2018 Step Therapy. ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, Exclusion)

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1 ACANYA GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR ACIPHEX SPRINKLE (2018 Preferred Formulary ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE, RABEPRAZOLE ACTICLATE ACTONEL BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE STEP 2: ATELVIA ACTONEL PLUS CALCIUM BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE STEP 2: ATELVIA ACTOPLUS MET DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) ACTOPLUS MET XR DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) ACTOS DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) ACZONE GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR ADALAT CC GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE ER, ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER ADAPALENE GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR ADDERALL XR RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-, METHYLPHENIDATE EXTENDED- ADOXA ADZENXS XR ODT RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-, METHYLPHENIDATE EXTENDED- AEROSPAN ASTHMA/COPD ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR ALA-SCALP HP ALCORTIN A SKIN INFECTIONS TOPICAL STEROID+MUPIROCIN ALLZITAL GENERIC PRODUCT WITH BUTALBITAL ALOCRIL EYE CONDITIONS CROMOLYN ALODOX KIT ALOGLIPTIN (2018 Preferred Formulary DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) ALOGLIPTIN/METFORMIN (2018 Preferred Formulary DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) ALOGLIPTIN/PIOGLITAZONE DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) ALOMIDE EYE CONDITIONS CROMOLYN ALOQUIN SKIN INFECTIONS MUPIROCIN ALREX EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE ALSUMA INJECTION ALTOPREV ALVESCO (2018 Preferred Formulary ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, ASTHMA/COPD QVAR AMBIEN SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER AMBIEN CR SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER AMERGE AMRIX ER MUSCLE RELAXANT GENERIC CYCLOBENZAPRINE ANAPROX ANAPROX DS 1 HCR

2 ANDROID HORMONAL SUPPLEMENTATION GENERIC OR METHITEST ANSAID ANTARA FENOFIBRATE, FENOFIBRIC ACID ANUSOL HC SUPPOSITORY (2018 Preferred Formulary INFLAMMATORY CONDITIONS GENERIC HYDROCORTISONE ACETATE SUPPOSITORY (25 MG OR 30 MG), ANUCORT-HC (25 MG), GRX HICORT (25 MG), HEMMOREX-HC (25 MG OR 30 MG), RECTACORT-HC (25 MG) APLENZIN BUPROPION SR, BUPROPION ER APTENSIO XR RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-, METHYLPHENIDATE EXTENDED- AQUA GLYCOLIC HC ARICEPT 10MG TABLET NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS) ARICEPT 23MG TABLET (BRAND OR GENERIC) NEUROLOGICAL DISORDERS ARICEPT 10 MG TABLETS (BRAND OR GENERIC) OR ARICEPT ODT 10 MG (BRAND OR GENERIC) ARICEPT 5MG TABLET NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS) ARICEPT ODT NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS) ARTHROTEC ASTAGRAF XL TRANSPLANT GENERIC TACROLIMUS ATACAND (2018 Preferred Formulary ATACAND HCT (2018 Preferred Formulary ATELVIA BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE STEP 2: ATELVIA AUBAGIO MULTIPLE SCLEROSIS AVONEX, BETASERON, COPAXONE 40 MG, EXTAVIA, GLATOPA, PLEGRIDY, REBIF AVALIDE AVANDAMET DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) AVANDARYL DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) AVANDIA DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) AVAPRO AVAR GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR AVAR LS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR AVAR-E GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR AVAR-E GREEN GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR AVAR-E LS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR AVAR-E LS CREAM GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR AVIDOXY KIT AVODART BPH FINASTERIDE 5 MG AXERT AZELEX GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR AZOR (2018 Preferred Formulary 2

3 BECONASE AQ (2018 Preferred Formulary BELBUCA - NARCOTIC BELSOMRA SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER BENICAR (2018 Preferred Formulary BENICAR HCT (2018 Preferred Formulary BENZACLIN GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR BENZAMYCIN GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR BENZAMYCIN PAK GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR BENZEFOAM GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR BENZEFOAM ULTRA GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR BENZEPRO GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR BEPREVE EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE BETAPACE GENERIC ORAL SOTALOL BETAPACE AF GENERIC ORAL SOTALOL BINOSTO BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE STEP 2: ATELVIA BONIVA BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE STEP 2: ATELVIA BRINTELLIX BRISDELLE BRIVIACT NEUROLOGICAL DISORDERS LEVETIRACETAM, LEVETIRACETAM XR, ROWEEPRA BUPAP (2018 Preferred Formulary GENERIC PRODUCT WITH BUTALBITAL BUTRANS (2018 Preferred Formulary - NARCOTIC BYSTOLIC BYVALSON CADUET CALAN VERAPAMIL SR, VERAPAMIL IR, VERAPAMIL ER CALAN SR VERAPAMIL SR, VERAPAMIL IR, VERAPAMIL ER CAMBIA CAPEX CARDENE SR GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE ER, ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER CARDURA BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN CARDURA XL BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN CATAFLAM 3

