| CONTRACEPTIVES | INCASSIA | GENERIC | ||
| CONTRACEPTIVES | INTROVALE | GENERIC | ||
| CONTRACEPTIVES | ISIBLOOM | GENERIC | ||
| CONTRACEPTIVES | JAIMIESS | GENERIC | ||
| CONTRACEPTIVES | JASMIEL | GENERIC | ||
| CONTRACEPTIVES | JENCYCLA | GENERIC | ||
| CONTRACEPTIVES | JOLESSA | GENERIC | ||
| CONTRACEPTIVES | JOYEAUX | GENERIC | ||
| CONTRACEPTIVES | JULEBER | GENERIC | ||
| CONTRACEPTIVES | JUNEL 1.5/30 | GENERIC | ||
| CONTRACEPTIVES | JUNEL 1/20 | GENERIC | ||
| CONTRACEPTIVES | JUNEL FE 1.5/30 | GENERIC | ||
| CONTRACEPTIVES | JUNEL FE 1/20 | GENERIC | ||
| CONTRACEPTIVES | JUNEL FE 24 | GENERIC | ||
| CONTRACEPTIVES | KAITLIB FE | GENERIC | ||
| CONTRACEPTIVES | KALLIGA | GENERIC | ||
| CONTRACEPTIVES | KARIVA | GENERIC | ||
| CONTRACEPTIVES | KELNOR 1/35 | GENERIC | ||
| CONTRACEPTIVES | KURVELO | GENERIC | ||
| CONTRACEPTIVES | KYLEENA | PREFERRED | PA | |
| CONTRACEPTIVES | LARIN 1.5/30 | GENERIC | ||
| CONTRACEPTIVES | LARIN 1/20 | GENERIC | ||
| CONTRACEPTIVES | LARIN 24 FE | GENERIC | ||
| CONTRACEPTIVES | LARIN FE 1.5/30 | GENERIC | ||
| CONTRACEPTIVES | LARIN FE 1/20 | GENERIC | ||
| CONTRACEPTIVES | LESSINA | GENERIC | ||
| CONTRACEPTIVES | LEVONEST | GENERIC | ||
| CONTRACEPTIVES | LEVONORGESTREL AND ETHINY L ESTRADIOL | GENERIC | ||
| CONTRACEPTIVES | LEVONORGESTREL/ETHINYL ES TRADIOL | GENERIC | ||
| CONTRACEPTIVES | LEVONORGESTREL/ETHINYL ES TRADIOL/FERROUS BISGLYCINATE | GENERIC | ||
| CONTRACEPTIVES | LILETTA | NON-PREFERRED | PA | |
| CONTRACEPTIVES | LO LOESTRIN FE | EXCLUDED | ||
| CONTRACEPTIVES | LOESTRIN 1.5/30-21 | EXCLUDED | ||
| CONTRACEPTIVES | LOESTRIN 1/20-21 | EXCLUDED | ||
| CONTRACEPTIVES | LOESTRIN FE 1.5/30 | EXCLUDED | ||
| CONTRACEPTIVES | LOESTRIN FE 1/20 | EXCLUDED | ||
| CONTRACEPTIVES | LOJAIMIESS | GENERIC | ||
| CONTRACEPTIVES | LORYNA | GENERIC | ||
| CONTRACEPTIVES | LOW-OGESTREL | GENERIC | ||
| CONTRACEPTIVES | LO-ZUMANDIMINE | GENERIC | ||
| CONTRACEPTIVES | LUIZZA 1.5/30 | GENERIC | ||
| CONTRACEPTIVES | LUIZZA 1/20 | GENERIC | ||
| CONTRACEPTIVES | LUTERA | GENERIC | ||
| CONTRACEPTIVES | LYLEQ | GENERIC | ||
| CONTRACEPTIVES | LYZA | GENERIC | ||
| CONTRACEPTIVES | MARLISSA | GENERIC | ||
| CONTRACEPTIVES | MEDROXYPROGESTERONE ACETA TE | GENERIC | ||
| CONTRACEPTIVES | MELEYA | GENERIC | ||
| CONTRACEPTIVES | MIBELAS 24 FE | GENERIC | ||
| CONTRACEPTIVES | MICROGESTIN 1.5/30 | GENERIC | ||
| CONTRACEPTIVES | MICROGESTIN 1/20 | GENERIC | ||
| CONTRACEPTIVES | MICROGESTIN FE 1.5/30 | GENERIC | ||
| CONTRACEPTIVES | MICROGESTIN FE 1/20 | GENERIC | ||
| CONTRACEPTIVES | MILI | GENERIC | ||
| CONTRACEPTIVES | MINZOYA | GENERIC | ||
| CONTRACEPTIVES | MIRENA | PREFERRED | PA | |
| CONTRACEPTIVES | MIUDELLA COPPER INTRAUTER INE SYSTEM | PREFERRED | ||
| CONTRACEPTIVES | MONO-LINYAH | GENERIC | ||
| CONTRACEPTIVES | NATAZIA | EXCLUDED | ||
| CONTRACEPTIVES | NECON 0.5/35-28 | GENERIC | ||
| CONTRACEPTIVES | NEXPLANON | EXCLUDED | PA | |
| CONTRACEPTIVES | NEXTSTELLIS | EXCLUDED | ||
| CONTRACEPTIVES | NIKKI | GENERIC | ||
| CONTRACEPTIVES | NORA-BE | GENERIC | ||
| CONTRACEPTIVES | NORELGESTROMIN/ETHINYL ES TRADIOL | GENERIC | ||
| CONTRACEPTIVES | NORETHINDRONE | GENERIC | ||
| CONTRACEPTIVES | NORETHINDRONE ACETATE/ETH INYL ESTRADIOL | GENERIC | ||
| CONTRACEPTIVES | NORETHINDRONE ACETATE/ETH INYL ESTRADIOL/FERROUS FUMARATE | GENERIC | ||
| CONTRACEPTIVES | NORGESTIMATE/ETHINYL ESTR ADIOL | GENERIC | ||
| CONTRACEPTIVES | NORTREL 0.5/35 (28) | GENERIC | ||
| CONTRACEPTIVES | NORTREL 1/35 | GENERIC | ||
| CONTRACEPTIVES | NORTREL 7/7/7 | GENERIC | ||
| CONTRACEPTIVES | NUVARING | EXCLUDED | ||
| CONTRACEPTIVES | NYLIA 1/35 | GENERIC | ||
| CONTRACEPTIVES | NYLIA 7/7/7 | GENERIC | ||
| CONTRACEPTIVES | ORQUIDEA | GENERIC | ||
| CONTRACEPTIVES | PARAGARD INTRAUTERINE COP PER CONTRACEPTIVE T380A | PREFERRED | ||
| CONTRACEPTIVES | PHILITH | GENERIC | ||
| CONTRACEPTIVES | PIMTREA | GENERIC | ||
| CONTRACEPTIVES | PORTIA-28 | GENERIC | ||
| CONTRACEPTIVES | RECLIPSEN | GENERIC | ||
| CONTRACEPTIVES | RIVELSA | GENERIC | ||
| CONTRACEPTIVES | ROSYRAH | GENERIC | ||
| CONTRACEPTIVES | SAFYRAL | EXCLUDED | ||
| CONTRACEPTIVES | SETLAKIN | GENERIC | ||
| CONTRACEPTIVES | SHAROBEL | GENERIC | ||
| CONTRACEPTIVES | SIMLIYA | GENERIC | ||
| CONTRACEPTIVES | SIMPESSE | GENERIC | ||
| CONTRACEPTIVES | SKYLA | PREFERRED | PA | |
| CONTRACEPTIVES | SLYND | EXCLUDED | ||
| CONTRACEPTIVES | SPRINTEC 28 | GENERIC | ||
| CONTRACEPTIVES | SRONYX | GENERIC | ||
| CONTRACEPTIVES | SYEDA | GENERIC | ||
| CONTRACEPTIVES | TARINA 24 FE | GENERIC | ||
| CONTRACEPTIVES | TARINA FE 1/20 EQ | GENERIC | ||
| CONTRACEPTIVES | TAYTULLA | EXCLUDED | ||
| CONTRACEPTIVES | TILIA FE | GENERIC | ||
| CONTRACEPTIVES | TRI-ESTARYLLA | GENERIC | ||
| CONTRACEPTIVES | TRI-LEGEST FE | GENERIC | ||
| CONTRACEPTIVES | TRI-LINYAH | GENERIC | ||
| CONTRACEPTIVES | TRI-LO-ESTARYLLA | GENERIC | ||
| CONTRACEPTIVES | TRI-LO-MARZIA | GENERIC | ||
| CONTRACEPTIVES | TRI-LO-MILI | GENERIC | ||
| CONTRACEPTIVES | TRI-LO-SPRINTEC | GENERIC | ||
| CONTRACEPTIVES | TRI-MILI | GENERIC | ||
| CONTRACEPTIVES | TRI-SPRINTEC | GENERIC | ||
| CONTRACEPTIVES | TRI-VYLIBRA | GENERIC | ||
| CONTRACEPTIVES | TRI-VYLIBRA LO | GENERIC | ||
| CONTRACEPTIVES | TURQOZ | GENERIC | ||
| CONTRACEPTIVES | TWIRLA | EXCLUDED | ||
| CONTRACEPTIVES | TYBLUME | EXCLUDED | ||
| CONTRACEPTIVES | TYDEMY | GENERIC | ||
| CONTRACEPTIVES | VALTYA 1/35 | GENERIC | ||
| CONTRACEPTIVES | VALTYA 1/50 | GENERIC | ||
| CONTRACEPTIVES | VELIVET | PREFERRED | ||
| CONTRACEPTIVES | VESTURA | GENERIC | ||
| CONTRACEPTIVES | VIENVA | GENERIC | ||
| CONTRACEPTIVES | VIORELE | GENERIC | ||
| CONTRACEPTIVES | VOLNEA | GENERIC | ||
| CONTRACEPTIVES | VYFEMLA | GENERIC | ||
| CONTRACEPTIVES | VYLIBRA | GENERIC | ||
| CONTRACEPTIVES | WERA | GENERIC | ||
| CONTRACEPTIVES | WYMZYA FE | GENERIC | ||
| CONTRACEPTIVES | XARAH FE | GENERIC | ||
| CONTRACEPTIVES | XELRIA FE | GENERIC | ||
| CONTRACEPTIVES | XULANE | GENERIC | ||
| CONTRACEPTIVES | YASMIN 28 | EXCLUDED | ||
| CONTRACEPTIVES | YAZ | EXCLUDED | ||
| CONTRACEPTIVES | ZAFEMY | GENERIC | ||
| CONTRACEPTIVES | ZOVIA 1/35 | GENERIC | ||
| CONTRACEPTIVES | ZUMANDIMINE | GENERIC | ||
| CORTICOSTEROIDS | AGAMREE | NON-PREFERRED | SP | PA |
| CORTICOSTEROIDS | BETAMETHASONE SODIUM PHOS PHATE | PREFERRED | ||
| CORTICOSTEROIDS | BETAMETHASONE SODIUM PHOS PHATE/BETAMETHASONE ACETATE | GENERIC | ||
| CORTICOSTEROIDS | BETAMETHASONE SODIUM PHOS PHATE/BETAMETHASONE ACETATE | PREFERRED | ||
| CORTICOSTEROIDS | BUDESONIDE | GENERIC | PA | |
| CORTICOSTEROIDS | BUDESONIDE ER | GENERIC | PA | |
| CORTICOSTEROIDS | BUPIVACAINE HCL/DEXAMETHA SONE SOD PHOSPHATE/EPINEPHRINE | EXCLUDED | ||
| CORTICOSTEROIDS | CELESTONE SOLUSPAN | EXCLUDED | ||
| CORTICOSTEROIDS | CORTEF | EXCLUDED | ||
| CORTICOSTEROIDS | CORTISONE ACETATE | PREFERRED | ||
| CORTICOSTEROIDS | DEFLAZACORT | GENERIC | SP | PA |
| CORTICOSTEROIDS | DEPO-MEDROL | EXCLUDED | ||
| CORTICOSTEROIDS | DEXAMETHASONE | GENERIC | ||
| CORTICOSTEROIDS | DEXAMETHASONE | PREFERRED | ||
| CORTICOSTEROIDS | DEXAMETHASONE ACETATE | PREFERRED | ||
| CORTICOSTEROIDS | DEXAMETHASONE INTENSOL | PREFERRED | ||
| CORTICOSTEROIDS | DEXAMETHASONE SODIUM PHOS PHATE | PREFERRED | ||
| CORTICOSTEROIDS | DEXAMETHASONE SODIUM PHOS PHATE | EXCLUDED | ||
| CORTICOSTEROIDS | DEXAMETHASONE SODIUM PHOS PHATE +RFID | EXCLUDED | ||
| CORTICOSTEROIDS | EMFLAZA | NON-PREFERRED | SP | PA |
| CORTICOSTEROIDS | EOHILIA | EXCLUDED | PA | |
| CORTICOSTEROIDS | FLUDROCORTISONE ACETATE | GENERIC | ||
| CORTICOSTEROIDS | HEXATRIONE | NON-PREFERRED | ||
| CORTICOSTEROIDS | HYDROCORTISONE | GENERIC | ||
| CORTICOSTEROIDS | HYDROCORTISONE SODIUM SUC CINATE | EXCLUDED | ||
| CORTICOSTEROIDS | JAYTHARI | GENERIC | SP | PA |
| CORTICOSTEROIDS | KENALOG-10 | EXCLUDED | ||
| CORTICOSTEROIDS | KENALOG-40 | EXCLUDED | ||
| CORTICOSTEROIDS | KENALOG-80 | EXCLUDED | ||
| CORTICOSTEROIDS | KHINDIVI | EXCLUDED | ||
| CORTICOSTEROIDS | KYMBEE | GENERIC | SP | PA |
| CORTICOSTEROIDS | MEDROL | EXCLUDED | ||
| CORTICOSTEROIDS | MEDROL DOSEPAK | EXCLUDED | ||
| CORTICOSTEROIDS | METHYLPREDNISOLONE | GENERIC | ||
| CORTICOSTEROIDS | METHYLPREDNISOLONE ACETAT E | PREFERRED | ||
| CORTICOSTEROIDS | METHYLPREDNISOLONE ACETAT E | EXCLUDED | ||
| CORTICOSTEROIDS | METHYLPREDNISOLONE DOSE P ACK | GENERIC | ||
| CORTICOSTEROIDS | METHYLPREDNISOLONE SODIUM SUCCINATE | EXCLUDED | ||
| CORTICOSTEROIDS | METHYLPREDNISOLONE SODIUM SUCCINATE | EXCLUDED | ||
| CORTICOSTEROIDS | PREDNISOLONE | GENERIC | ||
| CORTICOSTEROIDS | PREDNISOLONE SODIUM PHOSP HATE | GENERIC | ||
| CORTICOSTEROIDS | PREDNISONE | GENERIC | ||
| CORTICOSTEROIDS | PREDNISONE | PREFERRED | ||
| CORTICOSTEROIDS | PREDNISONE INTENSOL | PREFERRED | ||
| CORTICOSTEROIDS | PYQUVI | GENERIC | SP | PA |
| CORTICOSTEROIDS | SOLU-CORTEF | NON-PREFERRED | ||
| CORTICOSTEROIDS | SOLU-CORTEF | PREFERRED | ||
| CORTICOSTEROIDS | SOLU-MEDROL | EXCLUDED | ||
| CORTICOSTEROIDS | TRIAMCINOLONE ACETONIDE | GENERIC | ||
| CORTICOSTEROIDS | TRIAMCINOLONE ACETONIDE | PREFERRED | ||
| CORTICOSTEROIDS | UCERIS | EXCLUDED | PA | |
| COUGH/COLD/ALLERGY | ACETYLCYSTEINE | GENERIC | ||
| COUGH/COLD/ALLERGY | BENZONATATE | GENERIC | ||
| COUGH/COLD/ALLERGY | BROMPHEN/PSEUDOEPHEDRINE HCL/DEXTROMETHORPHAN HBR | GENERIC | ||
| COUGH/COLD/ALLERGY | BROMPHEN/PSEUDOEPHEDRINE HCL/DEXTROMETHORPHAN HYDROBROMIDE | GENERIC | ||
| COUGH/COLD/ALLERGY | CLARINEX-D 12 HOUR | EXCLUDED | ||
| COUGH/COLD/ALLERGY | HYCODAN | EXCLUDED | ||
| COUGH/COLD/ALLERGY | HYDROCODONE BITARTRATE/HO MATROPINE METHYLBROMIDE | GENERIC | ||
| COUGH/COLD/ALLERGY | HYDROCODONE POLISTIREX/CH LORPHENIRAMINE POLISTIREX | PREFERRED | ||
| COUGH/COLD/ALLERGY | HYDROMET | GENERIC | ||
| COUGH/COLD/ALLERGY | HYPERSAL | NON-PREFERRED | ||
| COUGH/COLD/ALLERGY | HYPERSAL | EXCLUDED | ||
| COUGH/COLD/ALLERGY | NEBUSAL | PREFERRED | ||
| COUGH/COLD/ALLERGY | NEBUSAL | NON-PREFERRED | ||
| COUGH/COLD/ALLERGY | NEOTUSS PLUS | NON-PREFERRED | ||
| COUGH/COLD/ALLERGY | POTASSIUM IODIDE | PREFERRED | ||
| COUGH/COLD/ALLERGY | PROMETHAZINE DM | GENERIC | ||
| COUGH/COLD/ALLERGY | PROMETHAZINE HYDROCHLORID E/DEXTROMETHORPHAN HYDROBROMIDE | GENERIC | ||
| COUGH/COLD/ALLERGY | PROMETHAZINE HYDROCHLORID E/PHENYLEPHRINE HYDROCHLORIDE | PREFERRED | ||
| COUGH/COLD/ALLERGY | PROMETHAZINE/CODEINE | GENERIC | ||
| COUGH/COLD/ALLERGY | PROMETHAZINE/DEXTROMETHOR PHAN | GENERIC | ||
| COUGH/COLD/ALLERGY | PULMOSAL | EXCLUDED | ||
| COUGH/COLD/ALLERGY | SODIUM CHLORIDE | PREFERRED | ||
| COUGH/COLD/ALLERGY | SSKI | PREFERRED | ||
| COUGH/COLD/ALLERGY | TUXARIN ER | EXCLUDED | ||
| DERMATOLOGICALS | ABENOR | EXCLUDED | ||
| DERMATOLOGICALS | ABENOR HP | EXCLUDED | ||
| DERMATOLOGICALS | ACCUTANE | GENERIC | PA | |
| DERMATOLOGICALS | ACIOXIA | EXCLUDED | ||
| DERMATOLOGICALS | ACIOXIAY | EXCLUDED | ||
| DERMATOLOGICALS | ACITRETIN | GENERIC | PA | |
| DERMATOLOGICALS | ACYCLOVIR | GENERIC | ||
| DERMATOLOGICALS | ADAINZOXIA | EXCLUDED | ||
| DERMATOLOGICALS | ADALINA | EXCLUDED | ||
| DERMATOLOGICALS | ADAPALENE | GENERIC | ||
| DERMATOLOGICALS | ADAPALENE | EXCLUDED | ||
| DERMATOLOGICALS | ADAPALENE PUMP | EXCLUDED | ||
| DERMATOLOGICALS | ADAPALENE/BENZOYL PEROXID E | GENERIC | ||
| DERMATOLOGICALS | ADBRY | PREFERRED | SP | PA |
| DERMATOLOGICALS | ADERMICA | EXCLUDED | ||
| DERMATOLOGICALS | ADERMICA HP | EXCLUDED | ||
| DERMATOLOGICALS | ADMIRAZOL | EXCLUDED | ||
| DERMATOLOGICALS | ADMIRAZOL HP | EXCLUDED | ||
| DERMATOLOGICALS | ALA-CORT | GENERIC | ||
| DERMATOLOGICALS | ALCLOMETASONE DIPROPIONAT E | GENERIC | ||
| DERMATOLOGICALS | ALCLOMETASONE DIPROPIONAT E | PREFERRED | ||
| DERMATOLOGICALS | ALIXI | EXCLUDED | ||
| DERMATOLOGICALS | ALIXI HP | EXCLUDED | ||
| DERMATOLOGICALS | ALOMIRA | EXCLUDED | ||
| DERMATOLOGICALS | ALOMIRA HP | EXCLUDED | ||
| DERMATOLOGICALS | ALOMIRA LP | EXCLUDED | ||
| DERMATOLOGICALS | ALTRENO | EXCLUDED | ||
| DERMATOLOGICALS | ALURIS | EXCLUDED | ||
| DERMATOLOGICALS | ALURIS HP | EXCLUDED | ||
| DERMATOLOGICALS | ALURIS HP PLUS | EXCLUDED | ||
| DERMATOLOGICALS | ALURIS LP | EXCLUDED | ||
| DERMATOLOGICALS | ALURIS LP PLUS | EXCLUDED | ||
| DERMATOLOGICALS | ALURIS PLUS | EXCLUDED | ||
| DERMATOLOGICALS | ALUXOF | EXCLUDED | ||
| DERMATOLOGICALS | ALUXOF HP | EXCLUDED | ||
| DERMATOLOGICALS | ALVOX | EXCLUDED | ||
| DERMATOLOGICALS | ALVOX HP | EXCLUDED | ||
| DERMATOLOGICALS | AMCINONIDE | PREFERRED | ||
| DERMATOLOGICALS | AMCINONIDE | EXCLUDED | ||
| DERMATOLOGICALS | AMMONIUM LACTATE | GENERIC | ||
| DERMATOLOGICALS | AMNESTEEM | GENERIC | PA | |
| DERMATOLOGICALS | AMZEEQ | EXCLUDED | ||
| DERMATOLOGICALS | ANZUPGO | NON-PREFERRED | PA | |
| DERMATOLOGICALS | APEXOL CLEANSER | EXCLUDED | ||
| DERMATOLOGICALS | APEXOL HP CLEANSER | EXCLUDED | ||
| DERMATOLOGICALS | APHORIA | EXCLUDED | ||
| DERMATOLOGICALS | APORIX | EXCLUDED | ||
| DERMATOLOGICALS | ARTILIS | EXCLUDED | ||
| DERMATOLOGICALS | ARTILIS HP | EXCLUDED | ||
| DERMATOLOGICALS | ARZOL SILVER NITRATE APP LICATORS | PREFERRED | ||
| DERMATOLOGICALS | AUGUSTIL | EXCLUDED | ||
| DERMATOLOGICALS | AVAR CLEANSER | EXCLUDED | ||
| DERMATOLOGICALS | AVAR LS CLEANSER | EXCLUDED | ||
| DERMATOLOGICALS | AVEIDAOXIA | EXCLUDED | ||
| DERMATOLOGICALS | AVIDORA | EXCLUDED | ||
| DERMATOLOGICALS | AVIDORA HP | EXCLUDED | ||
| DERMATOLOGICALS | AWANIS | EXCLUDED | ||
| DERMATOLOGICALS | AZALTA | EXCLUDED | ||
| DERMATOLOGICALS | AZALTA HP | EXCLUDED | ||
| DERMATOLOGICALS | AZELAIC ACID | GENERIC | ||
| DERMATOLOGICALS | AZELEX | EXCLUDED | ||
| DERMATOLOGICALS | BATIZIA | EXCLUDED | ||
| DERMATOLOGICALS | BAXONIL | EXCLUDED | ||
| DERMATOLOGICALS | BENZAMYCIN | EXCLUDED | ||
| DERMATOLOGICALS | BENZEPRO CREAMY WASH | EXCLUDED | ||
| DERMATOLOGICALS | BENZOIN TINCTURE | NON-PREFERRED | ||
| DERMATOLOGICALS | BETAMETHASONE DIPROPIONAT E | GENERIC | ||
| DERMATOLOGICALS | BETAMETHASONE DIPROPIONAT E AUGMENTED | GENERIC | ||
| DERMATOLOGICALS | BETAMETHASONE DIPROPIONAT E AUGMENTED | PREFERRED | ||
| DERMATOLOGICALS | BETAMETHASONE VALERATE | GENERIC | ||
| DERMATOLOGICALS | BETAMETHASONE VALERATE | PREFERRED | ||
| DERMATOLOGICALS | BEXAROTENE | GENERIC | SP | PA |
| DERMATOLOGICALS | BIMZELX | NON-PREFERRED | SP | PA |
| DERMATOLOGICALS | BRYHALI | EXCLUDED | ||
| DERMATOLOGICALS | CABTREO | EXCLUDED | ||
| DERMATOLOGICALS | CALCIPOTRIENE | PREFERRED | ||
| DERMATOLOGICALS | CALCIPOTRIENE | GENERIC | ||
| DERMATOLOGICALS | CALCIPOTRIENE/BETAMETHASO NE DIPROPIONATE | GENERIC | ||
| DERMATOLOGICALS | CALCITRIOL | PREFERRED | ||
| DERMATOLOGICALS | CHLOHUX | EXCLUDED | ||
| DERMATOLOGICALS | CHLOOXIA | EXCLUDED | ||
| DERMATOLOGICALS | CIBINQO | PREFERRED | SP | PA |
| DERMATOLOGICALS | CICLOPIROX | GENERIC | ||
| DERMATOLOGICALS | CICLOPIROX OLAMINE | GENERIC | ||
| DERMATOLOGICALS | CLARAVIS | GENERIC | PA | |
| DERMATOLOGICALS | CLEOCIN-T | EXCLUDED | ||
| DERMATOLOGICALS | CLINDAMYCIN PHOSPHATE | GENERIC | ||
| DERMATOLOGICALS | CLINDAMYCIN PHOSPHATE/BEN ZOYL PEROXIDE | GENERIC | ||
| DERMATOLOGICALS | CLOBETASOL PROPIONATE | GENERIC | ||
| DERMATOLOGICALS | CLOBETASOL PROPIONATE E | GENERIC | ||
| DERMATOLOGICALS | CLOBETASOL PROPIONATE EMO LLIENT | GENERIC | ||
| DERMATOLOGICALS | CLOBEX | EXCLUDED | ||
| DERMATOLOGICALS | CLOCORTOLONE PIVALATE | EXCLUDED | ||
| DERMATOLOGICALS | CLODAN | EXCLUDED | ||
| DERMATOLOGICALS | CLOTRIMAZOLE | GENERIC | ||
| DERMATOLOGICALS | CLOTRIMAZOLE/BETAMETHASON E DIPROPIONATE | GENERIC | ||
| DERMATOLOGICALS | CLOTRIMAZOLE/BETAMETHASON E DIPROPIONATE | PREFERRED | ||
| DERMATOLOGICALS | COSENTYX | EXCLUDED | SP | PA |
| DERMATOLOGICALS | COSENTYX SENSOREADY PEN | EXCLUDED | SP | PA |
| DERMATOLOGICALS | COSENTYX UNOREADY | EXCLUDED | SP | PA |
| DERMATOLOGICALS | CROTAN | EXCLUDED | ||
| DERMATOLOGICALS | CRYODOSE TA | EXCLUDED | ||
| DERMATOLOGICALS | DAPSONE | GENERIC | ||
| DERMATOLOGICALS | DAZAVEIDAOXIA | EXCLUDED | ||
| DERMATOLOGICALS | DAZOMON | EXCLUDED | ||
| DERMATOLOGICALS | DELIBON | EXCLUDED | ||
| DERMATOLOGICALS | DENVITA | EXCLUDED | ||
| DERMATOLOGICALS | DEOXIA | EXCLUDED | ||
| DERMATOLOGICALS | DEOXIATAR | EXCLUDED | ||
| DERMATOLOGICALS | DEOXIAVAR | EXCLUDED | ||
| DERMATOLOGICALS | DERMA-SMOOTHE/FS BODY | EXCLUDED | ||
| DERMATOLOGICALS | DERMA-SMOOTHE/FS SCALP | EXCLUDED | ||
| DERMATOLOGICALS | DESONIDE | GENERIC | ||
| DERMATOLOGICALS | DESONIDE | EXCLUDED | ||
| DERMATOLOGICALS | DESOXIMETASONE | GENERIC | ||
| DERMATOLOGICALS | DESOXIMETASONE | PREFERRED | ||
| DERMATOLOGICALS | DESOXIMETASONE | EXCLUDED | ||
| DERMATOLOGICALS | DIADIMAXIA | EXCLUDED | ||
| DERMATOLOGICALS | DIAOXIA | EXCLUDED | ||
| DERMATOLOGICALS | DIASAXIATAR | EXCLUDED | ||
| DERMATOLOGICALS | DIASDIMAXIA | EXCLUDED | ||
| DERMATOLOGICALS | DIASOXIA | EXCLUDED | ||
| DERMATOLOGICALS | DICLOFENAC SODIUM | GENERIC | ||
| DERMATOLOGICALS | DIFFERIN | EXCLUDED | ||
| DERMATOLOGICALS | DIFFERIN PUMP | EXCLUDED | ||
| DERMATOLOGICALS | DIFLORASONE DIACETATE | EXCLUDED | ||
| DERMATOLOGICALS | DIFMETIOXRIME | EXCLUDED | ||
| DERMATOLOGICALS | DIMOXIA | EXCLUDED | ||
| DERMATOLOGICALS | DIOCHLOY | EXCLUDED | ||
| DERMATOLOGICALS | DIONARIS | EXCLUDED | ||
| DERMATOLOGICALS | DIPROLENE | EXCLUDED | ||
| DERMATOLOGICALS | DIVENDO | EXCLUDED | ||
| DERMATOLOGICALS | DIVINIX | EXCLUDED | ||
| DERMATOLOGICALS | DOMELA | EXCLUDED | ||
| DERMATOLOGICALS | DRAXACE | EXCLUDED | ||
| DERMATOLOGICALS | DRIXECE | EXCLUDED | ||
| DERMATOLOGICALS | DRYSOL | PREFERRED | ||
| DERMATOLOGICALS | DUPIXENT | PREFERRED | SP | PA |
| DERMATOLOGICALS | DYCLOPRO | PREFERRED | ||
| DERMATOLOGICALS | DYNOMA | EXCLUDED | ||
| DERMATOLOGICALS | EBGLYSS | PREFERRED | SP | PA |
| DERMATOLOGICALS | ECEOXIA | EXCLUDED | ||
| DERMATOLOGICALS | ECONAZOLE NITRATE | GENERIC | ||
| DERMATOLOGICALS | EHA LOTION 4% | EXCLUDED | ||
| DERMATOLOGICALS | ELIMITE | EXCLUDED | ||
| DERMATOLOGICALS | ELYZIA | EXCLUDED | ||
