KeyCorp 2018 CLINICAL PROGRAMS ADMINISTERED BY EXPRESS SCRIPTS

Transcription

1 KeyCorp 2018 CLINICAL PROGRAMS ADMINISTERED BY EXPRESS SCRIPTS The prescription portion of the KeyCorp Medical Plan participates in a number of clinical programs that are structured to provide you with a progressive program of drug review and approval. This helps both you and the Plan because it allows the Plan to provide you with coverage that is clinically appropriate while allowing the Plan to maintain a predictable cost structure. Present Plan drug utilization programs include reviews for coverage of a drug under the benefit, or for certain amounts. These drug utilization programs are subject to change throughout the year. Additionally, new drug review and utilization programs may be added throughout the year. New programs are always being developed and existing programs modified. As these programs are developed, the Plan will continue to add new programs and modify its existing programs. If you have questions regarding whether your particular prescription drug is subject to one of the Plan's review programs, please check Express Scripts.com throughout the Plan year. Examples of common prescription drugs that fall into the Plan's required review programs. When you are prescribed one of the following drugs, the Plan will require that a coverage review be performed to determine whether there is an alternative that should first be prescribed as part of the Plan's program of drug utilization review. The following prescription drugs require preapproval by calling Express Scripts at : Prior Authorization Drug List (If the drug you take is on this list, Express Scripts will check to make sure it meet's your plan's conditions for coverage.) MEDICATION THERAPEUTIC CATEGORY ABSTRAL PAIN - NARCOTIC ACTEMRA INFLAMMATORY CONDITIONS ACTHAR GEL METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE ACTIQ PAIN - NARCOTIC ADCIRCA PULMONARY HYPERTENSION ADEMPAS PULMONARY HYPERTENSION ADVAIR DISKUS ASTHMA/COPD ADVAIR HFA ASTHMA/COPD AFINITOR AFINITOR ALECENSA ALECENSA ALUNBRIG ALUNBRIG AMPYRA MULTIPLE SCLEROSIS ANDRODERM ENDOCRINE DISORDERS

2 ANDROGEL ARALAST NP ARANESP ARCALYST ATRALIN AUSTEDO AVEED AVITA AVONEX AXIRON BERINERT BETASERON BIVIGAM BONIVA IV BOSULIF BOSULIF BOTOX BREO ELLIPTA BUNAVAIL BYDUREON BYETTA CABOMETYX CAPRELSA CARIMUNE CHEMET CHENODAL CHOLBAM CIMZIA CINQAIR CINRYZE CLINDAMYCIN/TRETINOIN GEL COMETRIQ COPAXONE COPEGUS CORLANOR COSENTYX COTELLIC COTELLIC CUVITRU DAKLINZA DALIRESP DELATESTRYL DEPO-TESTOSTERONE DICLEGIS DULERA ENDOCRINE DISORDERS METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE BLOOD CELL DEFICIENCY METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE SKIN CONDITIONS MENTAL/NEUROLOGICAL DISORDERS ENDOCRINE DISORDERS SKIN CONDITIONS MULTIPLE SCLEROSIS ENDOCRINE DISORDERS METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE MULTIPLE SCLEROSIS METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE BONE CONDITIONS NEUROLOGICAL DISORDERS ASTHMA/COPD PAIN - NARCOTIC DIABETES DIABETES METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE CHELATING AGENTS METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE INFLAMMATORY CONDITIONS ASTHMA SPECIALTY METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE SKIN CONDITIONS MULTIPLE SCLEROSIS HEPATITIS C HEART FAILURE INFLAMMATORY CONDITIONS METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE HEPATITIS C ASTHMA/COPD ENDOCRINE DISORDERS ENDOCRINE DISORDERS NAUSEA/VOMITING ASTHMA/COPD