4 CELEBREX BRAND OR GENERIC ORAL NSAIDS (MUST USE 2) FOR EXAMPLE: DICLOFENAC (IR AND ER), ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC, MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL CELECOXIB BRAND OR GENERIC ORAL NSAIDS (MUST USE 2) FOR EXAMPLE: DICLOFENAC (IR AND ER), ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC, MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL CELEXA CICLODAN 8% KIT ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION, CICLOPIROX TOPICAL SOLUTION 8%, CICLOPIROX 8% TREATMENT KIT CLARIFOAM EF GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR CLEOCIN T GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR CLINDACIN ETZ GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR CLINDACIN PAC GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR CLINDAGEL GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR CLOBEX CLODAN CLODERM CNL 8 NAIL KIT ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION, CICLOPIROX TOPICAL SOLUTION 8%, CICLOPIROX 8% TREATMENT KIT COLCHICINE CAPSULES (2018 Preferred Formulary GOUT COLCRYS, MITIGARE COLCHICINE TABLETS (2018 Preferred Formulary GOUT COLCRYS, MITIGARE COLESTID CHOLESTYRAMINE, COLESTIPOL, PREVALITE CONCERTA RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-, METHYLPHENIDATE EXTENDED- CONZIP TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN CORDRAN COREG COREG CR CORGARD CORZIDE 4

5 COZAAR CRESTOR CUTIVATE CYMBALTA (2018 Preferred Formulary SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE- DAKLINZA (2018 Preferred Formulary HEPATITIS C HARVONI, EPCLUSA, MAVYRET, VIEKIRA PAK, VIEKIRA XR, VOSEVI DAYPRO DAYTRANA RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-, METHYLPHENIDATE EXTENDED- DEPAKENE NEUROLOGICAL DISORDERS DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID DEPAKOTE NEUROLOGICAL DISORDERS DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID DEPAKOTE ER/EC/DR NEUROLOGICAL DISORDERS DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID DEPAKOTE SPRINKLE NEUROLOGICAL DISORDERS DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID DERMAPAK PLUS DERMA-SMOOTH FS DERMASORB HC DERMASORB TA DERMATOP DESONATE DESOWEN DESVENLAFAXINE ER (BRAND) ONE MED FROM RULE 1 AND ONE MED FROM RULE 2 RULE 1: GENERIC PRESCRIPTION TOPICAL BENZOYL PEROXIDE, ANTIBIOTIC, ETC CONTAINING PRODUCTS RULE 2: GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE- 5

6 DESVENLAFAXINE FUMARATE ER (BRAND) SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE- DETROL OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER DETROL LA OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER DEXEDRINE RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-, METHYLPHENIDATE EXTENDED- DEXILANT ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE, RABEPRAZOLE DEXPAK 6 DAY/10 DAY/13 DAY INFLAMMATORY CONDITIONS GENERIC DEXAMETHASON TABLETS DICLOFENAC SODIUM 1% GEL DIFFERIN GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR DIOVAN DIOVAN HCT DIPROLENE DIPROLENE/AF DISKETS - NARCOTIC DITROPAN XL OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER DITROPAN XL OVERACTIVE BLADDER DARIFENACIN ER, GELNIQUE, MYRBETRIQ, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TOVIAZ, TROSPIUM, TROSPIUM ER, VESICARE DOLOPHINE - NARCOTIC DORYX DORYX MPC DOXYCYCLINE 40MG CAPSULES (IR/DR) (BRAND) DUAC GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR DUETACT DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) DURAGESIC - NARCOTIC DURLAZA BLOOD MODIFYING TWO OTHER ASPIRIN PRODUCTS DUTASTERIDE BPH FINASTERIDE 5 MG DUTASTERIDE/TAMSULOSIN BPH FINASTERIDE 5 MG DUTOPROL DYMISTA DYNAVEL XR RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-, METHYLPHENIDATE EXTENDED- 6