| DERMATOLOGICALS | ENZNONUTY | EXCLUDED | ||
| DERMATOLOGICALS | EPIDUO | EXCLUDED | ||
| DERMATOLOGICALS | EPIFOAM | EXCLUDED | ||
| DERMATOLOGICALS | ERY | PREFERRED | ||
| DERMATOLOGICALS | ERYTHROMYCIN | GENERIC | ||
| DERMATOLOGICALS | ERYTHROMYCIN | PREFERRED | ||
| DERMATOLOGICALS | ERYTHROMYCIN/BENZOYL PERO XIDE | GENERIC | ||
| DERMATOLOGICALS | ETHOXIA | EXCLUDED | ||
| DERMATOLOGICALS | ETHYL CHLORIDE/FINE PINPO INT | PREFERRED | ||
| DERMATOLOGICALS | ETHYL CHLORIDE/FINE STREA M | PREFERRED | ||
| DERMATOLOGICALS | ETHYL CHLORIDE/MEDIUM JET STREAM | PREFERRED | ||
| DERMATOLOGICALS | ETHYL CHLORIDE/MEDIUM STR EAM | PREFERRED | ||
| DERMATOLOGICALS | ETHYL CHLORIDE/MIST | PREFERRED | ||
| DERMATOLOGICALS | EUCRISA | NON-PREFERRED | PA | |
| DERMATOLOGICALS | EXODERM | EXCLUDED | ||
| DERMATOLOGICALS | FENOVIA | EXCLUDED | ||
| DERMATOLOGICALS | FIDILA | EXCLUDED | ||
| DERMATOLOGICALS | FINACEA | EXCLUDED | ||
| DERMATOLOGICALS | FLUOCINOLONE ACETONIDE | GENERIC | ||
| DERMATOLOGICALS | FLUOCINOLONE ACETONIDE BO DY | GENERIC | ||
| DERMATOLOGICALS | FLUOCINOLONE ACETONIDE SC ALP | GENERIC | ||
| DERMATOLOGICALS | FLUOCINOLONE ACETONIDE TO PICAL | GENERIC | ||
| DERMATOLOGICALS | FLUOCINONIDE | GENERIC | ||
| DERMATOLOGICALS | FLUOCINONIDE EMULSIFIED B ASE | GENERIC | ||
| DERMATOLOGICALS | FLUOROURACIL | GENERIC | ||
| DERMATOLOGICALS | FLUOROURACIL | PREFERRED | ||
| DERMATOLOGICALS | FLURANDRENOLIDE | PREFERRED | ||
| DERMATOLOGICALS | FLUTICASONE PROPIONATE | GENERIC | ||
| DERMATOLOGICALS | FLUTICASONE PROPIONATE | PREFERRED | ||
| DERMATOLOGICALS | FRIVO | EXCLUDED | ||
| DERMATOLOGICALS | GEBAUERS PAIN EASE | EXCLUDED | ||
| DERMATOLOGICALS | GEBAUERS SPRAY AND STRETC H | EXCLUDED | ||
| DERMATOLOGICALS | GENTAMICIN SULFATE | GENERIC | ||
| DERMATOLOGICALS | GLYDO | GENERIC | ||
| DERMATOLOGICALS | GORDOFILM | NON-PREFERRED | ||
| DERMATOLOGICALS | HALCINONIDE | GENERIC | ||
| DERMATOLOGICALS | HALCINONIDE | EXCLUDED | ||
| DERMATOLOGICALS | HALOBETASOL PROPIONATE | GENERIC | ||
| DERMATOLOGICALS | HAXCHLO | EXCLUDED | ||
| DERMATOLOGICALS | HAXCHLODREX | EXCLUDED | ||
| DERMATOLOGICALS | HOVYN | EXCLUDED | ||
| DERMATOLOGICALS | HURRI-FREEZE MEDIUM STREA M | NON-PREFERRED | ||
| DERMATOLOGICALS | HURRI-FREEZE MIST SPRAY | NON-PREFERRED | ||
| DERMATOLOGICALS | HYDROCORTISONE | GENERIC | ||
| DERMATOLOGICALS | HYDROCORTISONE | PREFERRED | ||
| DERMATOLOGICALS | HYDROCORTISONE | EXCLUDED | ||
| DERMATOLOGICALS | HYDROCORTISONE ACETATE | EXCLUDED | ||
| DERMATOLOGICALS | HYDROCORTISONE BUTYRATE | PREFERRED | ||
| DERMATOLOGICALS | HYDROCORTISONE VALERATE | GENERIC | ||
| DERMATOLOGICALS | HYPOCYN ANTIPRURITIC GEL SPRAY | EXCLUDED | ||
| DERMATOLOGICALS | ILEXOR | EXCLUDED | ||
| DERMATOLOGICALS | ILUMYA | NON-PREFERRED | SP | PA |
| DERMATOLOGICALS | IMIOXIA | EXCLUDED | ||
| DERMATOLOGICALS | IMIQUIMOD | GENERIC | ||
| DERMATOLOGICALS | IMULDOSA | PREFERRED | SP | PA |
| DERMATOLOGICALS | INZDEAXIATAR | EXCLUDED | ||
| DERMATOLOGICALS | INZDEOXIA | EXCLUDED | ||
| DERMATOLOGICALS | ISOTRETINOIN | GENERIC | PA | |
| DERMATOLOGICALS | ISOTRETINOIN | EXCLUDED | PA | |
| DERMATOLOGICALS | ITHOXIA | EXCLUDED | ||
| DERMATOLOGICALS | KAZURI | EXCLUDED | ||
| DERMATOLOGICALS | KEFUNOVA | EXCLUDED | ||
| DERMATOLOGICALS | KERAXA | EXCLUDED | ||
| DERMATOLOGICALS | KERIDA | EXCLUDED | ||
| DERMATOLOGICALS | KETOCONAZOLE | GENERIC | ||
| DERMATOLOGICALS | KLARON | EXCLUDED | ||
| DERMATOLOGICALS | KLAYESTA | GENERIC | ||
| DERMATOLOGICALS | KYNARA | EXCLUDED | ||
| DERMATOLOGICALS | L.E.T. | EXCLUDED | ||
| DERMATOLOGICALS | LIDOCAINE | GENERIC | ||
| DERMATOLOGICALS | LIDOCAINE HCL | GENERIC | ||
| DERMATOLOGICALS | LIDOCAINE HCL JELLY | GENERIC | ||
| DERMATOLOGICALS | LIDOCAINE HYDROCHLORIDE | EXCLUDED | ||
| DERMATOLOGICALS | LIDOCAINE HYDROCHLORIDE J ELLY | PREFERRED | ||
| DERMATOLOGICALS | LIDOCAINE HYDROCHLORIDE/R ACEPINEPHRINE/TETRACAINE HCL | EXCLUDED | ||
| DERMATOLOGICALS | LIDOCAINE/PRILOCAINE | GENERIC | ||
| DERMATOLOGICALS | LIDOCAN | GENERIC | ||
| DERMATOLOGICALS | LIDODERM | EXCLUDED | ||
| DERMATOLOGICALS | LIDTOPIC | EXCLUDED | ||
| DERMATOLOGICALS | LOUNZDOMDIOXIATAR | EXCLUDED | ||
| DERMATOLOGICALS | MALATHION | GENERIC | ||
| DERMATOLOGICALS | METDRAY | EXCLUDED | ||
| DERMATOLOGICALS | METHOXSALEN | PREFERRED | ||
| DERMATOLOGICALS | METHYL SALICYLATE | PREFERRED | ||
| DERMATOLOGICALS | METHYL SALICYLATE | EXCLUDED | ||
| DERMATOLOGICALS | METROGEL | EXCLUDED | ||
| DERMATOLOGICALS | METRONIDAZOLE | GENERIC | ||
| DERMATOLOGICALS | MICONATATE | NON-PREFERRED | ||
| DERMATOLOGICALS | MICORT HC | EXCLUDED | ||
| DERMATOLOGICALS | MICURADERM | EXCLUDED | ||
| DERMATOLOGICALS | MOMETASONE FUROATE | GENERIC | ||
| DERMATOLOGICALS | MUPIROCIN | GENERIC | ||
| DERMATOLOGICALS | NAFTIFINE HYDROCHLORIDE | PREFERRED | ||
| DERMATOLOGICALS | NAFTIFINE HYDROCHLORIDE | GENERIC | ||
| DERMATOLOGICALS | NATROBA | EXCLUDED | ||
| DERMATOLOGICALS | NEMLUVIO | EXCLUDED | SP | PA |
| DERMATOLOGICALS | NEUAC | GENERIC | ||
| DERMATOLOGICALS | NEXOBRID | EXCLUDED | ||
| DERMATOLOGICALS | NOBELA | EXCLUDED | ||
| DERMATOLOGICALS | NOLIRA | EXCLUDED | ||
| DERMATOLOGICALS | NUCORT | NON-PREFERRED | ||
| DERMATOLOGICALS | NUJO | EXCLUDED | ||
| DERMATOLOGICALS | NUJU | EXCLUDED | ||
| DERMATOLOGICALS | NYAMYC | GENERIC | ||
| DERMATOLOGICALS | NYNUTEY | EXCLUDED | ||
| DERMATOLOGICALS | NYSTATIN | GENERIC | ||
| DERMATOLOGICALS | NYSTATIN/TRIAMCINOLONE | GENERIC | ||
| DERMATOLOGICALS | NYSTATIN/TRIAMCINOLONE AC ETONIDE | GENERIC | ||
| DERMATOLOGICALS | NYSTOP | GENERIC | ||
| DERMATOLOGICALS | ONZDEAXIATAR | EXCLUDED | ||
| DERMATOLOGICALS | ONZDEAXIAVAR | EXCLUDED | ||
| DERMATOLOGICALS | ONZDEOXIA | EXCLUDED | ||
| DERMATOLOGICALS | OPZELURA | NON-PREFERRED | PA | |
| DERMATOLOGICALS | OTULFI | EXCLUDED | SP | PA |
| DERMATOLOGICALS | OVIDE | EXCLUDED | ||
| DERMATOLOGICALS | OXIAICE | EXCLUDED | ||
| DERMATOLOGICALS | OXIANUJO | EXCLUDED | ||
| DERMATOLOGICALS | OXIATAR | EXCLUDED | ||
| DERMATOLOGICALS | OXIAVARRY | EXCLUDED | ||
| DERMATOLOGICALS | OXIAZAR | EXCLUDED | ||
| DERMATOLOGICALS | PERMETHRIN | GENERIC | ||
| DERMATOLOGICALS | PHEYO | EXCLUDED | ||
| DERMATOLOGICALS | PIMECROLIMUS | GENERIC | ||
| DERMATOLOGICALS | PLENURA | EXCLUDED | ||
| DERMATOLOGICALS | PLEXION CLEANSER | EXCLUDED | ||
| DERMATOLOGICALS | PODOCON-25 | EXCLUDED | ||
| DERMATOLOGICALS | PODOFILOX | PREFERRED | ||
| DERMATOLOGICALS | PR BENZOYL PEROXIDE WASH | PREFERRED | ||
| DERMATOLOGICALS | PR BENZOYL PEROXIDE WASH | EXCLUDED | ||
| DERMATOLOGICALS | PRAMOSONE | EXCLUDED | ||
| DERMATOLOGICALS | PRONAL GEL | EXCLUDED | ||
| DERMATOLOGICALS | PRURADIK | EXCLUDED | ||
| DERMATOLOGICALS | PURAZIL | EXCLUDED | ||
| DERMATOLOGICALS | PYZCHIVA | NON-PREFERRED | SP | PA |
| DERMATOLOGICALS | PYZCHIVA | EXCLUDED | SP | PA |
| DERMATOLOGICALS | QUIHOXVAR | EXCLUDED | ||
| DERMATOLOGICALS | REMYDA | EXCLUDED | ||
| DERMATOLOGICALS | RESTIMO | EXCLUDED | ||
| DERMATOLOGICALS | RETIN-A | EXCLUDED | ||
| DERMATOLOGICALS | ROAOXIA | EXCLUDED | ||
| DERMATOLOGICALS | ROSITARA | EXCLUDED | ||
| DERMATOLOGICALS | ROVIS | EXCLUDED | ||
| DERMATOLOGICALS | RUMILO | EXCLUDED | ||
| DERMATOLOGICALS | SANTYL | PREFERRED | ||
| DERMATOLOGICALS | SAROXIA | EXCLUDED | ||
| DERMATOLOGICALS | SCALACORT DK | NON-PREFERRED | ||
| DERMATOLOGICALS | SCARTRATE | EXCLUDED | ||
| DERMATOLOGICALS | SELARSDI | EXCLUDED | SP | PA |
| DERMATOLOGICALS | SELENIUM SULFIDE | PREFERRED | ||
| DERMATOLOGICALS | SELENIUM SULFIDE | EXCLUDED | ||
| DERMATOLOGICALS | SILIQ | EXCLUDED | SP | PA |
| DERMATOLOGICALS | SILVADENE | EXCLUDED | ||
| DERMATOLOGICALS | SILVER NITRATE | PREFERRED | ||
| DERMATOLOGICALS | SILVER SULFADIAZINE | GENERIC | ||
| DERMATOLOGICALS | SIRVANA | EXCLUDED | ||
| DERMATOLOGICALS | SKYRIZI | PREFERRED | SP | PA |
| DERMATOLOGICALS | SKYRIZI PEN | PREFERRED | SP | PA |
| DERMATOLOGICALS | SODIUM SULFACETAMIDE | GENERIC | ||
| DERMATOLOGICALS | SODIUM SULFACETAMIDE/SULF UR | PREFERRED | ||
| DERMATOLOGICALS | SODIUM SULFACETAMIDE/SULF UR | EXCLUDED | ||
| DERMATOLOGICALS | SODIUM SULFACETAMIDE/SULF UR CLEANSER | PREFERRED | ||
| DERMATOLOGICALS | SODIUM SULFACETAMIDE/SULF UR WASH | PREFERRED | ||
| DERMATOLOGICALS | SOFDRA | EXCLUDED | ||
| DERMATOLOGICALS | SORIXIA | EXCLUDED | ||
| DERMATOLOGICALS | SOTYKTU | PREFERRED | SP | PA |
| DERMATOLOGICALS | SPEVIGO | NON-PREFERRED | SP | PA |
| DERMATOLOGICALS | SPINOSAD | PREFERRED | ||
| DERMATOLOGICALS | SSD | GENERIC | ||
| DERMATOLOGICALS | STELARA | PREFERRED | SP | PA |
| DERMATOLOGICALS | STEQEYMA | EXCLUDED | SP | PA |
| DERMATOLOGICALS | STERILE TOPICAL L.E.T. GE L | EXCLUDED | ||
| DERMATOLOGICALS | SULFACETAMIDE SODIUM | GENERIC | ||
| DERMATOLOGICALS | SULFACLEANSE 8/4 | EXCLUDED | ||
| DERMATOLOGICALS | SULFAMYLON | PREFERRED | ||
| DERMATOLOGICALS | SYNALAR | EXCLUDED | ||
| DERMATOLOGICALS | TACLONEX | EXCLUDED | ||
| DERMATOLOGICALS | TACROLIMUS | GENERIC | ||
| DERMATOLOGICALS | TALTZ | PREFERRED | SP | PA |
| DERMATOLOGICALS | TARDEOXIA | EXCLUDED | ||
| DERMATOLOGICALS | TARDIMAXIA | EXCLUDED | ||
| DERMATOLOGICALS | TARGRETIN | EXCLUDED | SP | PA |
| DERMATOLOGICALS | TAROXIA | EXCLUDED | ||
| DERMATOLOGICALS | TAZAROTENE | GENERIC | ||
| DERMATOLOGICALS | TAZAROTENE | EXCLUDED | ||
| DERMATOLOGICALS | TAZORAC | EXCLUDED | ||
| DERMATOLOGICALS | TELIORA | EXCLUDED | ||
| DERMATOLOGICALS | TETOXIA | EXCLUDED | ||
| DERMATOLOGICALS | TEXACORT | EXCLUDED | ||
| DERMATOLOGICALS | TOLAK | EXCLUDED | ||
| DERMATOLOGICALS | TOPICORT | EXCLUDED | ||
| DERMATOLOGICALS | TREMFYA | PREFERRED | SP | PA |
| DERMATOLOGICALS | TREMFYA PEN | PREFERRED | SP | PA |
| DERMATOLOGICALS | TRETINOIN | GENERIC | ||
| DERMATOLOGICALS | TRIAMCINOLONE ACETONIDE | GENERIC | ||
| DERMATOLOGICALS | TRIAMCINOLONE ACETONIDE | PREFERRED | ||
| DERMATOLOGICALS | TRIAMCINOLONE ACETONIDE | EXCLUDED | ||
| DERMATOLOGICALS | TRIDERM | GENERIC | ||
| DERMATOLOGICALS | UNZDOMDIOXIAZAR | EXCLUDED | ||
| DERMATOLOGICALS | USTEKINUMAB | EXCLUDED | SP | PA |
| DERMATOLOGICALS | USTEKINUMAB-AAUZ | PREFERRED | SP | PA |
| DERMATOLOGICALS | USTEKINUMAB-AEKN | EXCLUDED | SP | PA |
| DERMATOLOGICALS | USTEKINUMAB-TTWE | EXCLUDED | SP | PA |
| DERMATOLOGICALS | VALCHLOR | PREFERRED | SP | PA |
| DERMATOLOGICALS | VANOS | EXCLUDED | ||
| DERMATOLOGICALS | VARDIMAXIA | EXCLUDED | ||
| DERMATOLOGICALS | VAROXIA | EXCLUDED | ||
| DERMATOLOGICALS | VECTICAL | EXCLUDED | ||
| DERMATOLOGICALS | VEVEN | EXCLUDED | ||
| DERMATOLOGICALS | WAYZEN | EXCLUDED | ||
| DERMATOLOGICALS | WELERIS | EXCLUDED | ||
| DERMATOLOGICALS | WEZLANA | EXCLUDED | SP | PA |
| DERMATOLOGICALS | XERAC AC | EXCLUDED | ||
| DERMATOLOGICALS | XEROFORM OCCLUSIVE GAUZE STRIP 1"X8" | EXCLUDED | ||
| DERMATOLOGICALS | XEROFORM OCCLUSIVE PETROL ATUM GAUZE STRIP 5"X9" | EXCLUDED | ||
| DERMATOLOGICALS | XIRUN | EXCLUDED | ||
| DERMATOLOGICALS | YCANTH | EXCLUDED | ||
| DERMATOLOGICALS | YESINTEK | PREFERRED | SP | PA |
| DERMATOLOGICALS | ZELSUVMI | EXCLUDED | ||
| DERMATOLOGICALS | ZENATANE | GENERIC | PA | |
| DERMATOLOGICALS | ZITHRANOL | NON-PREFERRED | ||
| DERMATOLOGICALS | ZORYVE | EXCLUDED | ||
| DERMATOLOGICALS | ZOVIRAX | EXCLUDED | ||
| DIAGNOSTIC PRODUCTS | ADENOSINE | GENERIC | ||
| DIAGNOSTIC PRODUCTS | ARIDOL | NON-PREFERRED | ||
| DIAGNOSTIC PRODUCTS | BINAXNOW COVID-19 AG CARD | EXCLUDED | ||
| DIAGNOSTIC PRODUCTS | BLUDIGO | NON-PREFERRED | ||
| DIAGNOSTIC PRODUCTS | CHIRHOSTIM | NON-PREFERRED | ||
| DIAGNOSTIC PRODUCTS | CORTROSYN | EXCLUDED | PA | |
| DIAGNOSTIC PRODUCTS | COSYNTROPIN | GENERIC | PA | |
| DIAGNOSTIC PRODUCTS | CYSVIEW | NON-PREFERRED | ||
| DIAGNOSTIC PRODUCTS | CYTALUX | EXCLUDED | ||
| DIAGNOSTIC PRODUCTS | DIPYRIDAMOLE | PREFERRED | ||
| DIAGNOSTIC PRODUCTS | GLEOLAN | EXCLUDED | ||
| DIAGNOSTIC PRODUCTS | GLUCAGON | NON-PREFERRED | ||
| DIAGNOSTIC PRODUCTS | GLUCAGON HCL DIAGNOSTIC | NON-PREFERRED | ||
| DIAGNOSTIC PRODUCTS | GVOKE VIALDX | PREFERRED | ||
| DIAGNOSTIC PRODUCTS | HISTATROL | NON-PREFERRED | ||
| DIAGNOSTIC PRODUCTS | IC GREEN | NON-PREFERRED | ||
| DIAGNOSTIC PRODUCTS | ID NOW COVID-19 | EXCLUDED | ||
| DIAGNOSTIC PRODUCTS | INDOCYANINE GREEN | PREFERRED | ||
| DIAGNOSTIC PRODUCTS | ISOSULFAN BLUE | GENERIC | ||
| DIAGNOSTIC PRODUCTS | KINEVAC | EXCLUDED | ||
| DIAGNOSTIC PRODUCTS | LEXISCAN | NON-PREFERRED | ||
| DIAGNOSTIC PRODUCTS | LUMISIGHT | EXCLUDED | ||
| DIAGNOSTIC PRODUCTS | METHACHOLINE CHLORIDE | PREFERRED | ||
| DIAGNOSTIC PRODUCTS | METOPIRONE | NON-PREFERRED | ||
| DIAGNOSTIC PRODUCTS | PRE-PEN | NON-PREFERRED | ||
| DIAGNOSTIC PRODUCTS | PROVOCHOLINE | NON-PREFERRED | ||
| DIAGNOSTIC PRODUCTS | QUICKVUE SARS ANTIGEN TES T | EXCLUDED | ||
| DIAGNOSTIC PRODUCTS | REGADENOSON | EXCLUDED | ||
| DIAGNOSTIC PRODUCTS | R-GENE 10 | NON-PREFERRED | ||
| DIAGNOSTIC PRODUCTS | SINCALIDE | EXCLUDED | ||
| DIAGNOSTIC PRODUCTS | SOFIA2 FLU/SARS ANTIGEN F IA | EXCLUDED | ||
| DIAGNOSTIC PRODUCTS | SOFIA2 SARS ANTIGEN FIA | EXCLUDED | ||
| DIAGNOSTIC PRODUCTS | SPY AGENT GREEN | NON-PREFERRED | ||
| DIAGNOSTIC PRODUCTS | SPY-MIS KIT | NON-PREFERRED | ||
| DIAGNOSTIC PRODUCTS | THYROGEN | PREFERRED | SP | PA |
| DIAGNOSTIC PRODUCTS | TYFAST FLU A/B & COVID-19 MULTIPLEX RAPID TEST | EXCLUDED | ||
| DIAGNOSTIC PRODUCTS | VUEBLU | EXCLUDED | ||
| DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS | AMINO PM RMS | EXCLUDED | ||
| DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS | HOMACTIN AA PLUS | EXCLUDED | ||
| DIGESTIVE AIDS | CREON | PREFERRED | PA | |
| DIGESTIVE AIDS | PANCREAZE | EXCLUDED | PA | |
| DIGESTIVE AIDS | PERTZYE | EXCLUDED | PA | |
| DIGESTIVE AIDS | SUCRAID | PREFERRED | SP | PA |
| DIGESTIVE AIDS | VIOKACE | PREFERRED | PA | |
| DIGESTIVE AIDS | ZENPEP | PREFERRED | PA | |
| DIURETICS | ACETAZOLAMIDE | GENERIC | ||
| DIURETICS | ACETAZOLAMIDE ER | GENERIC | ||
| DIURETICS | ACETAZOLAMIDE SODIUM | GENERIC | ||
| DIURETICS | ALDACTONE | EXCLUDED | ||
| DIURETICS | AMILORIDE HCL | GENERIC | ||
| DIURETICS | AMILORIDE HYDROCHLORIDE | GENERIC | ||
| DIURETICS | AMILORIDE/HYDROCHLOROTHIA ZIDE | PREFERRED | ||
| DIURETICS | BUMETANIDE | GENERIC | ||
| DIURETICS | CHLOROTHIAZIDE SODIUM | GENERIC | ||
| DIURETICS | CHLORTHALIDONE | GENERIC | ||
| DIURETICS | DICHLORPHENAMIDE | GENERIC | SP | PA |
| DIURETICS | DIURIL | EXCLUDED | ||
| DIURETICS | EDECRIN | EXCLUDED | PA | |
| DIURETICS | ETHACRYNATE SODIUM | GENERIC | ||
| DIURETICS | ETHACRYNIC ACID | GENERIC | PA | |
| DIURETICS | FUROSEMIDE | GENERIC | ||
| DIURETICS | FUROSEMIDE | PREFERRED | ||
| DIURETICS | FUROSEMIDE/SODIUM CHLORID E | PREFERRED | ||
| DIURETICS | HEMICLOR | EXCLUDED | ||
| DIURETICS | HYDROCHLOROTHIAZIDE | GENERIC | ||
| DIURETICS | INDAPAMIDE | GENERIC | ||
| DIURETICS | INZIRQO | EXCLUDED | ||
| DIURETICS | KEVEYIS | EXCLUDED | SP | PA |
| DIURETICS | LASIX | EXCLUDED | ||
| DIURETICS | MANNITOL | PREFERRED | ||
| DIURETICS | METHAZOLAMIDE | GENERIC | ||
| DIURETICS | METOLAZONE | GENERIC | ||
| DIURETICS | ORMALVI | GENERIC | SP | PA |
| DIURETICS | OSMITROL VIAFLEX | EXCLUDED | ||
| DIURETICS | SPIRONOLACTONE | GENERIC | ||
| DIURETICS | SPIRONOLACTONE/HYDROCHLOR OTHIAZIDE | GENERIC | ||
| DIURETICS | THALITONE | EXCLUDED | ||
| DIURETICS | TORSEMIDE | GENERIC | ||