3 DUPIXENT DYSPORT EGRIFTA ELIGARD ELIQUIS EMFLAZA ENBREL ENTRESTO ENTYVIO EPCLUSA EPOGEN ERBITUX ERIVEDGE ESBRIET EUFLEXXA EXJADE EXONDYS 51 EXTAVIA EYLEA FABIOR FARYDAK FENTORA FERRIPROX FIRAZYR FIRST-TESTOSTERONE FIRST-TESTOSTERONE MC FLEBOGAMMA FLOLAN FORTEO FORTESTA GAMMAGARD GAMMAGARD LIQUID GAMMAGARD S/D GAMMAKED GAMMAPLEX GAMUNEX GAMUNEX-C GEL-ONE GELSYN-3 GENOTROPIN GENVISC 850 GILOTRIF GILOTRIF GLASSIA GLEEVEC SKIN CONDITIONS NEUROLOGICAL DISORDERS ENDOCRINE DISORDERS ENDOCRINE DISORDERS CARDIOVASCULAR DUCHENNE MUSCULAR DYSTROPHY INFLAMMATORY CONDITIONS HEART FAILURE INFLAMMATORY CONDITIONS HEPATITIS C BLOOD CELL DEFICIENCY RESPIRATORY MISCELLANEOUS OSTEOARTHRITIS CHELATING AGENTS DUCHENNE MUSCULAR DYSTROPHY MULTIPLE SCLEROSIS EYE CONDITIONS SKIN CONDITIONS PAIN - NARCOTIC CHELATING AGENTS METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE ENDOCRINE DISORDERS ENDOCRINE DISORDERS METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE PULMONARY HYPERTENSION BONE CONDITIONS ENDOCRINE DISORDERS METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE OSTEOARTHRITIS OSTEOARTHRITIS GROWTH DEFICIENCY OSTEOARTHRITIS METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE

4 GLEEVEC GRANIX GRASTEK HAEGARDA HARVONI HERCEPTIN HETLIOZ HIZENTRA HUMATROPE HUMIRA HYALGAN HYMOVIS HYQVIA IBRANCE IBRANCE ICLUSIG ICLUSIG ILARIS IMBRUVICA INCRELEX INFLECTRA INGREZZA INLYTA IRESSA IRESSA JADENU JAKAFI KADCYLA KALBITOR KALYDECO KEVEYIS KEVZARA KINERET KISQALI KISQALI KORLYM KRYSTEXXA KUVAN LATANOPROST LAZANDA LEMTRADA LENVIMA LETAIRIS LIDOCAINE PATCH/LIDODERM LONSURF BLOOD CELL DEFICIENCY ALLERGIES HEREDITARY ANGIOEDEMA HEPATITIS C SLEEP DISORDERS METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE ENDOCRINE DISORDERS INFLAMMATORY CONDITIONS OSTEOARTHRITIS OSTEOARTHRITIS METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE ENDOCRINE DISORDERS INFLAMMATORY CONDITIONS MENTAL/NEUROLOGICAL DISORDERS CHELATING AGENTS METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE RESPIRATORY CONDITIONS METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE INFLAMMATORY CONDITIONS INFLAMMATORY CONDITIONS ENDOCRINE DISORDERS GOUT METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE GLAUCOMA PAIN - NARCOTIC MULTIPLE SCLEROSIS PULMONARY HYPERTENSION PAIN - NARCOTIC

5 LOVAZA LUCENTIS LUMIGAN LUPANETA LUPRON LUPRON DEPOT LUPRON DEPOT-PED LYNPARZA LYNPARZA MACUGEN MAKENA MEKINIST MEKINIST MIRCERA MIRVASO TOPICAL GEL MODERIBA MONOVISC MYALEPT MYOBLOC NATPARA NEULASTA NEUPOGEN NEXAVAR NINLARO NORDITROPIN NORTHERA NPLATE NUCALA NUTROPIN NUTROPIN AQ NUTROPIN AQ NUSPIN NUVIGIL OCALIVA OCREVUS OCTAGAM ODOMZO OFEV OLYSIO OMNITROPE ONSOLIS OPSUMIT ORALAIR ORENCIA ORENITRAM ORKAMBI HIGH BLOOD CHOLESTEROL EYE CONDITIONS EYE CONDITIONS ENDOCRINE DISORDERS ENDOCRINE DISORDERS ENDOCRINE DISORDERS ENDOCRINE DISORDERS EYE CONDITIONS HORMONAL SUPPLEMENTATION BLOOD CELL DEFICIENCY SKIN CONDITIONS HEPATITIS C OSTEOARTHRITIS ENDOCRINE DISORDERS NEUROMUSCULAR CONDITIONS/COSMETIC ENDOCRINE DISORDERS BLOOD CELL DEFICIENCY BLOOD CELL DEFICIENCY GROWTH DEFICIENCY NEUROLOGICAL DISORDERS BLOOD CELL DEFICIENCY ASTHMA SPECIALTY GROWTH DEFICIENCY GROWTH DEFICIENCY GROWTH DEFICIENCY NARCOLEPSY METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE MULTIPLE SCLEROSIS METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE RESPIRATORY MISCELLANEOUS HEPATITIS C ENDOCRINE DISORDERS PAIN - NARCOTIC PULMONARY HYPERTENSION ALLERGIES INFLAMMATORY CONDITIONS PULMONARY HYPERTENSION RESPIRATORY MISCELLANEOUS