7 EC-NAPROSYN EDARBI EDARBYCLOR EDLUAR SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER EFFEXOR SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE- EFFEXOR XR (2018 Preferred Formulary SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE- ELESTAT EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE ELIDEL REQUIRES USE OF ONE PRESCRIPTION TOPICAL CORTICOSTEROID FIRST (BRAND OR GENERIC): FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE ELOCON EMADINE EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE EMBEDA - NARCOTIC ENABLEX OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER ENVARSUS XR TRANSPLANT GENERIC TACROLIMUS EPIDUO GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR EPIDUO FORTE GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR ESGIC GENERIC PRODUCT WITH BUTALBITAL ESOMEPRAZOLE STRONTIUM ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE, RABEPRAZOLE EUCRISA REQUIRES USE OF ONE PRESCRIPTION TOPICAL CORTICOSTEROID FIRST (BRAND OR GENERIC): FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE EVOCLIN GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR EXELON PATCH NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS) EXELON TABLET NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS) EXFORGE EXFORGE HCT FARXIGA DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) FELDENE FENOFIBRATE CAPSULES (BRAND) FENOFIBRATE, FENOFIBRIC ACID FENOGLIDE FENOFIBRATE, FENOFIBRIC ACID 7

8 FENOPROFEN (BRAND) FETZIMA SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE- FEXMID MUSCLE RELAXANT GENERIC CYCLOBENZAPRINE FIBRICOR FENOFIBRATE, FENOFIBRIC ACID FINACEA FOAM FINACEA GEL FINACEA PLUS KIT FIORICET GENERIC PRODUCT WITH BUTALBITAL FIORINAL GENERIC PRODUCT WITH BUTALBITAL FIORINAL WITH CODEINE GENERIC PRODUCT WITH BUTALBITAL FLECTOR PATCH FLOMAX BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN FLONASE FLONASE BUDESONIDE (RX AND OTC), FLUNISOLIDE, FLUTICASONE, MOMETASONE, QNASL, TRIAMCINOLONE (RX AND OTC) FLOWTUSS COUGH AND COLD GENERIC COUGH/COLD LIQUID FLUOXETINE 60MG TABLETS FOCALIN XR RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-, METHYLPHENIDATE EXTENDED- FORFIVO XL BUPROPION SR, BUPROPION ER FORTAMET (BRAND AND GENERIC) DIABETES STEP 1: METFORMIN ER (GENERIC TO GLUCOPHAGE XR ONLY) STEP 2: GLUCOPHAGE XR (BRAND), FORTAMET (BRAND AND GENERIC) FOSAMAX PLUS D BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE STEP 2: ATELVIA FOSAMAX TABLETS BONE CONDITIONS STEP 1: ALENDRONATE, IBANDRONATE, RISEDRONATE STEP 2: ATELVIA FROVA GELNIQUE OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER GILENYA MULTIPLE SCLEROSIS AVONEX, BETASERON, COPAXONE 40 MG, EXTAVIA, GLATOPA, PLEGRIDY, REBIF GLUCOPHAGE DIABETES METFORMIN IR GLUCOPHAGE XR (BRAND) DIABETES STEP 1: METFORMIN ER (GENERIC TO GLUCOPHAGE XR ONLY) STEP 2: GLUCOPHAGE XR (BRAND), FORTAMET (BRAND AND GENERIC) GLUMETZA (BRAND AND GENERIC) (2018 STEP 1: METFORMIN ER (GENERIC TO GLUCOPHAGE XR ONLY) DIABETES Preferred Formulary STEP 2: GLUCOPHAGE XR (BRAND), FORTAMET (BRAND AND GENERIC) GLYXAMBI DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) GRALISE NEUROLOGICAL DISORDERS GABAPENTIN HALOG HECTOROL CAPSULES VITAMIN D DEFICIENCY CALCITRIOL CAPSULES, CALCITRIOL ORAL SOLUTION HORIZANT NEUROLOGICAL DISORDERS GABAPENTIN HYCOFENIX COUGH AND COLD GENERIC COUGH/COLD LIQUID HYDROMORPHONE ER - NARCOTIC HYSINGLA ER - NARCOTIC HYTRIN BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN 8