| DIURETICS | TRIAMTERENE/HYDROCHLOROTH IAZIDE | GENERIC | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | ACTHAR | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | ACTHAR GEL | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | ACTONEL | EXCLUDED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | ALDURAZYME | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | ALENDRONATE SODIUM | GENERIC | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | BOMYNTRA | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | BONSITY | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | BRINEURA | NON-PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | BUPHENYL | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | BYNFEZIA PEN | NON-PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | CABERGOLINE | GENERIC | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | CALCITRIOL | GENERIC | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | CALCITRIOL | EXCLUDED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | CARBAGLU | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | CARGLUMIC ACID | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | CARNITOR | EXCLUDED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | CARNITOR SF | EXCLUDED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | CINACALCET HYDROCHLORIDE | GENERIC | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | CLOMIPHENE CITRATE | GENERIC | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | CONEXXENCE | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | CORTROPHIN | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | CRENESSITY | NON-PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | CRYSVITA | NON-PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | DDAVP | EXCLUDED | PA | |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | DDAVP | EXCLUDED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | DESMOPRESSIN ACETATE | GENERIC | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | DESMOPRESSIN ACETATE | GENERIC | PA | |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | DESMOPRESSIN ACETATE | PREFERRED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | DESMOPRESSIN ACETATE | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | DOXERCALCIFEROL | PREFERRED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | DOXERCALCIFEROL | EXCLUDED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | EGRIFTA SV | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | EGRIFTA WR | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | ELAPRASE | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | ELFABRIO | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | EVENITY | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | EVISTA | EXCLUDED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | FABRAZYME | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | FENSOLVI | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | FOSAMAX | EXCLUDED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | FOSAMAX PLUS D | NON-PREFERRED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | GALAFOLD | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | GLYCEROL PHENYLBUTYRATE | GENERIC | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | HARLIKU | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | IBANDRONATE SODIUM | GENERIC | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | IMCIVREE | NON-PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | INCRELEX | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | JAVYGTOR | GENERIC | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | JUBBONTI | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | JYNARQUE | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | KANUMA | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | KEBILIDI | NON-PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | KERENDIA | EXCLUDED | PA | |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | KUVAN | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | LAMZEDE | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | LANREOTIDE ACETATE | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | LEVOCARNITINE | GENERIC | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | LEVOCARNITINE | EXCLUDED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | LEVOCARNITINE SF | GENERIC | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | LUMIZYME | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | LUPRON DEPOT-PED (1-MONTH ) | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | LUPRON DEPOT-PED (3-MONTH ) | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | LUPRON DEPOT-PED (6-MONTH ) | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | MEPSEVII | NON-PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | MIFEPREX | NON-PREFERRED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | MIFEPRISTONE | GENERIC | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | MYALEPT | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | MYCAPSSA | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | NAGLAZYME | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | NEXVIAZYME | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | NITISINONE | GENERIC | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | NITYR | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | NULIBRY | NON-PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | OCTREOTIDE ACETATE | GENERIC | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | OCTREOTIDE ACETATE | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | OCTREOTIDE ACETATE | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | OLPRUVA | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | OPFOLDA | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | ORFADIN | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | ORILISSA | PREFERRED | PA | |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | OSENVELT | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | OSPHENA | EXCLUDED | PA | |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | PALYNZIQ | NON-PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | PAMIDRONATE DISODIUM | GENERIC | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | PAMIDRONATE DISODIUM | PREFERRED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | PARICALCITOL | GENERIC | PA | |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | PARICALCITOL | EXCLUDED | PA | |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | PARSABIV | NON-PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | PHEBURANE | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | POMBILITI | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | PROLIA | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | RALOXIFENE HYDROCHLORIDE | GENERIC | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | RAVICTI | NON-PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | RECLAST | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | RECORLEV | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | REDEMPLO | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | REVCOVI | NON-PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | RISEDRONATE SODIUM | GENERIC | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | ROCALTROL | EXCLUDED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | SAMSCA | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | SANDOSTATIN | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | SANDOSTATIN LAR DEPOT | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | SAPROPTERIN DIHYDROCHLORI DE | GENERIC | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | SENSIPAR | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | SEPHIENCE | NON-PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | SIGNIFOR | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | SIGNIFOR LAR | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | SODIUM PHENYLACETATE/SODI UM BENZOATE | GENERIC | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | SODIUM PHENYLBUTYRATE | GENERIC | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | SOMATULINE DEPOT | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | SOMAVERT | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | STOBOCLO | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | STRENSIQ | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | SUPPRELIN LA | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | SYNAREL | PREFERRED | PA | |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | TEPEZZA | NON-PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | TERIPARATIDE | GENERIC | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | TERIPARATIDE | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | TERLIVAZ | EXCLUDED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | TOLVAPTAN | GENERIC | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | TOLVAPTAN | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | TRIPTODUR | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | TRYNGOLZA | NON-PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | TYMLOS | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | VASOPRESSIN | EXCLUDED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | VASOPRESSIN +RFID | EXCLUDED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | VASOPRESSIN/DEXTROSE | EXCLUDED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | VASOPRESSIN/SODIUM CHLORI DE | PREFERRED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | VASOPRESSIN/SODIUM CHLORI DE | EXCLUDED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | VASOSTRICT | EXCLUDED | ||
| ENDOCRINE AND METABOLIC AGENTS - MISC. | VEOZAH | EXCLUDED | PA | |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | VIMIZIM | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | VOXZOGO | NON-PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | VYKAT XR | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | WYOST | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | XENPOZYME | NON-PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | XGEVA | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | XPHOZAH | EXCLUDED | PA | |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | XURIDEN | PREFERRED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | YORVIPATH | EXCLUDED | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | ZELVYSIA | GENERIC | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | ZEMPLAR | EXCLUDED | PA | |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | ZOLEDRONIC ACID | GENERIC | SP | PA |
| ENDOCRINE AND METABOLIC AGENTS - MISC. | ZOLEDRONIC ACID | PREFERRED | SP | PA |
| ESTROGENS | ABIGALE | GENERIC | ||
| ESTROGENS | ABIGALE LO | GENERIC | ||
| ESTROGENS | ACTIVELLA | EXCLUDED | ||
| ESTROGENS | ANGELIQ | EXCLUDED | ||
| ESTROGENS | BIJUVA | EXCLUDED | ||
| ESTROGENS | CLIMARA | EXCLUDED | ||
| ESTROGENS | CLIMARA PRO | EXCLUDED | ||
| ESTROGENS | COMBIPATCH | PREFERRED | ||
| ESTROGENS | COVARYX | PREFERRED | ||
| ESTROGENS | COVARYX HS | PREFERRED | ||
| ESTROGENS | DELESTROGEN | NON-PREFERRED | ||
| ESTROGENS | DELESTROGEN | EXCLUDED | ||
| ESTROGENS | DEPO-ESTRADIOL | PREFERRED | ||
| ESTROGENS | DIVIGEL | EXCLUDED | ||
| ESTROGENS | DOTTI | GENERIC | ||
| ESTROGENS | DUAVEE | PREFERRED | ||
| ESTROGENS | EEMT | PREFERRED | ||
| ESTROGENS | EEMT HS | PREFERRED | ||
| ESTROGENS | ELESTRIN | EXCLUDED | ||
| ESTROGENS | ESTERIFIED ESTROGENS/METH YLTESTOSTERONE | PREFERRED | ||
| ESTROGENS | ESTERIFIED ESTROGENS/METH YLTESTOSTERONE DS | PREFERRED | ||
| ESTROGENS | ESTERIFIED ESTROGENS/METH YLTESTOSTERONE HS | PREFERRED | ||
| ESTROGENS | ESTRADIOL | GENERIC | ||
| ESTROGENS | ESTRADIOL | EXCLUDED | ||
| ESTROGENS | ESTRADIOL VALERATE | GENERIC | ||
| ESTROGENS | ESTRADIOL/NORETHINDRONE A CETATE | GENERIC | ||
| ESTROGENS | ESTRATEST H.S. | NON-PREFERRED | ||
| ESTROGENS | ESTROGEL | EXCLUDED | ||
| ESTROGENS | EVAMIST | EXCLUDED | ||
| ESTROGENS | FYAVOLV | GENERIC | ||
| ESTROGENS | JINTELI | GENERIC | ||
| ESTROGENS | LYLLANA | GENERIC | ||
| ESTROGENS | MENOSTAR | EXCLUDED | ||
| ESTROGENS | MIMVEY | GENERIC | ||
| ESTROGENS | MINIVELLE | EXCLUDED | ||
| ESTROGENS | MYFEMBREE | PREFERRED | PA | |
| ESTROGENS | NORETHINDRONE ACETATE/ETH INYL ESTRADIOL | GENERIC | ||
| ESTROGENS | ORIAHNN | PREFERRED | PA | |
| ESTROGENS | PREMARIN | PREFERRED | ||
| ESTROGENS | PREMARIN | NON-PREFERRED | ||
| ESTROGENS | PREMPHASE | PREFERRED | ||
| ESTROGENS | PREMPRO | PREFERRED | ||
| ESTROGENS | VIVELLE-DOT | EXCLUDED | ||
| FLUOROQUINOLONES | BAXDELA | PREFERRED | PA | |
| FLUOROQUINOLONES | CIPRO | EXCLUDED | ||
| FLUOROQUINOLONES | CIPROFLOXACIN HCL | GENERIC | ||
| FLUOROQUINOLONES | CIPROFLOXACIN HYDROCHLORI DE | GENERIC | ||
| FLUOROQUINOLONES | CIPROFLOXACIN I.V.-IN D5W | PREFERRED | ||
| FLUOROQUINOLONES | LEVOFLOXACIN | GENERIC | ||
| FLUOROQUINOLONES | LEVOFLOXACIN IN D5W | GENERIC | ||
| FLUOROQUINOLONES | MOXIFLOXACIN HYDROCHLORI DE/SODIUM HYDROCHLORIDE | PREFERRED | ||
| FLUOROQUINOLONES | MOXIFLOXACIN HYDROCHLORID E | GENERIC | ||
| FLUOROQUINOLONES | MOXIFLOXACIN HYDROCHLORID E | PREFERRED | ||
| FLUOROQUINOLONES | OFLOXACIN | PREFERRED | ||
| GASTROINTESTINAL AGENTS - MISC. | ALOSETRON HYDROCHLORIDE | GENERIC | PA | |
| GASTROINTESTINAL AGENTS - MISC. | ALVIMOPAN | GENERIC | PA | |
| GASTROINTESTINAL AGENTS - MISC. | AMITIZA | EXCLUDED | PA | |
| GASTROINTESTINAL AGENTS - MISC. | APRISO | EXCLUDED | ||
| GASTROINTESTINAL AGENTS - MISC. | AURYXIA | EXCLUDED | ||
| GASTROINTESTINAL AGENTS - MISC. | AVSOLA | EXCLUDED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | AZULFIDINE | EXCLUDED | ||
| GASTROINTESTINAL AGENTS - MISC. | AZULFIDINE EN-TABS | EXCLUDED | ||
| GASTROINTESTINAL AGENTS - MISC. | BALSALAZIDE DISODIUM | GENERIC | ||
| GASTROINTESTINAL AGENTS - MISC. | BYLVAY | NON-PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | BYLVAY (PELLETS) | NON-PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | CALCIUM ACETATE | GENERIC | ||
| GASTROINTESTINAL AGENTS - MISC. | CANASA | EXCLUDED | ||
| GASTROINTESTINAL AGENTS - MISC. | CHOLBAM | PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | CIMZIA | NON-PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | CIMZIA STARTER KIT | NON-PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | CROMOLYN SODIUM | GENERIC | ||
| GASTROINTESTINAL AGENTS - MISC. | CTEXLI | PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | DIPENTUM | EXCLUDED | ||
| GASTROINTESTINAL AGENTS - MISC. | ENTYVIO | NON-PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | ENTYVIO PEN | NON-PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | ENULOSE | GENERIC | ||
| GASTROINTESTINAL AGENTS - MISC. | FERRIC CITRATE | PREFERRED | ||
| GASTROINTESTINAL AGENTS - MISC. | FOSRENOL | EXCLUDED | ||
| GASTROINTESTINAL AGENTS - MISC. | GASTROCROM | EXCLUDED | ||
| GASTROINTESTINAL AGENTS - MISC. | GATTEX | NON-PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | GENERLAC | GENERIC | ||
| GASTROINTESTINAL AGENTS - MISC. | IBSRELA | EXCLUDED | PA | |
| GASTROINTESTINAL AGENTS - MISC. | IMULDOSA | PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | INFLECTRA | PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | INFLIXIMAB | EXCLUDED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | IQIRVO | PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | LACTULOSE | GENERIC | ||
| GASTROINTESTINAL AGENTS - MISC. | LANTHANUM CARBONATE | GENERIC | ||
| GASTROINTESTINAL AGENTS - MISC. | LIALDA | EXCLUDED | ||
| GASTROINTESTINAL AGENTS - MISC. | LINZESS | PREFERRED | PA | |
| GASTROINTESTINAL AGENTS - MISC. | LIVMARLI | PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | LOTRONEX | EXCLUDED | PA | |
| GASTROINTESTINAL AGENTS - MISC. | LUBIPROSTONE | GENERIC | PA | |
| GASTROINTESTINAL AGENTS - MISC. | MESALAMINE | GENERIC | ||
| GASTROINTESTINAL AGENTS - MISC. | MESALAMINE | GENERIC | PA | |
| GASTROINTESTINAL AGENTS - MISC. | MESALAMINE DR | GENERIC | ||
| GASTROINTESTINAL AGENTS - MISC. | MESALAMINE DR | EXCLUDED | ||
| GASTROINTESTINAL AGENTS - MISC. | MESALAMINE ER | GENERIC | ||
| GASTROINTESTINAL AGENTS - MISC. | MESALAMINE ER | EXCLUDED | ||
| GASTROINTESTINAL AGENTS - MISC. | METOCLOPRAMIDE HCL | GENERIC | ||
| GASTROINTESTINAL AGENTS - MISC. | METOCLOPRAMIDE HYDROCHLOR IDE | GENERIC | ||
| GASTROINTESTINAL AGENTS - MISC. | MOTEGRITY | EXCLUDED | PA | |
| GASTROINTESTINAL AGENTS - MISC. | MOVANTIK | PREFERRED | PA | |
| GASTROINTESTINAL AGENTS - MISC. | OMVOH | NON-PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | OTULFI | EXCLUDED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | PENTASA | PREFERRED | ||
| GASTROINTESTINAL AGENTS - MISC. | PRUCALOPRIDE | GENERIC | PA | |
| GASTROINTESTINAL AGENTS - MISC. | PYZCHIVA | EXCLUDED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | REBYOTA | NON-PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | REGLAN | EXCLUDED | ||
| GASTROINTESTINAL AGENTS - MISC. | RELISTOR | PREFERRED | PA | |
| GASTROINTESTINAL AGENTS - MISC. | REMICADE | EXCLUDED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | RENFLEXIS | EXCLUDED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | RENVELA | EXCLUDED | ||
| GASTROINTESTINAL AGENTS - MISC. | REZDIFFRA | NON-PREFERRED | PA | |
| GASTROINTESTINAL AGENTS - MISC. | ROWASA | EXCLUDED | PA | |
| GASTROINTESTINAL AGENTS - MISC. | SELARSDI | EXCLUDED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | SEVELAMER CARBONATE | GENERIC | ||
| GASTROINTESTINAL AGENTS - MISC. | SEVELAMER HYDROCHLORIDE | EXCLUDED | ||
| GASTROINTESTINAL AGENTS - MISC. | SFROWASA | EXCLUDED | ||
| GASTROINTESTINAL AGENTS - MISC. | SKYRIZI | PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | STELARA | PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | STEQEYMA | EXCLUDED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | SULFASALAZINE | GENERIC | ||
| GASTROINTESTINAL AGENTS - MISC. | SYMPROIC | PREFERRED | PA | |
| GASTROINTESTINAL AGENTS - MISC. | TREMFYA | PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | TREMFYA INDUCTION PACK FO R CROHNS DISEASE/ULCERATIVE COLITIS | PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | TRULANCE | PREFERRED | PA | |
| GASTROINTESTINAL AGENTS - MISC. | URSO FORTE | EXCLUDED | ||
| GASTROINTESTINAL AGENTS - MISC. | URSODIOL | GENERIC | ||
| GASTROINTESTINAL AGENTS - MISC. | USTEKINUMAB | EXCLUDED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | USTEKINUMAB-TTWE | EXCLUDED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | VELPHORO | EXCLUDED | PA | |
| GASTROINTESTINAL AGENTS - MISC. | VELSIPITY | NON-PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | VIBERZI | PREFERRED | PA | |
| GASTROINTESTINAL AGENTS - MISC. | VOWST | NON-PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | WEZLANA | EXCLUDED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | XERMELO | PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | YESINTEK | PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | ZYMFENTRA 1-PEN | PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | ZYMFENTRA 2-PEN | PREFERRED | SP | PA |
| GASTROINTESTINAL AGENTS - MISC. | ZYMFENTRA 2-SYRINGE | PREFERRED | SP | PA |
| GENITOURINARY AGENTS - MISCELLANEOUS | ACETIC ACID 0.25% | GENERIC | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | ALFUZOSIN HCL ER | GENERIC | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | ALFUZOSIN HYDROCHLORIDE E R | GENERIC | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | ARGYLE STERILE SALINE | EXCLUDED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | AVODART | EXCLUDED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | CYSTAGON | PREFERRED | SP | PA |
| GENITOURINARY AGENTS - MISCELLANEOUS | DEFLUX | NON-PREFERRED | PA | |
| GENITOURINARY AGENTS - MISCELLANEOUS | DUTASTERIDE | GENERIC | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | ELMIRON | PREFERRED | PA | |
| GENITOURINARY AGENTS - MISCELLANEOUS | FILSPARI | NON-PREFERRED | SP | PA |
| GENITOURINARY AGENTS - MISCELLANEOUS | FINASTERIDE | GENERIC | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | GLYCINE | GENERIC | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | GLYCINE | EXCLUDED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | K-PHOS NO 2 | EXCLUDED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | LITHOSTAT | NON-PREFERRED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | NEOMYCIN/POLYMYXIN B SULF ATES | PREFERRED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | OXLUMO | EXCLUDED | SP | PA |