6 ORTHOVISC OTEZLA PEGASYS PEGINTRON PERJETA PLEGRIDY POLYGAM PRADAXA PRIVIGEN PROCRIT PROLASTIN PROLASTIN C PROLIA PROMACTA PROVIGIL RAGWITEK REBETOL REBIF RECLAST REMICADE REMODULIN RESCULA RESTASIS RETIN-A RETIN-A MICRO REVATIO REVLIMID RHOFADE CREAM RIBASPHERE RIBAVIRIN RITUXAN RUBRACA RUBRACA RUCONEST RYDAPT RYDAPT SAIZEN SAMSCA SAYVASA SELZENTRY SEROSTIM SIGNIFOR SIGNIFOR LAR SILIQ SIMPONI OSTEOARTHRITIS INFLAMMATORY CONDITIONS HEPATITIS C HEPATITIS C MULTIPLE SCLEROSIS METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE CARDIOVASCULAR METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE BLOOD CELL DEFICIENCY METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE BONE CONDITIONS BLOOD CELL DEFICIENCY NARCOLEPSY ALLERGIES HEPATITIS C MULTIPLE SCLEROSIS BONE CONDITIONS INFLAMMATORY CONDITIONS PULMONARY HYPERTENSION EYE CONDITIONS EYE CONDITIONS SKIN CONDITIONS SKIN CONDITIONS PULMONARY HYPERTENSION SKIN CONDITIONS HEPATITIS C HEPATITIS C INFLAMMATORY CONDITIONS METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE ENDOCRINE DISORDERS ENDOCRINE DISORDERS CARDIOVASCULAR HIV ENDOCRINE DISORDERS ENDOCRINE DISORDERS ENDOCRINE DISORDERS INFLAMMATORY CONDITIONS INFLAMMATORY CONDITIONS

7 SIMPONI ARIA SOLARAZE SOVALDI SPINRAZA SPRYCEL SPRYCEL STELARA STIVARGA STIVARGA STRIANT SUBOXONE SUBSYS SUPARTX FX SUPARTZ SUTENT SYMBICORT SYMLIN SYNAGIS SYNVISC SYNVISC-ONE SYPRINE TAFINLAR TAFINLAR TAGRISSO TAGRISSO TALTZ TANZEUM TARCEVA TARCEVA TASIGNA TASIGNA TAZAROTENE TAZORAC TECHNIVIE TEMODAR (CAPSULES) TESTIM TESTOPEL TESTOSTERONE CYPIONATE TESTOSTERONE ENANTHATE TEV-TROPIN THALOMID TRACLEER TRAVATAN TRAVATAN Z TREMFYA INFLAMMATORY CONDITIONS SKIN CONDITIONS HEPATITIS C METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE INFLAMMATORY CONDITIONS ENDOCRINE DISORDERS PAIN - NARCOTIC PAIN - NARCOTIC OSTEOARTHRITIS OSTEOARTHRITIS ASTHMA/COPD DIABETES RESPIRATORY MISCELLANEOUS OSTEOARTHRITIS OSTEOARTHRITIS WILSON'S DISEASE INFLAMMATORY CONDITIONS DIABETES SKIN CONDITIONS SKIN CONDITIONS HEPATITIS C ENDOCRINE DISORDERS ENDOCRINE DISORDERS ENDOCRINE DISORDERS ENDOCRINE DISORDERS METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE PULMONARY HYPERTENSION EYE CONDITIONS EYE CONDITIONS INFLAMMATORY CONDITIONS