9 HYZAAR IMITREX (ORAL) IMITREX INJECTION IMITREX NASAL SPRAY INDERAL LA (2018 Preferred Formulary INDERAL XL INDOCIN INNOPRAN XL INOVA GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR INOVA 4-1 GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR INOVA 8-2 GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR INTERMEZZO SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER BRAND AND FOR EXAMPLE: ADDERALL, ADDERALL XR, ADZENYS XR ODT, APTENSIO XR, ATOMOXETINE, CONCERTA, DAYTRANA, INTUNIV (2018 Preferred Formulary DESOXYN, DEXEDRINE, DEXEDRINE SPANSULES, DEXTROAMPHETAMINE, DEXTROAMPHETAMINE SR, DEXMETHYLPHENIDATE IR, DYNAVEL XR, FOCALIN, FOCALIN XR, METADATE CD, METADATE ER, METHAMPHETAMINE, METHYLIN, METHYLIN ER, METHYLPHENIDATE ER, METHYLPHENIDATE IMMEDIATE RELEASE, MIXED AMPHETAMINE SALTS IR, QUILLICHEW ER, RITALIN LA, RITALIN SR, VYVANSE INVOKAMET DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) INVOKANA DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) IRENKA SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE- JALYN BPH FINASTERIDE 5 MG JANUMET DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) JANUMET XR DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) JANUVIA DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) JARDIANCE DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) JENTADUETO DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) JENTADUETO XR DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) JUBLIA ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION, CICLOPIROX TOPICAL SOLUTION 8%, CICLOPIROX 8% TREATMENT KIT JUVISYNC DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) KAPVAY BRAND AND FOR EXAMPLE: ADDERALL, ADDERALL XR, ADZENYS XR ODT, APTENSIO XR, ATOMOXETINE, CONCERTA, DAYTRANA, DESOXYN, DEXEDRINE, DEXEDRINE SPANSULES, DEXTROAMPHETAMINE, DEXTROAMPHETAMINE SR, DEXMETHYLPHENIDATE IR, DYNAVEL XR, FOCALIN, FOCALIN XR, METADATE CD, METADATE ER, METHAMPHETAMINE, METHYLIN, METHYLIN ER, METHYLPHENIDATE ER, METHYLPHENIDATE IMMEDIATE RELEASE, MIXED AMPHETAMINE SALTS IR, QUILLICHEW ER, RITALIN LA, RITALIN SR, VYVANSE KAZANO (2018 Preferred Formulary DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) KENALOG KEPPRA NEUROLOGICAL DISORDERS LEVETIRACETAM, LEVETIRACETAM XR, ROWEEPRA KEPPRA XR NEUROLOGICAL DISORDERS LEVETIRACETAM, LEVETIRACETAM XR, ROWEEPRA KERYDIN ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION, CICLOPIROX TOPICAL SOLUTION 8%, CICLOPIROX 8% TREATMENT KIT 9

10 KEVZARA KHEDEZLA KINERET INFLAMMATORY CONDITIONS INFLAMMATORY CONDITIONS RHEUMATOID ARTHRITIS: ACTEMRA SC, ENBREL, HUMIRA, XELJANZ/XR ANKYLOSING SPONDYLITIS: COSENTYX, ENBREL, HUMIRA JUVENILE IDIOPATHIC ARTHRITIS: ENBREL, HUMIRA PSORIATIC ARTHRITIS: COSENTYX, ENBREL, HUMIRA, STELARA SC PSORIASIS: COSENTYX, HUMIRA, OTEZLA, STELARA SC CROHN'S DISEASE: HUMIRA ULCERATIVE COLITIS: HUMIRA SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE- RHEUMATOID ARTHRITIS: ACTEMRA SC, ENBREL, HUMIRA, XELJANZ/XR ANKYLOSING SPONDYLITIS: COSENTYX, ENBREL, HUMIRA JUVENILE IDIOPATHIC ARTHRITIS: ENBREL, HUMIRA PSORIATIC ARTHRITIS: COSENTYX, ENBREL, HUMIRA, STELARA SC PSORIASIS: COSENTYX, HUMIRA, OTEZLA, STELARA SC CROHN'S DISEASE: HUMIRA ULCERATIVE COLITIS: HUMIRA KLARON GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR KLOFENSAID II KOMBIGLYZE XR (2018 Preferred Formulary DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) LAMICTAL NEUROLOGICAL DISORDERS LAMOTRIGINE, LAMOTRIGINE XR LAMICTAL XR NEUROLOGICAL DISORDERS LAMOTRIGINE, LAMOTRIGINE XR LASTACAFT EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE LESCOL LESCOL XL LETAIRIS LEVATOL LEXAPRO (2018 Preferred Formulary PULMONARY HYPERTENSION TRACLEER, OPSUMIT LIDOCAINE-TETRACAINE 7%-7% CREAM LIDOCAINE/PRILOCAINE CREAM LIPITOR LIPOFEN FENOFIBRATE, FENOFIBRIC ACID LIVALO LOCOID LOCORT 7 DAY/11 DAY INFLAMMATORY CONDITIONS GENERIC DEXAMETHASON TABLETS LOFIBRA FENOFIBRATE, FENOFIBRIC ACID LOPRESSOR LOPRESSOR HCT LORZONE MUSCLE RELAXANT GENERIC CHLORZOXAZONE LUMIGAN EYE CONDITIONS BIMATOPROST, LATANOPROST, TRAVOPROST 10