| GENITOURINARY AGENTS - MISCELLANEOUS | POTASSIUM CITRATE ER | GENERIC | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | POTASSIUM CITRATE/CITRIC ACID | EXCLUDED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | POTASSIUM CITRATE/SODIUM CITRATE/CITRIC ACID | EXCLUDED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | PROCYSBI | EXCLUDED | SP | PA |
| GENITOURINARY AGENTS - MISCELLANEOUS | PROSCAR | EXCLUDED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | RAPAFLO | EXCLUDED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | RENACIDIN | PREFERRED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | RIMSO-50 | EXCLUDED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | RIVFLOZA | NON-PREFERRED | SP | PA |
| GENITOURINARY AGENTS - MISCELLANEOUS | SILODOSIN | GENERIC | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | SODIUM CHLORIDE 0.9% | GENERIC | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | SODIUM CHLORIDE 0.9% | PREFERRED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | SORBITOL | PREFERRED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | SORBITOL/MANNITOL IRRIGAT ION | PREFERRED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | TAMSULOSIN HYDROCHLORIDE | GENERIC | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | THIOLA | NON-PREFERRED | SP | PA |
| GENITOURINARY AGENTS - MISCELLANEOUS | THIOLA EC | NON-PREFERRED | SP | PA |
| GENITOURINARY AGENTS - MISCELLANEOUS | TIOPRONIN | GENERIC | SP | PA |
| GENITOURINARY AGENTS - MISCELLANEOUS | TIOPRONIN DR | EXCLUDED | SP | PA |
| GENITOURINARY AGENTS - MISCELLANEOUS | TRICITRATES | EXCLUDED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | UROCIT-K 10 | EXCLUDED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | UROCIT-K 15 | EXCLUDED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | UROXATRAL | EXCLUDED | ||
| GENITOURINARY AGENTS - MISCELLANEOUS | VANRAFIA | PREFERRED | SP | PA |
| GENITOURINARY AGENTS - MISCELLANEOUS | VENXXIVA | EXCLUDED | SP | PA |
| GENITOURINARY AGENTS - MISCELLANEOUS | VOYXACT | EXCLUDED | SP | |
| GOUT AGENTS | ALLOPURINOL | GENERIC | ||
| GOUT AGENTS | ALLOPURINOL SODIUM | GENERIC | ||
| GOUT AGENTS | ALOPRIM | EXCLUDED | ||
| GOUT AGENTS | COLCHICINE | GENERIC | ||
| GOUT AGENTS | COLCHICINE | EXCLUDED | ||
| GOUT AGENTS | FEBUXOSTAT | GENERIC | ||
| GOUT AGENTS | GLOPERBA | EXCLUDED | ||
| GOUT AGENTS | MITIGARE | EXCLUDED | ||
| GOUT AGENTS | PROBENECID | GENERIC | ||
| GOUT AGENTS | PROBENECID/COLCHICINE | GENERIC | ||
| GOUT AGENTS | ULORIC | EXCLUDED | ||
| HEMATOLOGICAL AGENTS - MISC. | ADVATE | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | ADYNOVATE | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | ADZYNMA | EXCLUDED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | AFSTYLA | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | AGGRASTAT | NON-PREFERRED | ||
| HEMATOLOGICAL AGENTS - MISC. | AGRYLIN | EXCLUDED | ||
| HEMATOLOGICAL AGENTS - MISC. | ALHEMO | EXCLUDED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | ALPHANATE | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | ALPHANINE SD | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | ALPROLIX | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | ALTUVIIIO | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | ANAGRELIDE HYDROCHLORIDE | GENERIC | ||
| HEMATOLOGICAL AGENTS - MISC. | ANDEMBRY | EXCLUDED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | ASPIRIN/DIPYRIDAMOLE | GENERIC | ||
| HEMATOLOGICAL AGENTS - MISC. | ASPIRIN/DIPYRIDAMOLE ER | GENERIC | ||
| HEMATOLOGICAL AGENTS - MISC. | BALFAXAR | EXCLUDED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | BENEFIX | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | BERINERT | NON-PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | BKEMV | EXCLUDED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | BRILINTA | EXCLUDED | ||
| HEMATOLOGICAL AGENTS - MISC. | CABLIVI | NON-PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | CILOSTAZOL | GENERIC | ||
| HEMATOLOGICAL AGENTS - MISC. | CINRYZE | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | CLOPIDOGREL | GENERIC | ||
| HEMATOLOGICAL AGENTS - MISC. | COAGADEX | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | CORIFACT | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | DEFITELIO | NON-PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | DIPYRIDAMOLE | GENERIC | ||
| HEMATOLOGICAL AGENTS - MISC. | EFFIENT | EXCLUDED | ||
| HEMATOLOGICAL AGENTS - MISC. | EKTERLY | EXCLUDED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | ELOCTATE | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | EMPAVELI | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | ENJAYMO | NON-PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | EPTIFIBATIDE | GENERIC | ||
| HEMATOLOGICAL AGENTS - MISC. | EPTIFIBATIDE | EXCLUDED | ||
| HEMATOLOGICAL AGENTS - MISC. | EPYSQLI | EXCLUDED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | ESPEROCT | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | FABHALTA | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | FEIBA | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | FIBRYGA | NON-PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | FIRAZYR | EXCLUDED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | GIVLAARI | NON-PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | GOHIBIC | EXCLUDED | ||
| HEMATOLOGICAL AGENTS - MISC. | HAEGARDA | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | HEMGENIX | EXCLUDED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | HEMLIBRA | NON-PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | HEMOFIL M | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | HUMATE-P | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | HYMPAVZI | NON-PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | ICATIBANT ACETATE | GENERIC | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | IDELVION | EXCLUDED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | IXINITY | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | JIVI | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | KALBITOR | EXCLUDED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | KCENTRA | NON-PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | KENGREAL | NON-PREFERRED | ||
| HEMATOLOGICAL AGENTS - MISC. | KOATE | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | KOVALTRY | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | NOVOEIGHT | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | NOVOSEVEN RT | EXCLUDED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | NUWIQ | NON-PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | OBIZUR | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | ORLADEYO | NON-PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | PANHEMATIN | NON-PREFERRED | ||
| HEMATOLOGICAL AGENTS - MISC. | PENTOXIFYLLINE ER | GENERIC | ||
| HEMATOLOGICAL AGENTS - MISC. | PIASKY | EXCLUDED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | PLAVIX | EXCLUDED | ||
| HEMATOLOGICAL AGENTS - MISC. | PRASUGREL HYDROCHLORIDE | GENERIC | ||
| HEMATOLOGICAL AGENTS - MISC. | PROFILNINE | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | PYRUKYND | NON-PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | PYRUKYND TAPER PACK | NON-PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | QFITLIA | EXCLUDED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | REBINYN | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | RECOMBINATE | NON-PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | RIASTAP | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | RIXUBIS | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | ROCTAVIAN | EXCLUDED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | RUCONEST | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | SAJAZIR | GENERIC | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | SEVENFACT | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | SOLIRIS | NON-PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | TAKHZYRO | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | TAVALISSE | EXCLUDED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | TAVNEOS | NON-PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | TICAGRELOR | GENERIC | ||
| HEMATOLOGICAL AGENTS - MISC. | TIROFIBAN HYDROCHLORIDE | GENERIC | ||
| HEMATOLOGICAL AGENTS - MISC. | TIROFIBAN HYDROCHLORIDE | EXCLUDED | ||
| HEMATOLOGICAL AGENTS - MISC. | TRETTEN | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | ULTOMIRIS | NON-PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | VEOPOZ | NON-PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | VONVENDI | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | VOYDEYA | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | WILATE | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | XYNTHA | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | XYNTHA SOLOFUSE | PREFERRED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | ZILBRYSQ | EXCLUDED | SP | PA |
| HEMATOLOGICAL AGENTS - MISC. | ZONTIVITY | NON-PREFERRED | ||
| HEMATOPOIETIC AGENTS | ADAKVEO | NON-PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | ALVAIZ | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | APHEXDA | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | ARANESP ALBUMIN FREE | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | CASGEVY | NON-PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | CERDELGA | PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | CEREZYME | PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | DOPTELET | PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | DOPTELET SPRINKLE | PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | DROXIA | PREFERRED | ||
| HEMATOPOIETIC AGENTS | ELELYSO | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | ELTROMBOPAG OLAMINE | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | ENDARI | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | EPOGEN | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | FERAHEME | EXCLUDED | ||
| HEMATOPOIETIC AGENTS | FERRLECIT | EXCLUDED | ||
| HEMATOPOIETIC AGENTS | FERUMOXYTOL | EXCLUDED | ||
| HEMATOPOIETIC AGENTS | FOLIC ACID | GENERIC | ||
| HEMATOPOIETIC AGENTS | FOLIC ACID | EXCLUDED | ||
| HEMATOPOIETIC AGENTS | FULPHILA | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | FYLNETRA | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | GRANIX | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | INFED | NON-PREFERRED | ||
| HEMATOPOIETIC AGENTS | INJECTAFER | EXCLUDED | ||
| HEMATOPOIETIC AGENTS | IRON SUCROSE | GENERIC | ||
| HEMATOPOIETIC AGENTS | LEUKINE | PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | L-GLUTAMINE | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | LYFGENIA | NON-PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | MIGLUSTAT | GENERIC | SP | PA |
| HEMATOPOIETIC AGENTS | MIRCERA | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | MONOFERRIC | NON-PREFERRED | ||
| HEMATOPOIETIC AGENTS | MOZOBIL | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | NEULASTA | PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | NEULASTA ONPRO KIT | PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | NEUPOGEN | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | NIVESTYM | PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | NPLATE | PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | NYVEPRIA | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | PLERIXAFOR | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | PROCRIT | PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | PROMACTA | PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | RELEUKO | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | RETACRIT | PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | ROLVEDON | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | RYZNEUTA | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | SIKLOS | EXCLUDED | PA | |
| HEMATOPOIETIC AGENTS | SODIUM FERRIC GLUCONATE C OMPLEX/SUCROSE | EXCLUDED | ||
| HEMATOPOIETIC AGENTS | STIMUFEND | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | UDENYCA | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | UDENYCA ONBODY | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | VAFSEO | NON-PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | VENOFER | NON-PREFERRED | ||
| HEMATOPOIETIC AGENTS | VPRIV | NON-PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | XOLREMDI | NON-PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | XROMI | EXCLUDED | ||
| HEMATOPOIETIC AGENTS | YARGESA | GENERIC | SP | PA |
| HEMATOPOIETIC AGENTS | ZARXIO | PREFERRED | SP | PA |
| HEMATOPOIETIC AGENTS | ZAVESCA | EXCLUDED | SP | PA |
| HEMATOPOIETIC AGENTS | ZIEXTENZO | PREFERRED | SP | PA |
| HEMOSTATICS | AMINOCAPROIC ACID | GENERIC | ||
| HEMOSTATICS | CYKLOKAPRON | EXCLUDED | ||
| HEMOSTATICS | TRANEXAMIC ACID | GENERIC | ||
| HEMOSTATICS | TRANEXAMIC ACID/SODIUM CH LORIDE | GENERIC | ||
| HEMOSTATICS | TRANEXAMIC ACID/SODIUM CH LORIDE | PREFERRED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | AMBIEN | EXCLUDED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | AMBIEN CR | EXCLUDED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | BYFAVO | NON-PREFERRED | PA | |
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | DEXMEDETOMIDINE HYDROCHLO RIDE/DEXTROSE MONOHYDRATE | NON-PREFERRED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | DEXMEDETOMIDINE HYDROCHLO RIDE/SODIUM CHLORIDE | GENERIC | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | DEXMEDETOMIDINE HYDROCHLO RIDE/SODIUM CHLORIDE | PREFERRED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | DEXMEDETOMIDINE HYDROCHLO RIDE/SODIUM CHLORIDE | EXCLUDED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | ESTAZOLAM | GENERIC | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | ESZOPICLONE | GENERIC | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | FLURAZEPAM HYDROCHLORIDE | PREFERRED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | HALCION | EXCLUDED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | LUNESTA | EXCLUDED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | MIDAZOLAM | PREFERRED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | MIDAZOLAM | EXCLUDED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | MIDAZOLAM HCL | GENERIC | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | MIDAZOLAM HCL | EXCLUDED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | MIDAZOLAM HYDROCHLORIDE | PREFERRED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | MIDAZOLAM HYDROCHLORIDE | EXCLUDED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | MIDAZOLAM HYDROCHLORIDE/S ODIUM CHLORIDE | PREFERRED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | MIDAZOLAM HYDROCHLORIDE/S ODIUM CHLORIDE | EXCLUDED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | MIDAZOLAM/SODIUM CHLORIDE | EXCLUDED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | PENTOBARBITAL SODIUM | GENERIC | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | PHENOBARBITAL | PREFERRED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | PHENOBARBITAL SODIUM | PREFERRED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | PRECEDEX | NON-PREFERRED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | PRECEDEX | EXCLUDED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | RAMELTEON | EXCLUDED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | ROZEREM | EXCLUDED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | SEZABY | EXCLUDED | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | TEMAZEPAM | GENERIC | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | TRIAZOLAM | GENERIC | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | ZALEPLON | GENERIC | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | ZOLPIDEM TARTRATE | GENERIC | ||
| HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS | ZOLPIDEM TARTRATE ER | GENERIC | ||
| LAXATIVES | CLENPIQ | EXCLUDED | ||
| LAXATIVES | CONSTULOSE | GENERIC | ||
| LAXATIVES | GAVILYTE-C | PREFERRED | ||
| LAXATIVES | GAVILYTE-G | GENERIC | ||
| LAXATIVES | GAVILYTE-N/FLAVOR PACK | GENERIC | ||
| LAXATIVES | GOLYTELY | EXCLUDED | ||
| LAXATIVES | LACTULOSE | GENERIC | ||
| LAXATIVES | MINERAL OIL HEAVY | EXCLUDED | ||
| LAXATIVES | MINERAL OIL LIGHT | EXCLUDED | ||
| LAXATIVES | MOVIPREP | EXCLUDED | ||
| LAXATIVES | MURI-LUBE | EXCLUDED | ||
| LAXATIVES | PEG-3350/ELECTROLYTES | GENERIC | ||
| LAXATIVES | PEG-3350/ELECTROLYTES/ASC ORBATE | EXCLUDED | ||
| LAXATIVES | PEG-3350/NACL/NA BICARBON ATE/KCL | GENERIC | ||
| LAXATIVES | PEG-3350/SODIUM SULF/NACL POTASSIUM CL/NA ASCORBATE/ASCORBIC | EXCLUDED | ||
| LAXATIVES | PLENVU | EXCLUDED | ||
| LAXATIVES | SODIUM SULFATE/POTASSIUM SULFATE/MAGNESIUM SULFATE | GENERIC | ||
| LAXATIVES | SUFLAVE | EXCLUDED | ||
| LAXATIVES | SUPREP BOWEL PREP KIT | NON-PREFERRED | ||
| LAXATIVES | SUTAB | EXCLUDED | ||
| LAXATIVES | VIBRANT | EXCLUDED | ||
| LAXATIVES | VIBRANT STARTER KIT | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | ARTICADENT DENTAL | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | BUFFERED LIDOCAINE HYDROC HLORIDE/EPINEPHRINE/SODIUM CHLORIDE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | BUPIVACAINE FISIOPHARMA | PREFERRED | ||
| LOCAL ANESTHETICS-Parenteral | BUPIVACAINE HYDROCHLORIDE | GENERIC | ||
| LOCAL ANESTHETICS-Parenteral | BUPIVACAINE HYDROCHLORIDE | PREFERRED | ||
| LOCAL ANESTHETICS-Parenteral | BUPIVACAINE HYDROCHLORIDE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | BUPIVACAINE HYDROCHLORIDE /DEXTROSE SPINAL | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | BUPIVACAINE HYDROCHLORIDE /SODIUM CHLORIDE | PREFERRED | ||
| LOCAL ANESTHETICS-Parenteral | BUPIVACAINE HYDROCHLORIDE EPINEPHRINE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | BUPIVACAINE SPINAL | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | BUPIVACAINE/EPINEPHRINE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | CHLOROPROCAINE HYDROCHLOR IDE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | EXPAREL | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | LIDOCAINE HCL | GENERIC | ||
| LOCAL ANESTHETICS-Parenteral | LIDOCAINE HCL | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | LIDOCAINE HYDROCHLORIDE | PREFERRED | ||
| LOCAL ANESTHETICS-Parenteral | LIDOCAINE HYDROCHLORIDE | GENERIC | ||
| LOCAL ANESTHETICS-Parenteral | LIDOCAINE HYDROCHLORIDE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | LIDOCAINE HYDROCHLORIDE B UFFERED | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | LIDOCAINE HYDROCHLORIDE B UFFERED/EPINEPHRINE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | LIDOCAINE HYDROCHLORIDE/E PINEPHRINE | GENERIC | ||
| LOCAL ANESTHETICS-Parenteral | LIDOCAINE/EPINEPHRINE | GENERIC | ||
| LOCAL ANESTHETICS-Parenteral | LIDOCAINE/EPINEPHRINE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | MARCAINE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | MARCAINE SPINAL | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | MARCAINE/EPINEPHRINE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | NAROPIN | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | NESACAINE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | NESACAINE-MPF | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | ORABLOC | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | POLOCAINE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | POLOCAINE-MPF | PREFERRED | ||
| LOCAL ANESTHETICS-Parenteral | POLOCAINE-MPF | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | RECK | PREFERRED | ||
| LOCAL ANESTHETICS-Parenteral | ROPIVACAINE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | ROPIVACAINE HCL | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | ROPIVACAINE HYDROCHLORIDE | GENERIC | ||
| LOCAL ANESTHETICS-Parenteral | ROPIVACAINE HYDROCHLORIDE | PREFERRED | ||
| LOCAL ANESTHETICS-Parenteral | ROPIVACAINE HYDROCHLORIDE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | ROPIVACAINE HYDROCHLORIDE /CLONIDINE HYDROCHLORIDE/KETOROLAC | PREFERRED | ||
| LOCAL ANESTHETICS-Parenteral | ROPIVACAINE HYDROCHLORIDE /SODIUM CHLORIDE | PREFERRED | ||
| LOCAL ANESTHETICS-Parenteral | ROPIVACAINE HYDROCHLORIDE /SODIUM CHLORIDE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | SENSORCAINE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | SENSORCAINE/EPINEPHRINE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | SENSORCAINE-MPF | GENERIC | ||
| LOCAL ANESTHETICS-Parenteral | SENSORCAINE-MPF | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | SENSORCAINE-MPF/EPINEPHRI NE | PREFERRED | ||
| LOCAL ANESTHETICS-Parenteral | SENSORCAINE-MPF/EPINEPHRI NE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | TETRACAINE HYDROCHLORIDE | PREFERRED | ||
| LOCAL ANESTHETICS-Parenteral | XYLOCAINE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | XYLOCAINE/EPINEPHRINE | EXCLUDED | ||
| LOCAL ANESTHETICS-Parenteral | XYLOCAINE-MPF/EPINEPHRINE | EXCLUDED | ||
| MACROLIDES | AZITHROMYCIN | GENERIC | ||
| MACROLIDES | CLARITHROMYCIN | GENERIC | ||
| MACROLIDES | CLARITHROMYCIN | PREFERRED | ||
| MACROLIDES | CLARITHROMYCIN ER | GENERIC | ||
| MACROLIDES | DIFICID | NON-PREFERRED | PA | |
| MACROLIDES | E.E.S. 400 | NON-PREFERRED | ||
| MACROLIDES | E.E.S. GRANULES | EXCLUDED | ||
| MACROLIDES | ERYPED 400 | EXCLUDED | ||
| MACROLIDES | ERYTHROCIN LACTOBIONATE | EXCLUDED | ||
| MACROLIDES | ERYTHROMYCIN BASE | GENERIC | ||
| MACROLIDES | ERYTHROMYCIN DR | GENERIC | ||
| MACROLIDES | ERYTHROMYCIN DR | PREFERRED | ||
| MACROLIDES | ERYTHROMYCIN DR | EXCLUDED | ||
| MACROLIDES | ERYTHROMYCIN ETHYLSUCCINA TE | GENERIC | ||
| MACROLIDES | ERYTHROMYCIN LACTOBIONATE | EXCLUDED | ||
| MACROLIDES | FIDAXOMICIN | GENERIC | PA | |
| MACROLIDES | ZITHROMAX | EXCLUDED | ||
| MACROLIDES | ZITHROMAX TRI-PAK | EXCLUDED | ||
| MACROLIDES | ZITHROMAX Z-PAK | EXCLUDED | ||
| MEDICAL DEVICES AND SUPPLIES | ASSURE TITANIUM BLOOD GLU COSE MONITOR | EXCLUDED | ||
| MEDICAL DEVICES AND SUPPLIES | CONCEPTION KIT | NON-PREFERRED | ||
| MEDICAL DEVICES AND SUPPLIES | EXTENDED INFUSION SET 43" /6MM | NON-PREFERRED | ||
| MEDICAL DEVICES AND SUPPLIES | EXTENDED INFUSION SET 43" /9MM | NON-PREFERRED | ||
| MEDICAL DEVICES AND SUPPLIES | FREESTYLE LIBRE 2 PLUS/SE NSOR/FLASH GLUCOSE MONITOR SYSTEM | PREFERRED | ||
| MEDICAL DEVICES AND SUPPLIES | FREESTYLE LIBRE 3 PLUS/SE NSOR/GLUCOSE MONITORING SYSTEM | PREFERRED | ||
| MEDICAL DEVICES AND SUPPLIES | IVENIX LVP PRIMARY ADMINI STRATION 1-SET INLET | NON-PREFERRED | ||
| MEDICAL DEVICES AND SUPPLIES | IVENIX LVP PRIMARY ADMINI STRATION SET 1-INLET MICROBORE | NON-PREFERRED | ||
| MEDICAL DEVICES AND SUPPLIES | IVENIX LVP PRIMARY ADMINI STRATION SET DUAL INTEL & Y SITE | NON-PREFERRED | ||
| MEDICAL DEVICES AND SUPPLIES | LASIX ONYU REUSABLE UNIT AND CHARGER | NON-PREFERRED | ||
| MEDICAL DEVICES AND SUPPLIES | VAPRO PLUS POCKET/12FR/8" /STRAIGHT/INTERMITTENT | NON-PREFERRED | ||
| MEDICAL DEVICES AND SUPPLIES | VAPRO PLUS/14FR/16"/STRAI GHT/INTERMITTENT | NON-PREFERRED | ||
| MIGRAINE PRODUCTS | AIMOVIG | PREFERRED | PA | |
| MIGRAINE PRODUCTS | AJOVY | PREFERRED | PA | |
| MIGRAINE PRODUCTS | ALMOTRIPTAN | GENERIC | ||
| MIGRAINE PRODUCTS | ALMOTRIPTAN MALATE | GENERIC | ||
| MIGRAINE PRODUCTS | ELETRIPTAN HYDROBROMIDE | GENERIC | ||
| MIGRAINE PRODUCTS | ELYXYB | EXCLUDED | PA | |
| MIGRAINE PRODUCTS | EMGALITY | PREFERRED | PA | |
| MIGRAINE PRODUCTS | ERGOTAMINE TARTRATE/CAFFE INE | PREFERRED | ||
| MIGRAINE PRODUCTS | FROVA | EXCLUDED | ||
| MIGRAINE PRODUCTS | FROVATRIPTAN SUCCINATE | GENERIC | ||
| MIGRAINE PRODUCTS | IMITREX | EXCLUDED | ||
| MIGRAINE PRODUCTS | IMITREX STATDOSE REFILL | EXCLUDED | ||
| MIGRAINE PRODUCTS | IMITREX STATDOSE SYSTEM | EXCLUDED | ||
| MIGRAINE PRODUCTS | MAXALT | EXCLUDED | ||
| MIGRAINE PRODUCTS | MAXALT-MLT | EXCLUDED | ||
| MIGRAINE PRODUCTS | NARATRIPTAN HCL | GENERIC | ||
| MIGRAINE PRODUCTS | NURTEC | PREFERRED | PA | |
| MIGRAINE PRODUCTS | QULIPTA | PREFERRED | PA | |
| MIGRAINE PRODUCTS | RELPAX | EXCLUDED | ||
| MIGRAINE PRODUCTS | RIZATRIPTAN BENZOATE | GENERIC | ||
| MIGRAINE PRODUCTS | RIZATRIPTAN BENZOATE ODT | GENERIC | ||
| MIGRAINE PRODUCTS | SUMATRIPTAN | GENERIC | ||
| MIGRAINE PRODUCTS | SUMATRIPTAN SUCCINATE | GENERIC | ||
| MIGRAINE PRODUCTS | SYMBRAVO | EXCLUDED | ||
| MIGRAINE PRODUCTS | UBRELVY | PREFERRED | PA | |
| MIGRAINE PRODUCTS | VYEPTI | EXCLUDED | PA | |
| MIGRAINE PRODUCTS | ZAVZPRET | EXCLUDED | PA | |
| MIGRAINE PRODUCTS | ZOLMITRIPTAN | GENERIC | ||
| MIGRAINE PRODUCTS | ZOLMITRIPTAN | EXCLUDED | ||
| MIGRAINE PRODUCTS | ZOLMITRIPTAN ODT | GENERIC | ||
| MIGRAINE PRODUCTS | ZOMIG | GENERIC | ||
| MIGRAINE PRODUCTS | ZOMIG | PREFERRED | ||
| MINERALS & ELECTROLYTES | AQUASTAT | NON-PREFERRED | ||
| MINERALS & ELECTROLYTES | AQUASTAT SFR | NON-PREFERRED | ||
| MINERALS & ELECTROLYTES | BD POSIFLUSH | PREFERRED | ||
| MINERALS & ELECTROLYTES | BD POSIFLUSH NORMAL SALIN E FLUSH | PREFERRED | ||
| MINERALS & ELECTROLYTES | CALCIUM CHLORIDE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | CALCIUM GLUCONATE | PREFERRED | ||
| MINERALS & ELECTROLYTES | CALCIUM GLUCONATE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | CALCIUM GLUCONATE/SODIUM CHLORIDE | PREFERRED | ||
| MINERALS & ELECTROLYTES | CALCIUM GLUCONATE/SODIUM CHLORIDE | GENERIC | ||
| MINERALS & ELECTROLYTES | CALCIUM GLUCONATE/SODIUM CHLORIDE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | CHROMIC CHLORIDE | GENERIC | ||
| MINERALS & ELECTROLYTES | CHROMIUM CHLORIDE | PREFERRED | ||
| MINERALS & ELECTROLYTES | COPPER | PREFERRED | ||
| MINERALS & ELECTROLYTES | CUPRIC CHLORIDE | GENERIC | ||
| MINERALS & ELECTROLYTES | DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX | PREFERRED | ||
| MINERALS & ELECTROLYTES | DEXTROSE 10%/SODIUM CHLOR IDE 0.2% | EXCLUDED | ||
| MINERALS & ELECTROLYTES | DEXTROSE 10%/SODIUM CHLOR IDE 0.45% | EXCLUDED | ||
| MINERALS & ELECTROLYTES | DEXTROSE 2.5%/SODIUM CHLO RIDE 0.45% | EXCLUDED | ||
| MINERALS & ELECTROLYTES | DEXTROSE 5%/LACTATED RING ERS | EXCLUDED | ||
| MINERALS & ELECTROLYTES | DEXTROSE 5%/SODIUM CHLORI DE 0.2% | EXCLUDED | ||
| MINERALS & ELECTROLYTES | DEXTROSE 5%/SODIUM CHLORI DE 0.3% | EXCLUDED | ||
| MINERALS & ELECTROLYTES | DEXTROSE 5%/SODIUM CHLORI DE 0.33% | EXCLUDED | ||
| MINERALS & ELECTROLYTES | DEXTROSE 5%/SODIUM CHLORI DE 0.45% | EXCLUDED | ||
| MINERALS & ELECTROLYTES | DEXTROSE 5%/SODIUM CHLORI DE 0.9% | EXCLUDED | ||
| MINERALS & ELECTROLYTES | DEXTROSE/SODIUM CHLORIDE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | EFFER-K | PREFERRED | ||
| MINERALS & ELECTROLYTES | EFFER-K | EXCLUDED | ||
| MINERALS & ELECTROLYTES | ELLIOTTS B | NON-PREFERRED | ||
| MINERALS & ELECTROLYTES | FLUORIDE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | GALZIN | NON-PREFERRED | ||
| MINERALS & ELECTROLYTES | GLYCOPHOS | PREFERRED | ||
| MINERALS & ELECTROLYTES | IODINE STRONG | PREFERRED | ||
| MINERALS & ELECTROLYTES | IONOSOL-MB/DEXTROSE 5% | EXCLUDED | ||
| MINERALS & ELECTROLYTES | ISOLYTE-P/DEXTROSE 5% | EXCLUDED | ||
| MINERALS & ELECTROLYTES | ISOLYTE-S | EXCLUDED | ||
| MINERALS & ELECTROLYTES | ISOLYTE-S PH 7.4 | EXCLUDED | ||
| MINERALS & ELECTROLYTES | KCL 0.075%/D5W/NACL 0.45% | PREFERRED | ||
| MINERALS & ELECTROLYTES | KCL 0.15%/D5W/NACL 0.2% | PREFERRED | ||
| MINERALS & ELECTROLYTES | KCL 0.15%/D5W/NACL 0.225% | PREFERRED | ||
| MINERALS & ELECTROLYTES | KCL 0.15%/D5W/NACL 0.45% | PREFERRED | ||
| MINERALS & ELECTROLYTES | KCL 0.15%/D5W/NACL 0.9% | PREFERRED | ||
| MINERALS & ELECTROLYTES | KCL 0.3%/D5W/NACL 0.45% | PREFERRED | ||
| MINERALS & ELECTROLYTES | KCL 0.3%/D5W/NACL 0.9% | PREFERRED | ||
| MINERALS & ELECTROLYTES | KLOR-CON 10 | EXCLUDED | ||
| MINERALS & ELECTROLYTES | KLOR-CON 8 | EXCLUDED | ||
| MINERALS & ELECTROLYTES | KLOR-CON M10 | GENERIC | ||
| MINERALS & ELECTROLYTES | KLOR-CON M15 | GENERIC | ||
| MINERALS & ELECTROLYTES | KLOR-CON M20 | GENERIC | ||
| MINERALS & ELECTROLYTES | K-PHOS | PREFERRED | ||
| MINERALS & ELECTROLYTES | K-PHOS NEUTRAL | EXCLUDED | ||
| MINERALS & ELECTROLYTES | LACTATED RINGERS | NON-PREFERRED | ||
| MINERALS & ELECTROLYTES | LACTATED RINGERS | GENERIC | ||
| MINERALS & ELECTROLYTES | MAGNESIUM CHLORIDE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | MAGNESIUM SULFATE | GENERIC | ||
| MINERALS & ELECTROLYTES | MAGNESIUM SULFATE | PREFERRED | ||
| MINERALS & ELECTROLYTES | MAGNESIUM SULFATE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | MAGNESIUM SULFATE IN D5W | EXCLUDED | ||
| MINERALS & ELECTROLYTES | MAGNESIUM SULFATE/DEXTROS E | EXCLUDED | ||
| MINERALS & ELECTROLYTES | MANGANESE CHLORIDE | GENERIC | ||
| MINERALS & ELECTROLYTES | MANGANESE TRACE METAL | PREFERRED | ||
| MINERALS & ELECTROLYTES | MONOJECT PHARMA GRADE FLU SH SYRINGE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | MONOJECT SODIUM CHLORIDE FLUSH | EXCLUDED | ||
| MINERALS & ELECTROLYTES | MULTIPLE ELECTROLYTES INJ ECTION TYPE 1 | EXCLUDED | ||
| MINERALS & ELECTROLYTES | MULTRYS | EXCLUDED | ||
| MINERALS & ELECTROLYTES | NORMAL SALINE I.V. FLUSH | PREFERRED | ||
| MINERALS & ELECTROLYTES | NORMOSOL -R | EXCLUDED | ||
| MINERALS & ELECTROLYTES | NORMOSOL-M/D5W | EXCLUDED | ||
| MINERALS & ELECTROLYTES | NORMOSOL-R | EXCLUDED | ||
| MINERALS & ELECTROLYTES | NORMOSOL-R/5% DEXTROSE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | PHOSPHA 250 NEUTRAL | EXCLUDED | ||
| MINERALS & ELECTROLYTES | PHOSPHOROUS | EXCLUDED | ||
| MINERALS & ELECTROLYTES | PHOSPHO-TRIN 250 NEUTRAL | EXCLUDED | ||
| MINERALS & ELECTROLYTES | PHOSPHO-TRIN K500 | EXCLUDED | ||
| MINERALS & ELECTROLYTES | PLASMA-LYTE 148 | EXCLUDED | ||
| MINERALS & ELECTROLYTES | PLASMA-LYTE A | EXCLUDED | ||
| MINERALS & ELECTROLYTES | POKONZA | EXCLUDED | ||
| MINERALS & ELECTROLYTES | POTASSIUM ACETATE | PREFERRED | ||
| MINERALS & ELECTROLYTES | POTASSIUM ACETATE | GENERIC | ||
| MINERALS & ELECTROLYTES | POTASSIUM CHLORIDE | GENERIC | ||
| MINERALS & ELECTROLYTES | POTASSIUM CHLORIDE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | POTASSIUM CHLORIDE ER | GENERIC | ||
| MINERALS & ELECTROLYTES | POTASSIUM CHLORIDE ER | EXCLUDED | ||
| MINERALS & ELECTROLYTES | POTASSIUM CHLORIDE/DEXTRO SE | PREFERRED | ||
| MINERALS & ELECTROLYTES | POTASSIUM CHLORIDE/DEXTRO SE | GENERIC | ||
| MINERALS & ELECTROLYTES | POTASSIUM CHLORIDE/DEXTRO SE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | POTASSIUM CHLORIDE/DEXTRO SE/LACTATED RINGERS | EXCLUDED | ||
| MINERALS & ELECTROLYTES | POTASSIUM CHLORIDE/DEXTRO SE/SODIUM CHLORIDE | PREFERRED | ||
| MINERALS & ELECTROLYTES | POTASSIUM CHLORIDE/DEXTRO SE/SODIUM CHLORIDE | GENERIC | ||
| MINERALS & ELECTROLYTES | POTASSIUM CHLORIDE/LIDOCA INE HYDROCHLORIDE/SODIUM CHLORIDE | PREFERRED | ||
| MINERALS & ELECTROLYTES | POTASSIUM CHLORIDE/SODIUM CHLORIDE | PREFERRED | ||
| MINERALS & ELECTROLYTES | POTASSIUM CHLORIDE/SODIUM CHLORIDE | GENERIC | ||
| MINERALS & ELECTROLYTES | POTASSIUM CHLORIDE/SODIUM CHLORIDE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | POTASSIUM CHLORIDE/SODIUM CHLORIDE | PREFERRED | ||
| MINERALS & ELECTROLYTES | POTASSIUM PHOSPHATE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | POTASSIUM PHOSPHATE/SODIU M CHLORIDE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | POTASSIUM PHOSPHATES | EXCLUDED | ||
| MINERALS & ELECTROLYTES | POTASSIUM PHOSPHATES/SODI UM CHLORIDE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | RINGERS INJECTION | GENERIC | ||
| MINERALS & ELECTROLYTES | SALINE FLUSH | PREFERRED | ||
| MINERALS & ELECTROLYTES | SELENIOUS ACID | PREFERRED | ||
| MINERALS & ELECTROLYTES | SELENIOUS ACID | EXCLUDED | ||
| MINERALS & ELECTROLYTES | SODIUM ACETATE | PREFERRED | ||
| MINERALS & ELECTROLYTES | SODIUM ACETATE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | SODIUM BICARBONATE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | SODIUM CHLORIDE | GENERIC | ||
| MINERALS & ELECTROLYTES | SODIUM CHLORIDE | PREFERRED | ||
| MINERALS & ELECTROLYTES | SODIUM CHLORIDE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | SODIUM CHLORIDE 0.45% | GENERIC | ||
| MINERALS & ELECTROLYTES | SODIUM CHLORIDE FLUSH | PREFERRED | ||
| MINERALS & ELECTROLYTES | SODIUM FLUORIDE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | SODIUM PHOSPHATE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | SODIUM PHOSPHATES | EXCLUDED | ||
| MINERALS & ELECTROLYTES | THAM | EXCLUDED | ||
| MINERALS & ELECTROLYTES | TPN ELECTROLYTES | EXCLUDED | ||
| MINERALS & ELECTROLYTES | TRALEMENT | NON-PREFERRED | ||
| MINERALS & ELECTROLYTES | TROMETHAMINE | PREFERRED | ||
| MINERALS & ELECTROLYTES | TROMETHAMINE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | ZINC CHLORIDE | EXCLUDED | ||
| MINERALS & ELECTROLYTES | ZINC SULFATE | PREFERRED | ||
| MINERALS & ELECTROLYTES | ZINC SULFATE | GENERIC | ||
| MISCELLANEOUS THERAPEUTIC CLASSES | AMPHADASE | NON-PREFERRED | ||
| MISCELLANEOUS THERAPEUTIC CLASSES | ASCLERA | EXCLUDED | ||
| MISCELLANEOUS THERAPEUTIC CLASSES | ASTAGRAF XL | NON-PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | ATGAM | NON-PREFERRED | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | AZASAN | EXCLUDED | ||
| MISCELLANEOUS THERAPEUTIC CLASSES | AZATHIOPRINE | GENERIC | ||
| MISCELLANEOUS THERAPEUTIC CLASSES | AZATHIOPRINE | PREFERRED | ||
| MISCELLANEOUS THERAPEUTIC CLASSES | AZATHIOPRINE | EXCLUDED | ||
| MISCELLANEOUS THERAPEUTIC CLASSES | BENLYSTA | PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | CELLCEPT | EXCLUDED | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | CELLCEPT INTRAVENOUS | EXCLUDED | ||
| MISCELLANEOUS THERAPEUTIC CLASSES | CUPRIMINE | EXCLUDED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | CUVRIOR | EXCLUDED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | CYCLOSPORINE | GENERIC | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | CYCLOSPORINE MODIFIED | GENERIC | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | DEPEN TITRATABS | EXCLUDED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | ENSPRYNG | PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | ENVARSUS XR | NON-PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | ETHAMOLIN | PREFERRED | ||
| MISCELLANEOUS THERAPEUTIC CLASSES | EUA PATIENT ASSESSMENT | EXCLUDED | ||
| MISCELLANEOUS THERAPEUTIC CLASSES | EVEROLIMUS | GENERIC | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | GAMIFANT | NON-PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | GENGRAF | GENERIC | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | IMAAVY | EXCLUDED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | IMURAN | EXCLUDED | ||
| MISCELLANEOUS THERAPEUTIC CLASSES | JOENJA | NON-PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | KIONEX | GENERIC | ||
| MISCELLANEOUS THERAPEUTIC CLASSES | KORSUVA | NON-PREFERRED | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | LENALIDOMIDE | GENERIC | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | LOKELMA | PREFERRED | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | LUPKYNIS | NON-PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | MYCOPHENOLATE MOFETIL | GENERIC | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | MYCOPHENOLATE MOFETIL | GENERIC | ||