11 LUNESTA (2018 Preferred Formulary SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER LUVOX CR LUXIQ LYRICA NEUROLOGICAL DISORDERS GABAPENTIN MAXALT MAXALT MLT METADATE CD RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-, METHYLPHENIDATE EXTENDED- METHADOSE - NARCOTIC METROCREAM METROGEL METROLOTION MEVACOR MICARDIS MICARDIS HCT MINOCIN MINOCIN KIT MOBIC MONODOX MORGIDOX KIT MORPHINE SULFATE CR/ER - NARCOTIC MOTRIN MYRBETRIQ OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER NALFON NAMENDA ORAL SOLUTION NEUROLOGICAL DISORDERS MEMANTINE TABLETS, MEMANTINE ORAL SOLUTION NAMENDA TABLETS NEUROLOGICAL DISORDERS MEMANTINE TABLETS, MEMANTINE ORAL SOLUTION NAMENDA XR NEUROLOGICAL DISORDERS MEMANTINE TABLETS, MEMANTINE ORAL SOLUTION NAMZARIC NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS) 11

12 NAPRELAN NAPROSYN NAPROSYN EC NASACORT NASACORT AQ NASONEX (2018 Preferred Formulary NESINA (2018 Preferred Formulary DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) NEUAC GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR NEURONTIN NEUROLOGICAL DISORDERS GABAPENTIN NEXIUM ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE, RABEPRAZOLE NORITATE NORVASC GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE ER, ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER NOVACORT HYDROCORTISONE-PRAMOXINE NVOKAMET XR DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) OBERDON COUGH AND COLD GENERIC COUGH/COLD LIQUID OLEPTRO ER SLEEP DISORDERS GENERIC TRAZODONE OLUX OLUX-E OLYSIO (2018 Preferred Formulary HEPATITIS C HARVONI, EPCLUSA, MAVYRET, VIEKIRA PAK, VIEKIRA XR, VOSEVI OMNARIS (2018 Preferred Formulary ONEXTON GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR ONGLYZA (2018 Preferred Formulary DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) ONZETRA XSAIL OPTIVAR EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE ORACEA ORTHO EVRA AND BRAND ORAL CONTRACEPTIVES CONTRACEPTIVES XULANE AND GENERIC ORAL CONTRACEPTIVES OSENI DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) RHEUMATOID ARTHRITIS: ACTEMRA SC, ENBREL, HUMIRA, XELJANZ/XR ANKYLOSING SPONDYLITIS: COSENTYX, ENBREL, HUMIRA OTEZLA JUVENILE IDIOPATHIC ARTHRITIS: ENBREL, HUMIRA INFLAMMATORY PSORIATIC ARTHRITIS: COSENTYX, ENBREL, HUMIRA, STELARA SC CONDITIONS PSORIASIS: COSENTYX, HUMIRA, OTEZLA, STELARA SC CROHN'S DISEASE: HUMIRA ULCERATIVE COLITIS: HUMIRA OVACE PLUS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR 12