| MISCELLANEOUS THERAPEUTIC CLASSES | MYCOPHENOLIC ACID DR | GENERIC | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | MYFORTIC | EXCLUDED | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | MYHIBBIN | EXCLUDED | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | NEORAL | EXCLUDED | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | NIKTIMVO | EXCLUDED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | NULOJIX | NON-PREFERRED | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | PENICILLAMINE | GENERIC | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | PENICILLAMINE | EXCLUDED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | PROGRAF | NON-PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | PROGRAF | EXCLUDED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | REVLIMID | PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | REZUROCK | NON-PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | RYONCIL | NON-PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | RYONCIL | EXCLUDED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | RYSTIGGO | NON-PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | SANDIMMUNE | EXCLUDED | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | SAPHNELO | NON-PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | SIMULECT | NON-PREFERRED | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | SIROLIMUS | GENERIC | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | SODIUM POLYSTYRENE SULFON ATE | GENERIC | ||
| MISCELLANEOUS THERAPEUTIC CLASSES | SODIUM TETRADECYL SULFATE | EXCLUDED | ||
| MISCELLANEOUS THERAPEUTIC CLASSES | SOLESTA | NON-PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | SOTRADECOL | EXCLUDED | ||
| MISCELLANEOUS THERAPEUTIC CLASSES | SPS | GENERIC | ||
| MISCELLANEOUS THERAPEUTIC CLASSES | SPS | PREFERRED | ||
| MISCELLANEOUS THERAPEUTIC CLASSES | SYLVANT | PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | SYPRINE | EXCLUDED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | TACROLIMUS | GENERIC | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | THALOMID | PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | THYMOGLOBULIN | NON-PREFERRED | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | TRIENTINE HYDROCHLORIDE | GENERIC | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | TRIENTINE HYDROCHLORIDE | EXCLUDED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | UPLIZNA | NON-PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | VARITHENA | EXCLUDED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | VELTASSA | EXCLUDED | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | VIJOICE | NON-PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | VYVGART | NON-PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | VYVGART HYTRULO | NON-PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | XIAFLEX | PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | ZOKINVY | NON-PREFERRED | SP | PA |
| MISCELLANEOUS THERAPEUTIC CLASSES | ZORTRESS | NON-PREFERRED | PA | |
| MISCELLANEOUS THERAPEUTIC CLASSES | ZORTRESS | EXCLUDED | PA | |
| MOUTH/THROAT/DENTAL AGENTS | CEVIMELINE HYDROCHLORIDE | GENERIC | ||
| MOUTH/THROAT/DENTAL AGENTS | CHLORHEXIDINE GLUCONATE | GENERIC | ||
| MOUTH/THROAT/DENTAL AGENTS | CLINPRO 5000 | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | CLOTRIMAZOLE | GENERIC | ||
| MOUTH/THROAT/DENTAL AGENTS | DENTA 5000 PLUS | PREFERRED | ||
| MOUTH/THROAT/DENTAL AGENTS | DENTAGEL | PREFERRED | ||
| MOUTH/THROAT/DENTAL AGENTS | EVOXAC | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | FLUORIDEX DAILY DEFENSE | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | FLUORIDEX SENSITIVITY REL IEF | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | FLUORIMAX 5000 | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | FLUORIMAX 5000 SENSITIVE | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | JUST RIGHT 5000 | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | KOURZEQ | GENERIC | ||
| MOUTH/THROAT/DENTAL AGENTS | LIDOCAINE HCL | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | LIDOCAINE HYDROCHLORIDE V ISCOUS | GENERIC | ||
| MOUTH/THROAT/DENTAL AGENTS | LIDOCAINE VISCOUS | GENERIC | ||
| MOUTH/THROAT/DENTAL AGENTS | NYSTATIN | GENERIC | ||
| MOUTH/THROAT/DENTAL AGENTS | NYSTATIN | PREFERRED | ||
| MOUTH/THROAT/DENTAL AGENTS | ORALONE DENTAL PASTE | GENERIC | ||
| MOUTH/THROAT/DENTAL AGENTS | ORAMAGICRX | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | ORAPEUTIC | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | PERIDEX | NON-PREFERRED | ||
| MOUTH/THROAT/DENTAL AGENTS | PERIDEX | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | PERIOGARD | GENERIC | ||
| MOUTH/THROAT/DENTAL AGENTS | PILOCARPINE HYDROCHLORIDE | GENERIC | ||
| MOUTH/THROAT/DENTAL AGENTS | PREVIDENT 5000 BOOSTER PL US | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | PREVIDENT 5000 DRY MOUTH | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | PREVIDENT 5000 ENAMEL PRO TECT | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | PREVIDENT 5000 ORTHO DEFE NSE | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | PREVIDENT 5000 PLUS | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | PREVIDENT 5000 SENSITIVE | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | PREVIDENT FLUORIDE | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | PREVIDENT RINSE | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | SALAGEN | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | SF | PREFERRED | ||
| MOUTH/THROAT/DENTAL AGENTS | SF 5000 PLUS | PREFERRED | ||
| MOUTH/THROAT/DENTAL AGENTS | SODIUM FLUORIDE | PREFERRED | ||
| MOUTH/THROAT/DENTAL AGENTS | SODIUM FLUORIDE | EXCLUDED | ||
| MOUTH/THROAT/DENTAL AGENTS | SODIUM FLUORIDE 5000 PLUS | PREFERRED | ||
| MOUTH/THROAT/DENTAL AGENTS | SODIUM FLUORIDE 5000 PPM | PREFERRED | ||
| MOUTH/THROAT/DENTAL AGENTS | SODIUM FLUORIDE 5000 PPM DRY MOUTH | PREFERRED | ||
| MOUTH/THROAT/DENTAL AGENTS | SODIUM FLUORIDE 5000 PPM ENAMEL PROTECT | PREFERRED | ||
| MOUTH/THROAT/DENTAL AGENTS | SODIUM FLUORIDE 5000 PPM SENSITIVE | PREFERRED | ||
| MOUTH/THROAT/DENTAL AGENTS | TRIAMCINOLONE ACETONIDE | GENERIC | ||
| MOUTH/THROAT/DENTAL AGENTS | TRIAMCINOLONE ACETONIDE D ENTAL PASTE | GENERIC | ||
| MUSCULOSKELETAL THERAPY AGENTS | BACLOFEN | GENERIC | ||
| MUSCULOSKELETAL THERAPY AGENTS | BACLOFEN | GENERIC | PA | |
| MUSCULOSKELETAL THERAPY AGENTS | BACLOFEN | EXCLUDED | PA | |
| MUSCULOSKELETAL THERAPY AGENTS | BACLOFEN | EXCLUDED | ||
| MUSCULOSKELETAL THERAPY AGENTS | BACLOFEN REFILL KIT FOR S YNCHROMED | EXCLUDED | ||
| MUSCULOSKELETAL THERAPY AGENTS | CARISOPRODOL | GENERIC | ||
| MUSCULOSKELETAL THERAPY AGENTS | CHLORZOXAZONE | GENERIC | ||
| MUSCULOSKELETAL THERAPY AGENTS | CYCLOBENZAPRINE HYDROCHLO RIDE | GENERIC | ||
| MUSCULOSKELETAL THERAPY AGENTS | DANTRIUM | EXCLUDED | ||
| MUSCULOSKELETAL THERAPY AGENTS | DANTRIUM IV | EXCLUDED | ||
| MUSCULOSKELETAL THERAPY AGENTS | DANTROLENE SODIUM | GENERIC | ||
| MUSCULOSKELETAL THERAPY AGENTS | DANTROLENE SODIUM | EXCLUDED | ||
| MUSCULOSKELETAL THERAPY AGENTS | DUROLANE | EXCLUDED | SP | PA |
| MUSCULOSKELETAL THERAPY AGENTS | EUFLEXXA | PREFERRED | SP | PA |
| MUSCULOSKELETAL THERAPY AGENTS | GABLOFEN | NON-PREFERRED | PA | |
| MUSCULOSKELETAL THERAPY AGENTS | GABLOFEN | EXCLUDED | PA | |
| MUSCULOSKELETAL THERAPY AGENTS | GEL-ONE | EXCLUDED | PA | |
| MUSCULOSKELETAL THERAPY AGENTS | GELSYN-3 | EXCLUDED | SP | PA |
| MUSCULOSKELETAL THERAPY AGENTS | GENVISC 850 | EXCLUDED | SP | PA |
| MUSCULOSKELETAL THERAPY AGENTS | HYALGAN | EXCLUDED | SP | PA |
| MUSCULOSKELETAL THERAPY AGENTS | HYMOVIS | EXCLUDED | PA | |
| MUSCULOSKELETAL THERAPY AGENTS | HYMOVIS ONE | EXCLUDED | PA | |
| MUSCULOSKELETAL THERAPY AGENTS | LIORESAL INTRATHECAL | PREFERRED | PA | |
| MUSCULOSKELETAL THERAPY AGENTS | LIORESAL INTRATHECAL | NON-PREFERRED | PA | |
| MUSCULOSKELETAL THERAPY AGENTS | METAXALONE | GENERIC | ||
| MUSCULOSKELETAL THERAPY AGENTS | METAXALONE | EXCLUDED | ||
| MUSCULOSKELETAL THERAPY AGENTS | METHOCARBAMOL | GENERIC | ||
| MUSCULOSKELETAL THERAPY AGENTS | METHOCARBAMOL | EXCLUDED | ||
| MUSCULOSKELETAL THERAPY AGENTS | MONOVISC | PREFERRED | PA | |
| MUSCULOSKELETAL THERAPY AGENTS | ORPHENADRINE CITRATE | GENERIC | ||
| MUSCULOSKELETAL THERAPY AGENTS | ORPHENADRINE CITRATE ER | GENERIC | ||
| MUSCULOSKELETAL THERAPY AGENTS | ORTHOVISC | PREFERRED | PA | |
| MUSCULOSKELETAL THERAPY AGENTS | OZOBAX DS | EXCLUDED | PA | |
| MUSCULOSKELETAL THERAPY AGENTS | REVONTO | EXCLUDED | ||
| MUSCULOSKELETAL THERAPY AGENTS | ROBAXIN | EXCLUDED | ||
| MUSCULOSKELETAL THERAPY AGENTS | SOHONOS | NON-PREFERRED | SP | PA |
| MUSCULOSKELETAL THERAPY AGENTS | SOMA | EXCLUDED | ||
| MUSCULOSKELETAL THERAPY AGENTS | SUPARTZ FX | EXCLUDED | SP | PA |
| MUSCULOSKELETAL THERAPY AGENTS | SYNOJOYNT | EXCLUDED | SP | PA |
| MUSCULOSKELETAL THERAPY AGENTS | SYNVISC | EXCLUDED | PA | |
| MUSCULOSKELETAL THERAPY AGENTS | SYNVISC ONE | EXCLUDED | PA | |
| MUSCULOSKELETAL THERAPY AGENTS | TIZANIDINE HCL | GENERIC | ||
| MUSCULOSKELETAL THERAPY AGENTS | TIZANIDINE HCL | EXCLUDED | ||
| MUSCULOSKELETAL THERAPY AGENTS | TIZANIDINE HYDROCHLORIDE | GENERIC | ||
| MUSCULOSKELETAL THERAPY AGENTS | TIZANIDINE HYDROCHLORIDE | EXCLUDED | ||
| MUSCULOSKELETAL THERAPY AGENTS | TRILURON | EXCLUDED | SP | PA |
| MUSCULOSKELETAL THERAPY AGENTS | TRIVISC | EXCLUDED | SP | PA |
| MUSCULOSKELETAL THERAPY AGENTS | VISCO-3 | EXCLUDED | SP | PA |
| MUSCULOSKELETAL THERAPY AGENTS | ZANAFLEX | EXCLUDED | ||
| NASAL AGENTS - SYSTEMIC AND TOPICAL | AZELASTINE HYDROCHLORIDE | GENERIC | ||
| NASAL AGENTS - SYSTEMIC AND TOPICAL | FLUNISOLIDE | GENERIC | ||
| NASAL AGENTS - SYSTEMIC AND TOPICAL | FLUTICASONE PROPIONATE | GENERIC | ||
| NASAL AGENTS - SYSTEMIC AND TOPICAL | IPRATROPIUM BROMIDE | GENERIC | ||
| NASAL AGENTS - SYSTEMIC AND TOPICAL | MOMETASONE FUROATE | GENERIC | ||
| NASAL AGENTS - SYSTEMIC AND TOPICAL | OLOPATADINE HCL | GENERIC | ||
| NASAL AGENTS - SYSTEMIC AND TOPICAL | OLOPATADINE HYDROCHLORIDE | GENERIC | ||
| NASAL AGENTS - SYSTEMIC AND TOPICAL | RYALTRIS | EXCLUDED | ||
| NEUROMUSCULAR AGENTS | AMONDYS 45 | NON-PREFERRED | SP | PA |
| NEUROMUSCULAR AGENTS | BOTOX | PREFERRED | PA | |
| NEUROMUSCULAR AGENTS | DAXXIFY | EXCLUDED | ||
| NEUROMUSCULAR AGENTS | DAYBUE | NON-PREFERRED | SP | PA |
| NEUROMUSCULAR AGENTS | DUVYZAT | NON-PREFERRED | SP | PA |
| NEUROMUSCULAR AGENTS | DYSPORT | PREFERRED | PA | |
| NEUROMUSCULAR AGENTS | EDARAVONE | GENERIC | SP | PA |
| NEUROMUSCULAR AGENTS | EDARAVONE | EXCLUDED | SP | PA |
| NEUROMUSCULAR AGENTS | EVRYSDI | NON-PREFERRED | SP | PA |
| NEUROMUSCULAR AGENTS | EXONDYS 51 | NON-PREFERRED | SP | PA |
| NEUROMUSCULAR AGENTS | ITVISMA | EXCLUDED | SP | |
| NEUROMUSCULAR AGENTS | MYOBLOC | PREFERRED | PA | |
| NEUROMUSCULAR AGENTS | QALSODY | NON-PREFERRED | SP | PA |
| NEUROMUSCULAR AGENTS | RADICAVA | PREFERRED | SP | PA |
| NEUROMUSCULAR AGENTS | RADICAVA | NON-PREFERRED | SP | PA |
| NEUROMUSCULAR AGENTS | RADICAVA ORS | NON-PREFERRED | SP | PA |
| NEUROMUSCULAR AGENTS | RADICAVA ORS STARTER KIT | NON-PREFERRED | SP | PA |
| NEUROMUSCULAR AGENTS | RILUZOLE | GENERIC | PA | |
| NEUROMUSCULAR AGENTS | SKYCLARYS | NON-PREFERRED | SP | PA |
| NEUROMUSCULAR AGENTS | SPINRAZA | NON-PREFERRED | SP | PA |
| NEUROMUSCULAR AGENTS | TEGLUTIK | NON-PREFERRED | PA | |
| NEUROMUSCULAR AGENTS | TIGLUTIK | NON-PREFERRED | PA | |
| NEUROMUSCULAR AGENTS | VILTEPSO | NON-PREFERRED | SP | PA |
| NEUROMUSCULAR AGENTS | VYONDYS 53 | NON-PREFERRED | SP | PA |
| NEUROMUSCULAR AGENTS | XEOMIN | EXCLUDED | PA | |
| NUTRIENTS | AMINORELIEF RMS | EXCLUDED | ||
| NUTRIENTS | CLINIMIX 5%/DEXTROSE 20% | NON-PREFERRED | ||
| OPHTHALMIC AGENTS | ACULAR | EXCLUDED | ||
| OPHTHALMIC AGENTS | ACULAR LS | EXCLUDED | ||
| OPHTHALMIC AGENTS | ACUVAIL | EXCLUDED | ||
| OPHTHALMIC AGENTS | AK-FLUOR | GENERIC | ||
| OPHTHALMIC AGENTS | AKTEN | NON-PREFERRED | ||
| OPHTHALMIC AGENTS | ALCAINE | EXCLUDED | ||
| OPHTHALMIC AGENTS | ALPHAGAN P | EXCLUDED | ||
| OPHTHALMIC AGENTS | ALTACAINE | PREFERRED | ||
| OPHTHALMIC AGENTS | ALTAFLUOR BENOX | PREFERRED | ||
| OPHTHALMIC AGENTS | APRACLONIDINE | PREFERRED | ||
| OPHTHALMIC AGENTS | ATROPINE SULFATE | PREFERRED | ||
| OPHTHALMIC AGENTS | ATROPINE SULFATE | GENERIC | ||
| OPHTHALMIC AGENTS | ATROPINE SULFATE | EXCLUDED | ||
| OPHTHALMIC AGENTS | AZASITE | PREFERRED | ||
| OPHTHALMIC AGENTS | AZELASTINE HCL | GENERIC | ||
| OPHTHALMIC AGENTS | AZELASTINE HYDROCHLORIDE | GENERIC | ||
| OPHTHALMIC AGENTS | AZOPT | EXCLUDED | ||
| OPHTHALMIC AGENTS | BACITRACIN | PREFERRED | ||
| OPHTHALMIC AGENTS | BACITRACIN/POLYMYXIN B | PREFERRED | ||
| OPHTHALMIC AGENTS | BEOVU | NON-PREFERRED | SP | PA |
| OPHTHALMIC AGENTS | BEPOTASTINE BESILATE | GENERIC | ||
| OPHTHALMIC AGENTS | BEPREVE | EXCLUDED | ||
| OPHTHALMIC AGENTS | BESIVANCE | EXCLUDED | ||
| OPHTHALMIC AGENTS | BETADINE OPHTHALMIC PREP | EXCLUDED | ||
| OPHTHALMIC AGENTS | BETAXOLOL HCL | PREFERRED | ||
| OPHTHALMIC AGENTS | BETOPTIC-S | EXCLUDED | ||
| OPHTHALMIC AGENTS | BEVACIZUMAB | EXCLUDED | SP | PA |
| OPHTHALMIC AGENTS | BIMATOPROST | GENERIC | PA | |
| OPHTHALMIC AGENTS | BIO GLO | PREFERRED | ||
| OPHTHALMIC AGENTS | BRIMONIDE/DORZOLAMIDE P-F | PREFERRED | ||
| OPHTHALMIC AGENTS | BRIMONIDINE TARTRATE | GENERIC | ||
| OPHTHALMIC AGENTS | BRIMONIDINE TARTRATE | EXCLUDED | ||
| OPHTHALMIC AGENTS | BRIMONIDINE TARTRATE/DORZ OLAMIDE | EXCLUDED | ||
| OPHTHALMIC AGENTS | BRIMONIDINE TARTRATE/TIMO LOL MALEATE | EXCLUDED | ||
| OPHTHALMIC AGENTS | BRINZOLAMIDE | EXCLUDED | ||
| OPHTHALMIC AGENTS | BROMFENAC | GENERIC | ||
| OPHTHALMIC AGENTS | BROMFENAC SODIUM | EXCLUDED | ||
| OPHTHALMIC AGENTS | BROMSITE | EXCLUDED | ||
| OPHTHALMIC AGENTS | BSS | EXCLUDED | ||
| OPHTHALMIC AGENTS | BSS PLUS | EXCLUDED | ||
| OPHTHALMIC AGENTS | BUPIVACAINE HYDROCHLORIDE /LIDOCAINE HYDROCHLORIDE | EXCLUDED | ||
| OPHTHALMIC AGENTS | BUP-LIDO | EXCLUDED | ||
| OPHTHALMIC AGENTS | BYOOVIZ | PREFERRED | SP | PA |
| OPHTHALMIC AGENTS | CARTEOLOL HCL | PREFERRED | ||
| OPHTHALMIC AGENTS | CEQUA | PREFERRED | ||
| OPHTHALMIC AGENTS | CHONDROITIN SULFATE | EXCLUDED | ||
| OPHTHALMIC AGENTS | CIMERLI | EXCLUDED | SP | PA |
| OPHTHALMIC AGENTS | CIPROFLOXACIN HYDROCHLORI DE | GENERIC | ||
| OPHTHALMIC AGENTS | CLOBETASOL PROPIONATE | PREFERRED | ||
| OPHTHALMIC AGENTS | COMBIGAN | EXCLUDED | ||
| OPHTHALMIC AGENTS | COSOPT | EXCLUDED | ||
| OPHTHALMIC AGENTS | COSOPT PF | EXCLUDED | ||
| OPHTHALMIC AGENTS | CROMOLYN SODIUM | PREFERRED | ||
| OPHTHALMIC AGENTS | CYCLOGYL | NON-PREFERRED | ||
| OPHTHALMIC AGENTS | CYCLOGYL | EXCLUDED | ||
| OPHTHALMIC AGENTS | CYCLOMYDRIL | NON-PREFERRED | ||
| OPHTHALMIC AGENTS | CYCLOPENTOLATE HCL | GENERIC | ||
| OPHTHALMIC AGENTS | CYCLOPENTOLATE HYDROCHLOR IDE | GENERIC | ||
| OPHTHALMIC AGENTS | CYCLOSPORINE | EXCLUDED | ||
| OPHTHALMIC AGENTS | CYSTARAN | PREFERRED | SP | PA |
| OPHTHALMIC AGENTS | DEXAMETHASONE SODIUM PHOS PHATE | PREFERRED | ||
| OPHTHALMIC AGENTS | DEXAMETHASONE/MOXIFLOXACI N HCL | PREFERRED | ||
| OPHTHALMIC AGENTS | DEXAMETHASONE/MOXIFLOXACI N/KETOROLAC | PREFERRED | ||
| OPHTHALMIC AGENTS | DICLOFENAC SODIUM | GENERIC | ||
| OPHTHALMIC AGENTS | DIFLUPREDNATE | GENERIC | ||
| OPHTHALMIC AGENTS | DORZOLAMIDE HCL/TIMOLOL M ALEATE | GENERIC | ||
| OPHTHALMIC AGENTS | DORZOLAMIDE HYDROCHLORIDE | GENERIC | ||
| OPHTHALMIC AGENTS | DORZOLAMIDE HYDROCHLORIDE | PREFERRED | ||
| OPHTHALMIC AGENTS | DORZOLAMIDE HYDROCHLORIDE /TIMOLOL MALEATE | GENERIC | ||
| OPHTHALMIC AGENTS | DORZOLAMIDE HYDROCHLORIDE /TIMOLOL MALEATE PF | GENERIC | ||
| OPHTHALMIC AGENTS | DUREZOL | EXCLUDED | ||
| OPHTHALMIC AGENTS | DURYSTA | NON-PREFERRED | PA | |
| OPHTHALMIC AGENTS | ENCELTO | EXCLUDED | SP | PA |
| OPHTHALMIC AGENTS | EPINASTINE HCL | GENERIC | ||
| OPHTHALMIC AGENTS | ERYTHROMYCIN | GENERIC | ||
| OPHTHALMIC AGENTS | ERYTHROMYCIN | PREFERRED | ||
| OPHTHALMIC AGENTS | EYLEA | PREFERRED | SP | PA |
| OPHTHALMIC AGENTS | EYLEA HD | PREFERRED | SP | PA |
| OPHTHALMIC AGENTS | FLAREX | EXCLUDED | ||
| OPHTHALMIC AGENTS | FLUCAINE | PREFERRED | ||
| OPHTHALMIC AGENTS | FLUORESCEIN | GENERIC | ||
| OPHTHALMIC AGENTS | FLUORESCEIN SODIUM | PREFERRED | ||
| OPHTHALMIC AGENTS | FLUORESCEIN SODIUM | EXCLUDED | ||
| OPHTHALMIC AGENTS | FLUORESCEIN SODIUM/BENOXI NATE HYDROCHLORIDE | PREFERRED | ||
| OPHTHALMIC AGENTS | FLUORESCITE | EXCLUDED | ||
| OPHTHALMIC AGENTS | FLUOROMETHOLONE | GENERIC | ||
| OPHTHALMIC AGENTS | FLURBIPROFEN SODIUM | PREFERRED | ||
| OPHTHALMIC AGENTS | FML FORTE | EXCLUDED | ||
| OPHTHALMIC AGENTS | FML LIQUIFILM | EXCLUDED | ||
| OPHTHALMIC AGENTS | GATIFLOXACIN | GENERIC | ||
| OPHTHALMIC AGENTS | GENTAMICIN SULFATE | GENERIC | ||
| OPHTHALMIC AGENTS | GREEN GLO LISSAMINE GREEN OPHTHALMIC STRIPS | PREFERRED | ||
| OPHTHALMIC AGENTS | HOMATROPAIRE | PREFERRED | ||
| OPHTHALMIC AGENTS | IDOSE TR | EXCLUDED | ||
| OPHTHALMIC AGENTS | ILEVRO | NON-PREFERRED | ||
| OPHTHALMIC AGENTS | INVELTYS | EXCLUDED | ||
| OPHTHALMIC AGENTS | IOPIDINE | EXCLUDED | ||
| OPHTHALMIC AGENTS | ISTALOL | EXCLUDED | ||
| OPHTHALMIC AGENTS | IYUZEH | EXCLUDED | ||
| OPHTHALMIC AGENTS | IZERVAY | NON-PREFERRED | SP | PA |
| OPHTHALMIC AGENTS | KETOROLAC TROMETHAMINE | GENERIC | ||
| OPHTHALMIC AGENTS | LATANOPROST | GENERIC | ||
| OPHTHALMIC AGENTS | LEVOBUNOLOL HCL | PREFERRED | ||
| OPHTHALMIC AGENTS | LEVOFLOXACIN | PREFERRED | ||
| OPHTHALMIC AGENTS | LEVOFLOXACIN | EXCLUDED | ||
| OPHTHALMIC AGENTS | LIDOCAINE HYDROCHLORIDE/E PINEPHRINE | EXCLUDED | ||
| OPHTHALMIC AGENTS | LIDOCAINE HYDROCHLORIDE/P HENYLEPHRINE HYDROCHLORIDE | PREFERRED | ||
| OPHTHALMIC AGENTS | LIDOCAINE HYDROCHLORIDE/P HENYLEPHRINE HYDROCHLORIDE | EXCLUDED | ||
| OPHTHALMIC AGENTS | LOTEMAX | PREFERRED | ||
| OPHTHALMIC AGENTS | LOTEMAX SM | PREFERRED | ||
| OPHTHALMIC AGENTS | LOTEPREDNOL ETABONATE | GENERIC | ||
| OPHTHALMIC AGENTS | LOTEPREDNOL ETABONATE | EXCLUDED | ||
| OPHTHALMIC AGENTS | LUCENTIS | EXCLUDED | SP | PA |
| OPHTHALMIC AGENTS | LUMIGAN | EXCLUDED | PA | |
| OPHTHALMIC AGENTS | MAXIDEX | EXCLUDED | PA | |
| OPHTHALMIC AGENTS | MAXITROL | EXCLUDED | ||
| OPHTHALMIC AGENTS | MIEBO | EXCLUDED | PA | |
| OPHTHALMIC AGENTS | MIOCHOL-E | NON-PREFERRED | ||
| OPHTHALMIC AGENTS | MIOSTAT | NON-PREFERRED | ||
| OPHTHALMIC AGENTS | MITOMYCIN | EXCLUDED | ||
| OPHTHALMIC AGENTS | MOXIFLOXACIN HYDROCHLORID E/SODIUM CHLORIDE | PREFERRED | ||
| OPHTHALMIC AGENTS | MOXIFLOXACIN/BROMFENAC | EXCLUDED | ||
| OPHTHALMIC AGENTS | MYDCOMBI | EXCLUDED | ||
| OPHTHALMIC AGENTS | MYDRIACYL | EXCLUDED | ||
| OPHTHALMIC AGENTS | NATACYN | PREFERRED | ||
| OPHTHALMIC AGENTS | NEOMYCIN/BACITRACIN/POLYM YXIN | PREFERRED | ||
| OPHTHALMIC AGENTS | NEOMYCIN/POLYMYXIN/BACITR ACIN/HYDROCORTISONE | PREFERRED | ||
| OPHTHALMIC AGENTS | NEOMYCIN/POLYMYXIN/DEXAME THASONE | GENERIC | ||
| OPHTHALMIC AGENTS | NEOMYCIN/POLYMYXIN/GRAMIC IDIN | PREFERRED | ||
| OPHTHALMIC AGENTS | NEOMYCIN/POLYMYXIN/HYDROC ORTISONE | PREFERRED | ||
| OPHTHALMIC AGENTS | NEVANAC | EXCLUDED | ||
| OPHTHALMIC AGENTS | OCUFLOX | EXCLUDED | ||
| OPHTHALMIC AGENTS | OFLOXACIN | GENERIC | ||
| OPHTHALMIC AGENTS | OLOPATADINE HYDROCHLORIDE | GENERIC | ||
| OPHTHALMIC AGENTS | OMLONTI | EXCLUDED | ||
| OPHTHALMIC AGENTS | PAVBLU | EXCLUDED | SP | PA |
| OPHTHALMIC AGENTS | PHENYLEPHRINE HYDROCHLORI DE | GENERIC | ||
| OPHTHALMIC AGENTS | PHENYLEPHRINE HYDROCHLORI DE | PREFERRED | ||
| OPHTHALMIC AGENTS | PHOSPHOLINE IODIDE | PREFERRED | ||
| OPHTHALMIC AGENTS | PILOCARPINE HCL | GENERIC | ||
| OPHTHALMIC AGENTS | PILOCARPINE HYDROCHLORIDE | GENERIC | ||
| OPHTHALMIC AGENTS | PILOCARPINE HYDROCHLORIDE | EXCLUDED | PA | |
| OPHTHALMIC AGENTS | POLYMYXIN B SULFATE/TRIME THOPRIM SULFATE | GENERIC | ||
| OPHTHALMIC AGENTS | POVIDONE IODINE | PREFERRED | ||
| OPHTHALMIC AGENTS | PRED FORTE | EXCLUDED | ||
| OPHTHALMIC AGENTS | PRED MILD | EXCLUDED | ||
| OPHTHALMIC AGENTS | PREDNISOLONE ACETATE | GENERIC | ||
| OPHTHALMIC AGENTS | PREDNISOLONE ACETATE P-F | PREFERRED | ||
| OPHTHALMIC AGENTS | PREDNISOLONE ACETATE/MOXI FLOXACIN | PREFERRED | ||
| OPHTHALMIC AGENTS | PREDNISOLONE ACETATE/MOXI FLOXACIN/NEPAFENAC | PREFERRED | ||
| OPHTHALMIC AGENTS | PREDNISOLONE ACETATE/NEPA FENAC | PREFERRED | ||
| OPHTHALMIC AGENTS | PREDNISOLONE PHOSPHATE/BR OMFENAC | EXCLUDED | ||
| OPHTHALMIC AGENTS | PREDNISOLONE SODIUM PHOSP HATE | PREFERRED | ||
| OPHTHALMIC AGENTS | PREDNISOLONE SODIUM PHOSP HATE/MOXIFLOXACIN | PREFERRED | ||
| OPHTHALMIC AGENTS | PREDNISOLONE/BROMFENAC | PREFERRED | ||
| OPHTHALMIC AGENTS | PROLENSA | NON-PREFERRED | ||
| OPHTHALMIC AGENTS | PROPARACAINE HCL | GENERIC | ||
| OPHTHALMIC AGENTS | PROPARACAINE HYDROCHLORID E | GENERIC | ||
| OPHTHALMIC AGENTS | QLOSI | EXCLUDED | ||
| OPHTHALMIC AGENTS | RESTASIS | PREFERRED | ||
| OPHTHALMIC AGENTS | RESTASIS MULTIDOSE | PREFERRED | ||
| OPHTHALMIC AGENTS | RHOPRESSA | EXCLUDED | PA | |
| OPHTHALMIC AGENTS | ROCKLATAN | NON-PREFERRED | PA | |
| OPHTHALMIC AGENTS | SIMBRINZA | EXCLUDED | ||
| OPHTHALMIC AGENTS | SULFACETAMIDE SODIUM | PREFERRED | ||
| OPHTHALMIC AGENTS | SULFACETAMIDE SODIUM/PRED NISOLONE SODIUM PHOSPHATE | PREFERRED | ||
| OPHTHALMIC AGENTS | SUSVIMO | EXCLUDED | SP | PA |
| OPHTHALMIC AGENTS | SYFOVRE | NON-PREFERRED | SP | PA |
| OPHTHALMIC AGENTS | TAFLUPROST | GENERIC | ||
| OPHTHALMIC AGENTS | TETRACAINE HCL | PREFERRED | ||
| OPHTHALMIC AGENTS | TETRACAINE HYDROCHLORIDE | GENERIC | ||
| OPHTHALMIC AGENTS | TETRACAINE HYDROCHLORIDE | PREFERRED | ||
| OPHTHALMIC AGENTS | TIMOLOL MALEATE | GENERIC | ||
| OPHTHALMIC AGENTS | TIMOLOL MALEATE | EXCLUDED | ||
| OPHTHALMIC AGENTS | TIMOLOL MALEATE IN OCUDOS E | EXCLUDED | ||
| OPHTHALMIC AGENTS | TIMOLOL MALEATE OPHTHALMI C GEL FORMING | GENERIC | ||
| OPHTHALMIC AGENTS | TIMOLOL MALEATE/BIMATOPRO ST | PREFERRED | ||
| OPHTHALMIC AGENTS | TIMOLOL/BRIMONIDE TARTRAT E/DORZOLAMIDE | PREFERRED | ||
| OPHTHALMIC AGENTS | TIMOLOL/BRIMONIDE/DORZOLA MIDE | PREFERRED | ||
| OPHTHALMIC AGENTS | TIMOLOL/BRIMONIDINE TARTR ATE/DORZOLAMIDE/BIMATOPROST | PREFERRED | ||
| OPHTHALMIC AGENTS | TIMOLOL/BRIMONIDINE/DORZO LAMIDE/BIMATOPROST | EXCLUDED | ||
| OPHTHALMIC AGENTS | TIMOLOL/DORZOLAMIDE/BIMAT OPROST | EXCLUDED | ||
| OPHTHALMIC AGENTS | TIMOPTIC OCUDOSE | EXCLUDED | ||
| OPHTHALMIC AGENTS | TOBRADEX | PREFERRED | ||
| OPHTHALMIC AGENTS | TOBRADEX ST | PREFERRED | ||
| OPHTHALMIC AGENTS | TOBRAMYCIN | GENERIC | ||
| OPHTHALMIC AGENTS | TOBRAMYCIN SULFATE | GENERIC | ||
| OPHTHALMIC AGENTS | TOBRAMYCIN/DEXAMETHASONE | GENERIC | ||
| OPHTHALMIC AGENTS | TOBRAMYCIN/VANCOMYCIN HYD ROCHLORIDE | EXCLUDED | ||
| OPHTHALMIC AGENTS | TOBREX | NON-PREFERRED | ||
| OPHTHALMIC AGENTS | TRAVATAN Z | EXCLUDED | ||
| OPHTHALMIC AGENTS | TRAVOPROST | GENERIC | ||
| OPHTHALMIC AGENTS | TRIFLURIDINE | PREFERRED | ||
| OPHTHALMIC AGENTS | TROPICAMIDE | GENERIC | ||
| OPHTHALMIC AGENTS | TROPICAMIDE/CYCLOPENTOLAT E HYDROCHLORIDE/PHENYLEPHRINE HYDRO | NON-PREFERRED | ||
| OPHTHALMIC AGENTS | TROPICAMIDE/CYCLOPENTOLAT E HYDROCHLORIDE/PHENYLEPHRINE HYDRO | PREFERRED | ||
| OPHTHALMIC AGENTS | TROPICAMIDE/CYCLOPENTOLAT E/PHENYLEPHRINE/KETOROLAC | PREFERRED | ||
| OPHTHALMIC AGENTS | TROPICAMIDE/CYCLOPENTOLAT E/PHENYLEPHRINE/KETOROLAC/PROPARACA | PREFERRED | ||
| OPHTHALMIC AGENTS | TROPICAMIDE/PHENYLEPHRINE | PREFERRED | ||
| OPHTHALMIC AGENTS | TROPICAMIDE/PHENYLEPHRINE HYDROCHLORIDE | PREFERRED | ||
| OPHTHALMIC AGENTS | TROPICAMIDE/PROPARACAINE/ PHENYLEPHRINE/KETOROLAC | EXCLUDED | ||
| OPHTHALMIC AGENTS | TRYPTYR | EXCLUDED | ||
| OPHTHALMIC AGENTS | UPNEEQ | EXCLUDED | ||
| OPHTHALMIC AGENTS | VABYSMO | EXCLUDED | SP | PA |
| OPHTHALMIC AGENTS | VEVYE | EXCLUDED | ||
| OPHTHALMIC AGENTS | VIZZ | NON-PREFERRED | ||
| OPHTHALMIC AGENTS | VUITY | NON-PREFERRED | PA | |
| OPHTHALMIC AGENTS | VYZULTA | EXCLUDED | ||
| OPHTHALMIC AGENTS | XALATAN | EXCLUDED | ||
| OPHTHALMIC AGENTS | XDEMVY | NON-PREFERRED | ||
| OPHTHALMIC AGENTS | XELPROS | EXCLUDED | ||
| OPHTHALMIC AGENTS | XIIDRA | EXCLUDED | ||
| OPHTHALMIC AGENTS | ZERVIATE | EXCLUDED | ||
| OPHTHALMIC AGENTS | ZIOPTAN | NON-PREFERRED | ||
| OPHTHALMIC AGENTS | ZIRGAN | NON-PREFERRED | ||
| OPHTHALMIC AGENTS | ZYLET | PREFERRED | ||
| OTIC AGENTS | ACETIC ACID | GENERIC | ||
| OTIC AGENTS | CETRAXAL | EXCLUDED | ||
| OTIC AGENTS | CIPRO HC | EXCLUDED | ||
| OTIC AGENTS | CIPROFLOXACIN | GENERIC | ||
| OTIC AGENTS | CIPROFLOXACIN/DEXAMETHASO NE | GENERIC | ||
| OTIC AGENTS | CIPROFLOXACIN/FLUOCINOLON E ACETONIDE PF | EXCLUDED | ||
| OTIC AGENTS | CORTISPORIN-TC | EXCLUDED | ||
| OTIC AGENTS | DERMOTIC | EXCLUDED | ||
| OTIC AGENTS | FLUOCINOLONE ACETONIDE | GENERIC | ||
| OTIC AGENTS | FLUOCINOLONE ACETONIDE EA R DROPS | GENERIC | ||
| OTIC AGENTS | HYDROCORTISONE/ACETIC ACI D | GENERIC | ||
| OTIC AGENTS | NEOMYCIN/POLYMYXIN/HC | GENERIC | ||
| OTIC AGENTS | NEOMYCIN/POLYMYXIN/HYDROC ORTISONE | GENERIC | ||
| OTIC AGENTS | OFLOXACIN | GENERIC | ||
| OTIC AGENTS | OTOVEL | EXCLUDED | ||
| OXYTOCICS | CARBOPROST TROMETHAMINE | GENERIC | ||
| OXYTOCICS | CARBOPROST TROMETHAMINE | EXCLUDED | ||
| OXYTOCICS | CERVIDIL | NON-PREFERRED | ||
| OXYTOCICS | HEMABATE | NON-PREFERRED | ||
| OXYTOCICS | METHYLERGONOVINE MALEATE | GENERIC | ||
| OXYTOCICS | OXYTOCIN | EXCLUDED | ||
| OXYTOCICS | OXYTOCIN/LACTATED RINGERS | PREFERRED | ||
| OXYTOCICS | OXYTOCIN/SODIUM CHLORIDE | PREFERRED | ||
| OXYTOCICS | PITOCIN | EXCLUDED | ||
| OXYTOCICS | PREPIDIL | NON-PREFERRED | ||
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | ALYGLO | EXCLUDED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | ANASCORP | NON-PREFERRED | ||
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | ANAVIP | EXCLUDED | ||
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | ANTIVENIN LATRODECTUS MAC TANS | EXCLUDED | ||
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | ANTIVENIN NORTH AMERICAN CORAL SNAKE | EXCLUDED | ||
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | ASCENIV | EXCLUDED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | BABYBIG | NON-PREFERRED | PA | |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | BEYFORTUS | PREFERRED | ||
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | BIVIGAM | NON-PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | CNJ-016 | EXCLUDED | ||
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | CROFAB | EXCLUDED | ||
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | CUTAQUIG | EXCLUDED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | CUVITRU | NON-PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | CYTOGAM | PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | ENFLONSIA | PREFERRED | ||
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | FLEBOGAMMA DIF | NON-PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | GAMASTAN | PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | GAMMAGARD LIQUID | NON-PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | GAMMAGARD S/D IGA LESS TH AN 1MCG/ML | PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | GAMMAKED | EXCLUDED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | GAMMAPLEX | NON-PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | GAMUNEX-C | PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | HEPAGAM B | PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | HIZENTRA | NON-PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | HYPERHEP B | PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | HYPERRAB | NON-PREFERRED | ||
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | HYPERRHO | PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | HYPERRHO MINI-DOSE | PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | HYPERTET | PREFERRED | ||
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | HYQVIA | NON-PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | KEDRAB | PREFERRED | ||
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | NABI-HB | PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | OCTAGAM | EXCLUDED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | PANZYGA | NON-PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | PEMGARDA | EXCLUDED | ||
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | PRIVIGEN | EXCLUDED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | RHOGAM ULTRA-FILTERED PLU S | EXCLUDED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | RHOPHYLAC | NON-PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | VARIZIG | PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | WINRHO SDF | NON-PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | XEMBIFY | PREFERRED | SP | PA |
| PASSIVE IMMUNIZING AND TREATMENT AGENTS | ZINPLAVA | EXCLUDED | ||
| PENICILLINS | AMOXICILLIN | GENERIC | ||
| PENICILLINS | AMOXICILLIN | PREFERRED | ||
| PENICILLINS | AMOXICILLIN/CLAVULANATE P OTASSIUM | GENERIC | ||
| PENICILLINS | AMOXICILLIN/CLAVULANATE P OTASSIUM ER | GENERIC | ||
| PENICILLINS | AMPICILLIN | GENERIC | ||
| PENICILLINS | AMPICILLIN SODIUM | GENERIC | ||
| PENICILLINS | AMPICILLIN SODIUM | PREFERRED | ||
| PENICILLINS | AMPICILLIN/SULBACTAM | GENERIC | ||
| PENICILLINS | AMPICILLIN-SULBACTAM | PREFERRED | ||
| PENICILLINS | AMPICILLIN-SULBACTAM | GENERIC | ||
| PENICILLINS | AUGMENTIN | EXCLUDED | ||
| PENICILLINS | AUGMENTIN ES-600 | EXCLUDED | ||
| PENICILLINS | BICILLIN C-R | PREFERRED | ||
| PENICILLINS | BICILLIN L-A | PREFERRED | ||
| PENICILLINS | DICLOXACILLIN SODIUM | GENERIC | ||
| PENICILLINS | LENTOCILIN | EXCLUDED | ||
| PENICILLINS | NAFCILLIN | PREFERRED | ||
| PENICILLINS | NAFCILLIN SODIUM | GENERIC | ||
| PENICILLINS | OXACILLIN SODIUM | PREFERRED | ||
| PENICILLINS | OXACILLIN SODIUM | GENERIC | ||
| PENICILLINS | PENICILLIN G POTASSIUM | GENERIC | ||
| PENICILLINS | PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE | PREFERRED | ||
| PENICILLINS | PENICILLIN G SODIUM | PREFERRED | ||
| PENICILLINS | PENICILLIN V POTASSIUM | GENERIC | ||
| PENICILLINS | PENICILLIN V POTASSIUM | PREFERRED | ||
| PENICILLINS | PFIZERPEN | GENERIC | ||
| PENICILLINS | PIPERACILLIN SODIUM/TAZOB ACTAM SODIUM | GENERIC | ||
| PENICILLINS | PIPERACILLIN SODIUM/TAZOB ACTAM SODIUM/NACL | PREFERRED | ||
| PENICILLINS | UNASYN | EXCLUDED | ||
| PENICILLINS | UNASYN BULK PACK | EXCLUDED | ||
| PENICILLINS | ZOSYN | NON-PREFERRED | ||
| PROGESTINS | GALLIFREY | GENERIC | ||
| PROGESTINS | MEDROXYPROGESTERONE ACETA TE | GENERIC | ||
| PROGESTINS | MEGESTROL ACETATE | PREFERRED | ||
| PROGESTINS | NORETHINDRONE ACETATE | GENERIC | ||
| PROGESTINS | PROGESTERONE | GENERIC | PA | |
| PROGESTINS | PROGESTERONE | GENERIC | ||
| PROGESTINS | PROMETRIUM | EXCLUDED | ||
| PROGESTINS | PROVERA | EXCLUDED | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | ACAMPROSATE CALCIUM DR | GENERIC | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | AMPYRA | EXCLUDED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | AQNEURSA | NON-PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | ARICEPT | EXCLUDED | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | AUBAGIO | EXCLUDED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | AUSTEDO | NON-PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | AUSTEDO XR | NON-PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | AUSTEDO XR PATIENT TITRAT ION KIT | NON-PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | AVONEX | PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | AVONEX PEN | PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | BAFIERTAM | EXCLUDED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | BETASERON | PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | BRIUMVI | EXCLUDED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | BUPROPION HYDROCHLORIDE E R (SR) | GENERIC | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | CHANTIX | EXCLUDED | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | CHLORDIAZEPOXIDE/AMITRIPT YLINE | PREFERRED | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | CLADRIBINE | EXCLUDED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | COPAXONE | EXCLUDED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | DALFAMPRIDINE ER | GENERIC | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | DIMETHYL FUMARATE | GENERIC | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | DIMETHYL FUMARATE STARTER PACK | GENERIC | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | DISULFIRAM | GENERIC | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | DONEPEZIL HCL | GENERIC | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | DONEPEZIL HYDROCHLORIDE | GENERIC | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | DONEPEZIL HYDROCHLORIDE O DT | GENERIC | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | EXELON | EXCLUDED | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | FINGOLIMOD HYDROCHLORIDE | GENERIC | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | GALANTAMINE HYDROBROMIDE | PREFERRED | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | GALANTAMINE HYDROBROMIDE | GENERIC | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | GALANTAMINE HYDROBROMIDE ER | GENERIC | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | GILENYA | EXCLUDED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | GLATIRAMER ACETATE | GENERIC | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | GLATOPA | GENERIC | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | INGREZZA | NON-PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | KESIMPTA | PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | KISUNLA | NON-PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | LEMTRADA | PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | LENMELDY | NON-PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | LEQEMBI | NON-PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | LEQEMBI IQLIK | PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | LOFEXIDINE HYDROCHLORIDE | GENERIC | PA | |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | LUCEMYRA | EXCLUDED | PA | |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | MAVENCLAD | EXCLUDED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | MAYZENT | EXCLUDED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | MAYZENT STARTER PACK | EXCLUDED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | MEMANTINE HCL TITRATION P AK | EXCLUDED | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | MEMANTINE HYDROCHLORIDE | GENERIC | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | MEMANTINE HYDROCHLORIDE E R | GENERIC | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | MIPLYFFA | NON-PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | NICOTROL NS | NON-PREFERRED | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | NUEDEXTA | PREFERRED | PA | |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | OCREVUS | PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | OCREVUS ZUNOVO | PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | ONPATTRO | NON-PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | PERPHENAZINE/AMITRIPTYLIN E | PREFERRED | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | PIMOZIDE | PREFERRED | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | PLEGRIDY | PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | PLEGRIDY STARTER PACK | PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | PONVORY | EXCLUDED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | PONVORY 14-DAY STARTER PA CK | EXCLUDED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | REBIF | PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | REBIF REBIDOSE | PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | REBIF REBIDOSE TITRATION PACK | PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | REBIF TITRATION PACK | PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | RIVASTIGMINE TARTRATE | GENERIC | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | RIVASTIGMINE TRANSDERMAL SYSTEM | GENERIC | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | SAVELLA | PREFERRED | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | SAVELLA TITRATION PACK | PREFERRED | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | SKYSONA | NON-PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | TASCENSO ODT | EXCLUDED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | TECFIDERA | EXCLUDED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | TECFIDERA STARTER PACK | EXCLUDED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | TERIFLUNOMIDE | GENERIC | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | TETRABENAZINE | GENERIC | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | TYSABRI | NON-PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | VARENICLINE STARTING MONT H | GENERIC | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | VARENICLINE STARTING PACK | GENERIC | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | VARENICLINE TARTRATE | GENERIC | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | VARENICLINE TARTRATE CONT INUING MONTH | GENERIC | ||