13 OXTELLAR XR NEUROLOGICAL DISORDERS OXCARBAZEPINE OXYCODONE ER (BRAND) (2018 Preferred - NARCOTIC Formulary OXYMORPHONE ER - NARCOTIC OXYTROL OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER PACNEX GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR PACNEX HP GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR PACNEX LP GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR PANDEL PATADAY EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE PATANOL EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE PAXIL PAXIL CR PAZEO EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE PEDIADERM PEDIADERM TA PEDIPIROX-4 NAIL KIT ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION, CICLOPIROX TOPICAL SOLUTION 8%, CICLOPIROX 8% TREATMENT KIT PENLAC ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION, CICLOPIROX TOPICAL SOLUTION 8%, CICLOPIROX 8% TREATMENT KIT PENNSAID PEXEVA PLEXION GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR PLEXION SCT GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR PONSTEL PR BENZOYL PEROXIDE GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR PRAVACHOL PRESTALIA MUST USE ONE GENERIC DHP CCB AND ONE ACE-INHIBITOR (BRAND OR GENERIC) PREVACID (2018 Preferred Formulary ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE, RABEPRAZOLE PREVACID SOLUTAB (2018 Preferred Formulary ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE, RABEPRAZOLE PRILOSEC ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE, RABEPRAZOLE PRISTIQ (2018 Preferred Formulary PROCARDIA SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE- GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE ER, ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER 13

14 PROCARDIA XL GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE ER, ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER PROCYSBI DR URINARY DISORDERS CYSTAGON PROSCAR BPH FINASTERIDE 5 MG PROTOCORT SUPPOSITORY INFLAMMATORY GENERIC HYDROCORTISONE ACETATE SUPPOSITORY (25 MG OR 30 MG), ANUCORT-HC (25 MG), GRX HICORT (25 MG), CONDITIONS HEMMOREX-HC (25 MG OR 30 MG), RECTACORT-HC (25 MG) PROTONIX (2018 Preferred Formulary ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE, RABEPRAZOLE PROTOPIC REQUIRES USE OF ONE PRESCRIPTION TOPICAL CORTICOSTEROID FIRST (BRAND OR GENERIC): FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE PROZAC (2018 Preferred Formulary PROZAC WEEKLY PSORCON QDEXY XR NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGEN QNASAL QUESTRAN CHOLESTYRAMINE, COLESTIPOL, PREVALITE QUESTRAN LIGHT CHOLESTYRAMINE, COLESTIPOL, PREVALITE QUILLICHEW ER RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-, METHYLPHENIDATE EXTENDED- QUILLIVANT XR RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-, METHYLPHENIDATE EXTENDED- RAPAFLO BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN RAYALDEE CAPSULES VITAMIN D DEFICIENCY CALCITRIOL CAPSULES, CALCITRIOL ORAL SOLUTION RAZADYNE NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS) RAZADYNE ER NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS) RELISTOR CONSTIPATION REQUIRES USE OF BOTH AMITIZA AND MOVANTIK FIRST RELPAX RESCULA EYE CONDITIONS BIMATOPROST, LATANOPROST, TRAVOPROST REVATIO ORAL SUSPENSION REVATIO TABLETS PULMONARY HYPERTENSION SILDENAFIL 20MG PULMONARY HYPERTENSION SILDENAFIL 20MG RHINOCORT RHINOCORT AQUA RIOMET DIABETES METFORMIN IR RITALIN LA RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-, METHYLPHENIDATE EXTENDED- RITALIN SR RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-, METHYLPHENIDATE EXTENDED- ROCALTROL CAPSULES VITAMIN D DEFICIENCY CALCITRIOL CAPSULES, CALCITRIOL ORAL SOLUTION 14

15 ROCALTROL ORAL SOLUTION VITAMIN D DEFICIENCY CALCITRIOL CAPSULES, CALCITRIOL ORAL SOLUTION ROSADAN CREAM KIT ROSADAN GEL KIT ROSANIL GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR ROSULA GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR ROZEREM SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER SANCTURA OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER SANCTURA XR OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER SARAFEM SAVELLA /INFLAMMATION REQUIRES USE OF ANY TWO (BRAND OR GENERIC SSRIS) OR (BRAND OR GENERIC SNRIS) SNRIS: DESVENLAFAXINE ER (BRAND), DESVENLAFAXINE FUMARATE ER (BRAND), FETZIMA, IRENKA, KHEDEZLA, PRISTIQ, VENLAFAXINE IR OR ER (EFFEXOR, EFFEXOR XR), VENLAFAXINE ER (BRAND PRODUCT) SCALACORT SECTRAL SERNIVO SILENOR SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER SITAVIG BUCCAL TABLETS VIRAL INFECTIONS GENERIC ACYCLOVIR SOLODYN SONATA SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER SOOLANTRA SOVALDI (2018 Preferred Formulary HEPATITIS C HARVONI, EPCLUSA, MAVYRET, VIEKIRA PAK, VIEKIRA XR, VOSEVI SPIRITAM NEUROLOGICAL DISORDERS LEVETIRACETAM, LEVETIRACETAM XR, ROWEEPRA SPRIX STAVZOR NEUROLOGICAL DISORDERS DIVALPROEX SODIUM, DIVALPROEX SODIUM ER/EC/DR, VALPROIC ACID BRAND AND FOR EXAMPLE: ADDERALL, ADDERALL XR, ADZENYS XR ODT, APTENSIO XR, ATOMOXETINE, CONCERTA, DAYTRANA, STRATTERA (2018 Preferred Formulary DESOXYN, DEXEDRINE, DEXEDRINE SPANSULES, DEXTROAMPHETAMINE, DEXTROAMPHETAMINE SR, DEXMETHYLPHENIDATE IR, DYNAVEL XR, FOCALIN, FOCALIN XR, METADATE CD, METADATE ER, METHAMPHETAMINE, METHYLIN, METHYLIN ER, METHYLPHENIDATE ER, METHYLPHENIDATE IMMEDIATE RELEASE, MIXED AMPHETAMINE SALTS IR, QUILLICHEW ER, RITALIN LA, RITALIN SR, VYVANSE GENERIC DHP CCBS: AFEDITAB CR, AMLODIPINE, AMLODIPINE/ATORVASTATIN, AMLODIPINE/BENAZEPRIL, FELODIPINE SULAR ER, ISRADIPINE IR, NICARDIPINE IR, NIFEDIPINE, NIFEDIPINE ER, NIFEDIPINE XL, NIFEDIAC CC, NIFEDICAL XL, NISOLDIPINE ER SUMADAN GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR SUMADAN XLT GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR SUMAVEL DOSEPRO (2018 Preferred Formulary SUMAXIN GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR SUMAXIN CP GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR SUMAXIN TS GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR SYNALAR 15

16 SYNALAR TS KIT SYNDROS NAUSEA/VOMITING AT LEAST 2 CONVENTIONAL ANTIEMETIC TREATMENT (FOR N/V ASSOCIATED WITH CANCER CHEMOTHERAPY) SYNJARDY DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) TACROLIMUS OINTMENT(GENERIC) REQUIRES USE OF ONE PRESCRIPTION TOPICAL CORTICOSTEROID FIRST (BRAND OR GENERIC): FOR EXAMPLE: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE TARGADOX TECFIDERA MULTIPLE SCLEROSIS AVONEX, BETASERON, COPAXONE 40 MG, EXTAVIA, GLATOPA, PLEGRIDY, REBIF TEMOVATE TENORETIC TENORMIN TESTRED HORMONAL SUPPLEMENTATION GENERIC OR METHITEST TEVETEN TEVETEN HCT TEXACORT TIVORBEX TOPAMAX NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGEN TOPAMAX SPRINKLE NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGEN TOPICORT TOPICORT SPRAY TOPIRAMATE ER NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGEN TOPROL XL TOVIAZ OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER TRADJENTA DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) TRAMADOL EXTENDED RELEASE TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN 16

17 TRANDATE TREXIMET TRIBENZOR (2018 Preferred Formulary TRICOR FENOFIBRATE, FENOFIBRIC ACID TRIGLIDE FENOFIBRATE, FENOFIBRIC ACID TRILEPTAL NEUROLOGICAL DISORDERS OXCARBAZEPINE TRILIPIX FENOFIBRATE, FENOFIBRIC ACID TROKENDI XR NEUROLOGICAL DISORDERS TOPIRAMATE, TOPIRAGEN TUSSICAPS COUGH AND COLD GENERIC COUGH/COLD LIQUID TUZISTRA XR COUGH AND COLD GENERIC COUGH/COLD LIQUID TWYNSTA ULORIC GOUT ALLOPURINOL, PROBENECID, PROBENECID/COLCHICHINE ULTRACET TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN ULTRAM TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN ULTRAM ER TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN ULTRAVATE ULTRAVATE X UROXATROL BPH ALFUZOSIN ER, DOXAZOSIN, TAMSULOSIN, TERAZOSIN VANATOL LQ GENERIC PRODUCT WITH BUTALBITAL VANOS VANOXIDE-HC GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR VELTIN (2018 Preferred Formulary VENLAFAXINE EXTENDED-RELEASE (BRAND) VENTAVIS VERAMYST PULMONARY HYPERTENSION TYVASO GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR SNRIS: VENLAFAXINE IR OR ER, VENLAFAXINE IMMEDIATE- VERAMYST BUDESONIDE (RX AND OTC), FLUNISOLIDE, FLUTICASONE, MOMETASONE, QNASL, TRIAMCINOLONE (RX AND OTC) VERDESO VERELAN VERAPAMIL SR, VERAPAMIL IR, VERAPAMIL ER VERELAN PM VERAPAMIL SR, VERAPAMIL IR, VERAPAMIL ER VESICARE OVERACTIVE BLADDER DARIFENACIN ER, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TROSPIUM, TROSPIUM ER VIBRAMYCIN VIIBRYD VITUZ COUGH AND COLD GENERIC COUGH/COLD LIQUID 17