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | VUMERITY | EXCLUDED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | VYLEESI | NON-PREFERRED | PA | |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | WAINUA | EXCLUDED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | XENAZINE | EXCLUDED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | XYWAV | NON-PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | ZEPOSIA | PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | ZEPOSIA 7-DAY STARTER PAC K | PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | ZEPOSIA STARTER KIT | PREFERRED | SP | PA |
| PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. | ZUNVEYL | EXCLUDED | ||
| RESPIRATORY AGENTS - MISC. | ALYFTREK | EXCLUDED | SP | PA |
| RESPIRATORY AGENTS - MISC. | ARALAST NP | PREFERRED | SP | PA |
| RESPIRATORY AGENTS - MISC. | BRINSUPRI | NON-PREFERRED | SP | PA |
| RESPIRATORY AGENTS - MISC. | BRONCHITOL | EXCLUDED | SP | PA |
| RESPIRATORY AGENTS - MISC. | BRONCHITOL TOLERANCE TEST | EXCLUDED | SP | PA |
| RESPIRATORY AGENTS - MISC. | CUROSURF | NON-PREFERRED | ||
| RESPIRATORY AGENTS - MISC. | GLASSIA | PREFERRED | SP | PA |
| RESPIRATORY AGENTS - MISC. | INFASURF | NON-PREFERRED | ||
| RESPIRATORY AGENTS - MISC. | KALYDECO | PREFERRED | SP | PA |
| RESPIRATORY AGENTS - MISC. | OFEV | PREFERRED | SP | PA |
| RESPIRATORY AGENTS - MISC. | ORKAMBI | PREFERRED | SP | PA |
| RESPIRATORY AGENTS - MISC. | PIRFENIDONE | GENERIC | SP | PA |
| RESPIRATORY AGENTS - MISC. | PIRFENIDONE | EXCLUDED | SP | PA |
| RESPIRATORY AGENTS - MISC. | PROLASTIN-C | PREFERRED | SP | PA |
| RESPIRATORY AGENTS - MISC. | PULMOZYME | PREFERRED | SP | PA |
| RESPIRATORY AGENTS - MISC. | STERITALC | NON-PREFERRED | ||
| RESPIRATORY AGENTS - MISC. | SURVANTA INTRATRACHEAL | NON-PREFERRED | ||
| RESPIRATORY AGENTS - MISC. | SYMDEKO | PREFERRED | SP | PA |
| RESPIRATORY AGENTS - MISC. | TRIKAFTA | PREFERRED | SP | PA |
| RESPIRATORY AGENTS - MISC. | ZEMAIRA | PREFERRED | SP | PA |
| SULFONAMIDES | SULFADIAZINE | GENERIC | ||
| TETRACYCLINES | AVIDOXY | EXCLUDED | ||
| TETRACYCLINES | DEMECLOCYCLINE HCL | GENERIC | ||
| TETRACYCLINES | DEMECLOCYCLINE HYDROCHLOR IDE | GENERIC | ||
| TETRACYCLINES | DOXYCYCLINE | GENERIC | ||
| TETRACYCLINES | DOXYCYCLINE HYCLATE | GENERIC | ||
| TETRACYCLINES | DOXYCYCLINE HYCLATE | EXCLUDED | ||
| TETRACYCLINES | DOXYCYCLINE MONOHYDRATE | GENERIC | ||
| TETRACYCLINES | DOXYCYCLINE MONOHYDRATE | EXCLUDED | ||
| TETRACYCLINES | MINOCIN | NON-PREFERRED | ||
| TETRACYCLINES | MINOCYCLINE HCL | GENERIC | ||
| TETRACYCLINES | MINOCYCLINE HCL | EXCLUDED | ||
| TETRACYCLINES | MINOCYCLINE HYDROCHLORIDE | GENERIC | ||
| TETRACYCLINES | MINOCYCLINE HYDROCHLORIDE | EXCLUDED | ||
| TETRACYCLINES | MONDOXYNE NL | GENERIC | ||
| TETRACYCLINES | TARGADOX | EXCLUDED | ||
| TETRACYCLINES | TETRACYCLINE HYDROCHLORID | EXCLUDED | ||
| TETRACYCLINES | TETRACYCLINE HYDROCHLORID E | GENERIC | ||
| TETRACYCLINES | TETRACYCLINE HYDROCHLORID E | EXCLUDED | ||
| TETRACYCLINES | TIGECYCLINE | EXCLUDED | ||
| TETRACYCLINES | TYGACIL | EXCLUDED | ||
| TETRACYCLINES | XERAVA | NON-PREFERRED | ||
| THYROID AGENTS | ARMOUR THYROID | PREFERRED | ||
| THYROID AGENTS | ARMOUR THYROID | NON-PREFERRED | ||
| THYROID AGENTS | CYTOMEL | EXCLUDED | ||
| THYROID AGENTS | LEVO-T | EXCLUDED | ||
| THYROID AGENTS | LEVOTHYROXINE SODIUM | GENERIC | ||
| THYROID AGENTS | LEVOTHYROXINE SODIUM | EXCLUDED | ||
| THYROID AGENTS | LEVOXYL | EXCLUDED | ||
| THYROID AGENTS | LIOMNY | GENERIC | ||
| THYROID AGENTS | LIOTHYRONINE SODIUM | GENERIC | ||
| THYROID AGENTS | LIOTHYRONINE SODIUM | PREFERRED | ||
| THYROID AGENTS | METHIMAZOLE | GENERIC | ||
| THYROID AGENTS | NP THYROID 120 | PREFERRED | ||
| THYROID AGENTS | NP THYROID 15 | PREFERRED | ||
| THYROID AGENTS | NP THYROID 30 | PREFERRED | ||
| THYROID AGENTS | NP THYROID 60 | PREFERRED | ||
| THYROID AGENTS | NP THYROID 90 | PREFERRED | ||
| THYROID AGENTS | PROPYLTHIOURACIL | GENERIC | ||
| THYROID AGENTS | RENTHYROID | NON-PREFERRED | ||
| THYROID AGENTS | SYNTHROID | EXCLUDED | ||
| THYROID AGENTS | THYROID | PREFERRED | ||
| THYROID AGENTS | UNITHROID | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | ACIPHEX | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | ATROPINE SULFATE | PREFERRED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | ATROPINE SULFATE | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | ATROPINE SULFATE | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | CARAFATE | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | CHLORDIAZEPOXIDE HYDROCHL ORIDE/CLIDINIUM BROMIDE | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | CHLORDIAZEPOXIDE HYDROCHL ORIDE/CLIDINIUM BROMIDE | PREFERRED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | CIMETIDINE | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | CIMETIDINE HYDROCHLORIDE | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | CUVPOSA | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | CYTOTEC | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | DEXILANT | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | DEXLANSOPRAZOLE | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | DICYCLOMINE HCL | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | DICYCLOMINE HYDROCHLORIDE | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | DICYCLOMINE HYDROCHLORIDE | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | DONNATAL | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | ED-SPAZ | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | ESOMEPRAZOLE MAGNESIUM | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | ESOMEPRAZOLE MAGNESIUM DR | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | ESOMEPRAZOLE SODIUM | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | FAMOTIDINE | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | FAMOTIDINE | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | FAMOTIDINE PREMIXED | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | GLYCATE | EXCLUDED | PA | |
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | GLYCOPYRROLATE | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | GLYCOPYRROLATE | PREFERRED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | GLYCOPYRROLATE | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | GLYCOPYRROLATE | EXCLUDED | PA | |
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | GLYRX-PF | NON-PREFERRED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | HYOSCYAMINE SULFATE | PREFERRED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | HYOSCYAMINE SULFATE ER | PREFERRED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | HYOSCYAMINE SULFATE ODT | PREFERRED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | HYOSCYAMINE SULFATE SL | PREFERRED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | HYOSYNE | PREFERRED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | LANSOPRAZOLE | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | LANSOPRAZOLE/AMOXICILLIN/ CLARITHROMYCIN | PREFERRED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | LEVBID | NON-PREFERRED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | LEVSIN | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | LEVSIN/SL | NON-PREFERRED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | LIBRAX | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | METHSCOPOLAMINE BROMIDE | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | MISOPROSTOL | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | NEXIUM | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | NIZATIDINE | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | NIZATIDINE | PREFERRED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | NULEV | NON-PREFERRED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | OMEPRAZOLE | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | OMEPRAZOLE DR | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | OSCIMIN | PREFERRED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | PANTOPRAZOLE SODIUM | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | PANTOPRAZOLE SODIUM | PREFERRED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | PANTOPRAZOLE SODIUM/SODIU M CHLORIDE | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | PEPCID | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | PHENOBARBITAL/HYOSCYAMINE SULFATE/ATROPINE SULFATE/SCOPOLAMI | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | PHENOHYTRO | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | PREVACID | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | PRILOSEC | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | PROTONIX | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | RABEPRAZOLE SODIUM | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | SUCRALFATE | GENERIC | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | VOQUEZNA | EXCLUDED | ||
| ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS | VOQUEZNA TRIPLE PAK | NON-PREFERRED | ||
| URINARY ANTISPASMODICS | BETHANECHOL CHLORIDE | GENERIC | ||
| URINARY ANTISPASMODICS | DARIFENACIN HYDROBROMIDE ER | GENERIC | ||
| URINARY ANTISPASMODICS | FESOTERODINE FUMARATE ER | GENERIC | ||
| URINARY ANTISPASMODICS | FLAVOXATE HCL | GENERIC | ||
| URINARY ANTISPASMODICS | GEMTESA | PREFERRED | PA | |
| URINARY ANTISPASMODICS | MIRABEGRON ER | EXCLUDED | ||
| URINARY ANTISPASMODICS | MYRBETRIQ | PREFERRED | ||
| URINARY ANTISPASMODICS | OXYBUTYNIN CHLORIDE | GENERIC | ||
| URINARY ANTISPASMODICS | OXYBUTYNIN CHLORIDE | EXCLUDED | ||
| URINARY ANTISPASMODICS | OXYBUTYNIN CHLORIDE ER | GENERIC | ||
| URINARY ANTISPASMODICS | SOLIFENACIN SUCCINATE | GENERIC | ||
| URINARY ANTISPASMODICS | TOLTERODINE TARTRATE | GENERIC | ||
| URINARY ANTISPASMODICS | TOVIAZ | EXCLUDED | ||
| URINARY ANTISPASMODICS | TROSPIUM CHLORIDE | GENERIC | ||
| URINARY ANTISPASMODICS | VESICARE | EXCLUDED | ||
| VACCINES | ABRYSVO | PREFERRED | ||
| VACCINES | ACAM2000 | NON-PREFERRED | ||
| VACCINES | ACTHIB | PREFERRED | ||
| VACCINES | ADACEL | PREFERRED | ||
| VACCINES | AFLURIA 2025-2026 | NON-PREFERRED | ||
| VACCINES | AREXVY | PREFERRED | ||
| VACCINES | AUDENZ | NON-PREFERRED | ||
| VACCINES | BCG VACCINE | PREFERRED | ||
| VACCINES | BEXSERO | PREFERRED | ||
| VACCINES | BIOTHRAX | PREFERRED | ||
| VACCINES | BOOSTRIX | PREFERRED | ||
| VACCINES | CAPVAXIVE | NON-PREFERRED | ||
| VACCINES | COMIRNATY 2025-26 | PREFERRED | ||
| VACCINES | COMIRNATY/5-11Y/2025-26 | PREFERRED | ||
| VACCINES | DAPTACEL | PREFERRED | ||
| VACCINES | DENGVAXIA | PREFERRED | ||
| VACCINES | ENGERIX-B | PREFERRED | ||
| VACCINES | ERVEBO | NON-PREFERRED | ||
| VACCINES | FLUAD 2025-2026 | NON-PREFERRED | ||
| VACCINES | FLUARIX 2025-2026 | NON-PREFERRED | ||
| VACCINES | FLUBLOK 2025-2026 | NON-PREFERRED | ||
| VACCINES | FLUCELVAX 2025-2026 | NON-PREFERRED | ||
| VACCINES | FLULAVAL 2025-2026 | NON-PREFERRED | ||
| VACCINES | FLUMIST NASAL VACCINE 202 5-2026 | NON-PREFERRED | ||
| VACCINES | FLUZONE 2025-2026 | NON-PREFERRED | ||
| VACCINES | FLUZONE HIGH-DOSE 2025-20 26 | NON-PREFERRED | ||
| VACCINES | GARDASIL 9 | PREFERRED | ||
| VACCINES | HAVRIX | PREFERRED | ||
| VACCINES | HEPLISAV-B | PREFERRED | ||
| VACCINES | HIBERIX | PREFERRED | ||
| VACCINES | IMOVAX RABIES (H.D.C.V.) | PREFERRED | ||
| VACCINES | INFANRIX | PREFERRED | ||
| VACCINES | IPOL INACTIVATED IPV | PREFERRED | ||
| VACCINES | IXCHIQ | EXCLUDED | ||
| VACCINES | IXIARO | PREFERRED | ||
| VACCINES | JYNNEOS | NON-PREFERRED | ||
| VACCINES | KINRIX | EXCLUDED | ||
| VACCINES | MENQUADFI | NON-PREFERRED | ||
| VACCINES | MENVEO | NON-PREFERRED | ||
| VACCINES | MENVEO | PREFERRED | ||
| VACCINES | M-M-R II | PREFERRED | ||
| VACCINES | MNEXSPIKE COVID-19 VACCIN E/2025-26 | PREFERRED | ||
| VACCINES | MRESVIA | NON-PREFERRED | ||
| VACCINES | NUVAXOVID COVID-19 VACCIN E/2025-26 | PREFERRED | ||
| VACCINES | PEDIARIX | PREFERRED | ||
| VACCINES | PEDVAX HIB | PREFERRED | ||
| VACCINES | PENBRAYA | NON-PREFERRED | ||
| VACCINES | PENMENVY | PREFERRED | ||
| VACCINES | PENTACEL | PREFERRED | ||
| VACCINES | PNEUMOVAX 23 | PREFERRED | ||
| VACCINES | PREVNAR 20 | PREFERRED | ||
| VACCINES | PRIORIX | PREFERRED | ||
| VACCINES | PROQUAD | PREFERRED | ||
| VACCINES | QUADRACEL | NON-PREFERRED | ||
| VACCINES | RABAVERT | PREFERRED | ||
| VACCINES | RECOMBIVAX HB | PREFERRED | ||
| VACCINES | ROTARIX | EXCLUDED | ||
| VACCINES | ROTATEQ | PREFERRED | ||
| VACCINES | SHINGRIX | PREFERRED | ||
| VACCINES | SPIKEVAX COVID-19 VACCINE /2025-26 | PREFERRED | ||
| VACCINES | SPIKEVAX COVID-19 VACCINE /6MO-11Y/2025-26 | PREFERRED | ||
| VACCINES | TENIVAC | PREFERRED | ||
| VACCINES | TICOVAC | PREFERRED | ||
| VACCINES | TRUMENBA | PREFERRED | ||
| VACCINES | TWINRIX | PREFERRED | ||
| VACCINES | TYPHIM VI | PREFERRED | ||
| VACCINES | VAQTA | PREFERRED | ||
| VACCINES | VARIVAX | PREFERRED | ||
| VACCINES | VAXCHORA | PREFERRED | ||
| VACCINES | VAXELIS | PREFERRED | ||
| VACCINES | VAXNEUVANCE | PREFERRED | ||
| VACCINES | VIMKUNYA | PREFERRED | ||
| VACCINES | VIVOTIF | PREFERRED | ||
| VACCINES | YF-VAX | PREFERRED | ||
| VAGINAL AND RELATED PRODUCTS | CLEOCIN | EXCLUDED | ||
| VAGINAL AND RELATED PRODUCTS | CLINDAMYCIN PHOSPHATE | GENERIC | ||
| VAGINAL AND RELATED PRODUCTS | CLINDESSE | EXCLUDED | ||
| VAGINAL AND RELATED PRODUCTS | ESTRACE | EXCLUDED | ||
| VAGINAL AND RELATED PRODUCTS | ESTRADIOL | GENERIC | ||
| VAGINAL AND RELATED PRODUCTS | ESTRING | PREFERRED | ||
| VAGINAL AND RELATED PRODUCTS | FEM PH | EXCLUDED | ||
| VAGINAL AND RELATED PRODUCTS | FEMRING | EXCLUDED | PA | |
| VAGINAL AND RELATED PRODUCTS | GYNAZOLE-1 | NON-PREFERRED | ||
| VAGINAL AND RELATED PRODUCTS | IMVEXXY MAINTENANCE PACK | EXCLUDED | ||
| VAGINAL AND RELATED PRODUCTS | IMVEXXY STARTER PACK | EXCLUDED | ||
| VAGINAL AND RELATED PRODUCTS | INTRAROSA | EXCLUDED | PA | |
| VAGINAL AND RELATED PRODUCTS | METRONIDAZOLE VAGINAL | GENERIC | ||
| VAGINAL AND RELATED PRODUCTS | MICONAZOLE 3 | PREFERRED | ||
| VAGINAL AND RELATED PRODUCTS | PHEXX | EXCLUDED | ||
| VAGINAL AND RELATED PRODUCTS | PREMARIN | PREFERRED | ||
| VAGINAL AND RELATED PRODUCTS | TERCONAZOLE | GENERIC | ||
| VAGINAL AND RELATED PRODUCTS | VAGIFEM | EXCLUDED | ||
| VAGINAL AND RELATED PRODUCTS | VANDAZOLE | EXCLUDED | ||
| VAGINAL AND RELATED PRODUCTS | XACIATO | EXCLUDED | ||
| VAGINAL AND RELATED PRODUCTS | YUVAFEM | GENERIC | ||
| VASOPRESSORS | ADRENALIN | NON-PREFERRED | ||
| VASOPRESSORS | ADRENALIN | EXCLUDED | ||
| VASOPRESSORS | AKOVAZ | EXCLUDED | ||
| VASOPRESSORS | AUVI-Q | PREFERRED | ||
| VASOPRESSORS | AUVI-Q | NON-PREFERRED | ||
| VASOPRESSORS | BIORPHEN | NON-PREFERRED | ||
| VASOPRESSORS | BIORPHEN | EXCLUDED | ||
| VASOPRESSORS | DROXIDOPA | GENERIC | SP | PA |
| VASOPRESSORS | EMERPHED | EXCLUDED | ||
| VASOPRESSORS | EPHEDRINE SULFATE | GENERIC | ||
| VASOPRESSORS | EPHEDRINE SULFATE | PREFERRED | ||
| VASOPRESSORS | EPHEDRINE SULFATE | EXCLUDED | ||
| VASOPRESSORS | EPHEDRINE SULFATE/SODIUM CHLORIDE | PREFERRED | ||
| VASOPRESSORS | EPHEDRINE SULFATE/SODIUM CHLORIDE | EXCLUDED | ||
| VASOPRESSORS | EPINEPHRINE | GENERIC | ||
| VASOPRESSORS | EPINEPHRINE | PREFERRED | ||
| VASOPRESSORS | EPINEPHRINE | EXCLUDED | ||
| VASOPRESSORS | EPINEPHRINE BITARTRATE/SO DIUM CHLORIDE | EXCLUDED | ||
| VASOPRESSORS | EPINEPHRINE HCL | PREFERRED | ||
| VASOPRESSORS | EPINEPHRINE HYDROCHLORIDE /DEXTROSE | PREFERRED | ||
| VASOPRESSORS | EPINEPHRINE HYDROCHLORIDE /SODIUM CHLORIDE | PREFERRED | ||
| VASOPRESSORS | EPINEPHRINE PROFESSIONAL | EXCLUDED | ||
| VASOPRESSORS | EPINEPHRINE/DEXTROSE | PREFERRED | ||
| VASOPRESSORS | EPINEPHRINE/SODIUM CHLORI DE | PREFERRED | ||
| VASOPRESSORS | EPINEPHRINE/SODIUM CHLORI DE | EXCLUDED | ||
| VASOPRESSORS | EPINEPHRINESNAP | EXCLUDED | ||
| VASOPRESSORS | EPINEPHRINESNAP-EMS | EXCLUDED | ||
| VASOPRESSORS | EPINEPHRINESNAP-V | EXCLUDED | ||
| VASOPRESSORS | EPIPEN 2-PAK | NON-PREFERRED | ||
| VASOPRESSORS | EPIPEN-JR 2-PAK | NON-PREFERRED | ||
| VASOPRESSORS | GIAPREZA | EXCLUDED | ||
| VASOPRESSORS | IMMPHENTIV | EXCLUDED | ||
| VASOPRESSORS | LEVOPHED | EXCLUDED | ||
| VASOPRESSORS | MIDODRINE HYDROCHLORIDE | GENERIC | ||
| VASOPRESSORS | NEFFY | EXCLUDED | ||
| VASOPRESSORS | NOREPINEPHRINE BITARTRATE | GENERIC | ||
| VASOPRESSORS | NOREPINEPHRINE BITARTRATE /DEXTROSE | PREFERRED | ||
| VASOPRESSORS | NOREPINEPHRINE BITARTRATE /SODIUM CHLORIDE | PREFERRED | ||
| VASOPRESSORS | NOREPINEPHRINE/DEXTROSE | PREFERRED | ||
| VASOPRESSORS | NOREPINEPHRINE/SODIUM CHL ORIDE | PREFERRED | ||
| VASOPRESSORS | NORTHERA | EXCLUDED | SP | PA |
| VASOPRESSORS | PHENYLEPHRINE HYDROCHLORI DE | PREFERRED | ||
| VASOPRESSORS | PHENYLEPHRINE HYDROCHLORI DE | GENERIC | ||
| VASOPRESSORS | PHENYLEPHRINE HYDROCHLORI DE | EXCLUDED | ||
| VASOPRESSORS | PHENYLEPHRINE HYDROCHLORI DE/SODIUM CHLORIDE | PREFERRED | ||
| VASOPRESSORS | PHENYLEPHRINE HYDROCHLORI DE/SODIUM CHLORIDE | EXCLUDED | ||
| VASOPRESSORS | PHENYLEPHRINE HYDROCHLORI DE/SODIUM CHORIDE | EXCLUDED | ||
| VASOPRESSORS | VAZCULEP | EXCLUDED |