18 VIVLODEX VOLTAREN GEL VOLTAREN XR VYTORIN (2018 Preferred Formulary VYVANSE RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED-, METHYLPHENIDATE EXTENDED- WELCHOL CHOLESTYRAMINE, COLESTIPOL, PREVALITE WELLBUTRIN SR (2018 Preferred Formulary BUPROPION SR, BUPROPION ER WELLBUTRIN XL BUPROPION SR, BUPROPION ER XALATAN EYE CONDITIONS BIMATOPROST, LATANOPROST, TRAVOPROST XATMEP ONCOLOGY/INFLAMMATORY METHOTREXATE TABLETS, TREXALL CONDITIONS XIGDUO XR DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN-CONTAINING PRODUCT (BRAND OR GENERIC) XTAMPZA ER - NARCOTIC YOSPRALA ULCER ASPIRIN + RX PPI ZAVESCA METABOLIC, IMMUNE DISORDERS OR INHERITED CERDELGA RARE DISEASE ZEBETA ZEGERID (BRAND AND SELECT GENERICS) ULCER TRY 5 OTHER GENERICS. IF A PATIENT HAS TRIED THE FIRST LINE ALTERNATIVES, A COVERAGE REVIEW MUST BE COMPLETED IN ORDER TO GAIN ACCESS TO A STEP 2 DRUG. ZEMBRACE SYMTOUCH ZEMPLAR CAPSULES VITAMIN D DEFICIENCY CALCITRIOL CAPSULES, CALCITRIOL ORAL SOLUTION ZEPATIER (2018 Preferred Formulary HEPATITIS C HARVONI, EPCLUSA, MAVYRET, VIEKIRA PAK, VIEKIRA XR, VOSEVI ZETIA (2018 Preferred Formulary GENERIC HMG-COA REDUCTASE INHIBITORS* (I.E., ATORVASTATIN, ATORVASTATIN PLUS, AMLODIPINE, FLUVASTATIN, FLUVASTATIN ER, LOVASTATIN, PRAVASTATIN, ROSUVASTATIN, SIMVASTATIN) BRAND NAME HMG-COA REDUCTASE INHIBITORS (I.E., ALTOPREV, CRESTOR, LESCOL, LESCOL XL, LIPITOR, LIVALO, MEVACOR, PRAVACHOL, ZOCOR) BRAND NAME HMG-COA REDUCTASE INHIBITOR COMBINATION PRODUCTS (I.E., CADUET, VYTORIN) *TRY ONE OF THESE GENERICS FIRST TO AVOID BEING TARGETED BY ANOTHER STEP THERAPY PROGRAM ZETONNA (2018 Preferred Formulary ZIAC ZIANA GENERIC PRESCRIPTION TOPICAL CLEANSERS CONTAINING BENZOYL PEROXIDE OR SULFACETAMIDE/SULFUR ZIOPTAN (2018 Preferred Formulary EYE CONDITIONS BIMATOPROST, LATANOPROST, TRAVOPROST ZIPSOR ZOCOR 18

19 ZOCOR ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, LIVALO, ZOHYDRO ER - NARCOTIC ZOLOFT (2018 Preferred Formulary ZOLPIMIST SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER ZOMIG ZOMIG NASAL SPRAY ZOMIG ZMT ZONACORT 7 DAY/11 DAY INFLAMMATORY CONDITIONS GENERIC DEXAMETHASON TABLETS ZORVOLEX ZURAMPIC GOUT ALLOPURINOL, PROBENECID, PROBENECID/COLCHICHINE ZYFLO ASTHMA/COPD GENERIC MONTELUKAST ZYFLO CR (2018 Preferred Formulary ASTHMA/COPD GENERIC MONTELUKAST 19