8 TRETIN X TRETINOIN TOPICAL PRODUCTS TRULICITY TYKERB TYKERB TYMLOS TYSABRI TYVASO UPTRAVI VASCEPA VECTIBIX VELETRI VELTIN VENCLEXTA VENCLEXTA VENTAVIS VICTOZA VIEKIRA VIVAGLOBIN VOTRIENT XALATAN XALKORI XALKORI XARELTO XELJANZ XENAZINE XEOMIN XERMELO XIIDRA XOLAIR XTANDI ZARXIO ZEJULA ZELBORAF ZELBORAF ZEMAIRA ZEPATIER ZIANA ZINBRYTA ZIOPTAN ZOMACTON ZONTIVITY ZORBTIVE ZOVIRAX ZUBSOLV SKIN CONDITIONS SKIN CONDITIONS DIABETES BONE CONDITIONS MULTIPLE SCLEROSIS PULMONARY HYPERTENSION PULMONARY HYPERTENSION HIGH BLOOD CHOLESTEROL PULMONARY HYPERTENSION SKIN CONDITIONS PULMONARY HYPERTENSION DIABETES HEPATITIS C METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE EYE CONDITIONS CARDIOVASCULAR INFLAMMATORY CONDITIONS NEUROLOGICAL DISORDERS NEUROLOGICAL DISORDERS GASTROINTESTINAL EYE CONDITIONS ASTHMA SPECIALTY BLOOD CELL DEFICIENCY METABOLIC, IMMUNE DISORDERS OR INHERITED RARE DISEASE HEPATITIS C SKIN CONDITIONS MULTIPLE SCLEROSIS EYE CONDITIONS ENDOCRINE DISORDERS CARDIOVASCULAR ENDOCRINE DISORDERS SKIN CONDITIONS PAIN - NARCOTIC

9 ZYDELIG ZYKADIA ZYKADIA ZYTIGA Step-Therapy Requirement As a condition of coverage, the Plan also requires that certain generic/preferred drugs be prescribed before non-preferred brands will be authorized for Plan coverage. For questions, call Express Scripts at The following drugs are subject to the Step-Therapy review process: Step Therapy Drug List MEDICATION THERAPEUTIC CATEGORY FIRST LINE ALTERNATIVE ACANYA SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ACIPHEX ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE, RABEPRAZOLE ACIPHEX SPRINKLE ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE, RABEPRAZOLE ACTEMRA IV INFLAMMATORY CONDITIONS - IV RHEUMATOID ARTHRITIS: ENBREL, HUMIRA ANKYLOSING SPONDYLITIS: ENBREL, HUMIRA JUVENILE IDIOPATHIC ARTHRITIS: ENBREL, HUMIRA PSORIATIC ARTHRITIS: ENBREL, HUMIRA PSORIASIS: HUMIRA CROHN'S DISEASE: HUMIRA ULCERATIVE COLITIS: HUMIRA ACTICLATE ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE ACTONEL BONE CONDITIONS ALENDRONATE, IBANDRONATE, RISEDRONATE

10 ACTONEL PLUS CALCIUM BONE CONDITIONS ALENDRONATE, IBANDRONATE, RISEDRONATE 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) ACTOSPLUS MET DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN- CONTAINING PRODUCT (BRAND OR GENERIC) ACZONE SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADAPALENE SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL ADCIRCA PULMONARY SILDENAFIL HYPERTENSION ADDERALL XR ADHD GENERIC STIMULANT MEDICATIONS AMPHETAMINE/DEXTROAMPHETAM INE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED- RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED- RELEASE CAPSULES, METHYLPHENIDATE EXTENDED- RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED- RELEASE TABLETS ADOXA ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE

11 ADZENXS XR ODT ADHD GENERIC STIMULANT MEDICATIONS AMPHETAMINE/DEXTROAMPHETAM INE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED- RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED- RELEASE CAPSULES, METHYLPHENIDATE EXTENDED- RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED- RELEASE TABLETS AEROSPAN ASTHMA/COPD ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR ALA-SCALP HP SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE ALCORTIN A SKIN INFECTIONS TOPICAL STEROID+MUPIROCIN ALLZITAL PAIN GENERIC PRODUCT WITH BUTALBITAL ALOCRIL EYE CONDITIONS CROMOLYN ALODOX KIT ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE ALOMIDE EYE CONDITIONS CROMOLYN ALOQUIN SKIN INFECTIONS MUPIROCIN ALREX EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE

12 ALSUMA INJECTION MIGRAINE HEADACHES ALMOTRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN ALTOPREV HIGH BLOOD CHOLESTEROL ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, LIVALO, ROSUVASTATIN, AND ATORVASTATIN/AMLODIPINE ALVESCO ASTHMA/COPD ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR AMBIEN SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER AMBIEN CR SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER AMERGE MIGRAINE HEADACHES ALMOTRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN AMRIX ER MUSCLE RELAXANT GENERIC CYCLOBENZAPRINE ANAPROX PAIN GENERIC NSAIDS (MUST USE TWO) RULE 1: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL

13 ANAPROX DS PAIN GENERIC NSAIDS (MUST USE TWO) RULE 1: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL ANDROID HORMONAL GENERIC OR METHITEST SUPPLEMENTATION ANSAID PAIN GENERIC NSAIDS (MUST USE TWO) RULE 1: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL ANTARA HIGH BLOOD FENOFIBRATE, FENOFIBRIC ACID ANUSOL HC SUPPOSITORY CHOLESTEROL 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 DEPRESSION BUPROPION SR, BUPROPION ER

14 APTENSIO XR ADHD GENERIC STIMULANT MEDICATIONS AMPHETAMINE/DEXTROAMPHETAM INE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED- RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED- RELEASE CAPSULES, METHYLPHENIDATE EXTENDED- RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED- RELEASE TABLETS AQUA GLYCOLIC HC SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE ARANESP BLOOD CELL DEFICIENCY PROCRIT ARCALYST METABOLIC, IMMUNE DISORDERS OR INHERITED RARE ILARIS ARICEPT 10MG TABLET ARICEPT 23MG TABLET ARICEPT 5MG TABLET DISEASE NEUROLOGICAL DISORDERS NEUROLOGICAL DISORDERS NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS) ARICEPT 10 MG TABLETS (BRAND OR GENERIC) OR ARICEPT ODT 10 MG (BRAND OR GENERIC) GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS)

15 ARICEPT ODT NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS) ARTHROTEC PAIN GENERIC NSAIDS (MUST USE TWO) RULE 1: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL ASTAGRAF XL TRANSPLANT GENERIC TACROLIMUS ATACAND HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, AND VALSARTAN/AMLODIPINE/HYDROCH LOROTHIAZIDE ATACAND HCT HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN,

16 VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, AND VALSARTAN/AMLODIPINE/HYDROCH LOROTHIAZIDE ATELVIA BONE CONDITIONS ALENDRONATE, IBANDRONATE, RISEDRONATE AUBAGIO MULTIPLE SCLEROSIS AVONEX, BETASERON, COPAXONE 40 MG, EXTAVIA, GLATOPA, PLEGRIDY, REBIF AVALIDE HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, AND VALSARTAN/AMLODIPINE/HYDROCH LOROTHIAZIDE 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)

17 AVAPRO HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, AND VALSARTAN/AMLODIPINE/HYDROCH LOROTHIAZIDE AVAR AVAR LS AVAR-E AVAR-E GREEN AVAR-E LS AVAR-E LS CREAM SKIN CONDITIONS SKIN CONDITIONS SKIN CONDITIONS SKIN CONDITIONS SKIN CONDITIONS SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL GENERIC PRESCRIPTION TOPICAL GENERIC PRESCRIPTION TOPICAL GENERIC PRESCRIPTION TOPICAL GENERIC PRESCRIPTION TOPICAL GENERIC PRESCRIPTION TOPICAL

18 AVIDOXY KIT ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE AVINZA PAIN - NARCOTIC N/A AVODART BPH FINASTERIDE 5 MG AXERT MIGRAINE HEADACHES ALMOTRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN AZELEX SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL AZOR HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, AND VALSARTAN/AMLODIPINE/HYDROCH LOROTHIAZIDE BECONASE AQ ALLERGIES BUDESONIDE (RX AND OTC), FLUNISOLIDE, FLUTICASONE, MOMETASONE, QNASL, TRIAMCINOLONE (RX AND OTC) BELBUCA PAIN - NARCOTIC N/A BELSOMRA SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER

19 BENICAR HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, AND VALSARTAN/AMLODIPINE/HYDROCH LOROTHIAZIDE BENICAR HCT HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, AND VALSARTAN/AMLODIPINE/HYDROCH LOROTHIAZIDE BENZACLIN SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL BENZAMYCIN SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL BENZAMYCIN PAK SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL

20 BENZEFOAM SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL BENZEFOAM ULTRA SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL BENZEPRO SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL BEPREVE EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE BINOSTO BONE CONDITIONS ALENDRONATE, IBANDRONATE, RISEDRONATE BONIVA BONE CONDITIONS ALENDRONATE, IBANDRONATE, RISEDRONATE BRAVELLE INFERTILITY FIRST: CLOMIPHENE CITRATE; SECOND: GONAL-F, GONAL-F RFF BRINTELLIX DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI : CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE BRISDELLE DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI : CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE BRIVIACT NEUROLOGICAL DISORDERS BUPAP PAIN GENERIC PRODUCT WITH BUTALBITAL BUTRANS PAIN - NARCOTIC N/A CADUET HIGH BLOOD CHOLESTEROL LEVETIRACETAM, LEVETIRACETAM XR, ROWEEPRA ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, LIVALO, ROSUVASTATIN, AND ATORVASTATIN/AMLODIPINE

21 CAMBIA PAIN GENERIC NSAIDS (MUST USE TWO) RULE 1: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL CAPEX SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE CATAFLAM PAIN GENERIC NSAIDS (MUST USE TWO) RULE 1: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL

22 CELEBREX PAIN BRAND OR GENERIC ORAL NSAIDS (MUST USE 2) 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 PAIN BRAND OR GENERIC ORAL NSAIDS (MUST USE 2) 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 DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI : CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE CEREZYME METABOLIC, IMMUNE VPRIV DISORDERS OR INHERITED RARE DISEASE CICLODAN ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION, CICLOPIROX TOPICAL SOLUTION 8%, CICLOPIROX 8% TREATMENT KIT

23 CIMZIA INFLAMMATORY CONDITIONS - SC & ORAL RHEUMATOID ARTHRITIS: ACTEMRA SC, ENBREL, HUMIRA, XELJANZ/XR ANKYLOSING SPONDYLITIS: COSENTYX, ENBREL, HUMIRA JUVENILE IDIOPATHIC ARTHRITIS: ENBREL, HUMIRA PSORIATIC ARTHRITIS: COSENTYX, ENBREL, HUMIRA, STELARA PSORIASIS: COSENTYX, HUMIRA, OTEZLA, STELARA CROHN'S DISEASE: HUMIRA ULCERATIVE COLITIS: HUMIRA CLARIFOAM EF SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLEOCIN T SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLINDACIN ETZ SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLINDACIN PAC SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLINDAGEL SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL CLOBEX SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

24 CLODAN SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE CLODERM SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE CNL 8 NAIL KIT ANTI-FUNGAL GENERIC CICLODAN 8% TOPICAL SOLUTION, CICLOPIROX TOPICAL SOLUTION 8%, CICLOPIROX 8% TREATMENT KIT COLCHICINE CAPSULES GOUT COLCRYS, MITIGARE COLCHICINE TABLETS GOUT COLCRYS, MITIGARE CONCERTA ADHD GENERIC STIMULANT MEDICATIONS AMPHETAMINE/DEXTROAMPHETAM INE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED- RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED- RELEASE CAPSULES, METHYLPHENIDATE EXTENDED- RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS,

25 METHYLPHENIDATE EXTENDED- RELEASE TABLETS CONZIP PAIN TRAMADOL, TRAMADOL ER, TRAMADOL/ACETAMINOPHEN COPAXONE 20MG MULTIPLE SCLEROSIS AVONEX, BETASERON, COPAXONE 40 MG, EXTAVIA, GLATOPA, PLEGRIDY, REBIF CORDRAN SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE COZAAR HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, AND VALSARTAN/AMLODIPINE/HYDROCH LOROTHIAZIDE

26 CRESTOR HIGH BLOOD CHOLESTEROL ATORVASTATIN, LOVASTATIN, PRAVASTATIN, SIMVASTATIN, FLUVASTATIN, FLUVASTATIN EXTENDED-RELEASE, LIVALO, ROSUVASTATIN, AND ATORVASTATIN/AMLODIPINE CUTIVATE SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE CYMBALTA DEPRESSION REQUIRES USE OF ANY ONE (BRAND OR GENERIC SSRI) OR (GENERIC SNRI): SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD; SNRIS: VENLAFAXINE IR OR ER VENLAFAXINE IMMEDIATE-RELEASE TABLETS DAKLINZA HEPATITIS C HARVONI, VIEKIRA PAK, VIEKIRA XR

27 DAYPRO PAIN GENERIC NSAIDS (MUST USE TWO) RULE 1: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL DAYTRANA ADHD GENERIC STIMULANT MEDICATIONS AMPHETAMINE/DEXTROAMPHETAM INE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED- RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED- RELEASE CAPSULES, METHYLPHENIDATE EXTENDED- RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED- RELEASE TABLETS 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 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 SKIN CONDITIONS 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

28 BENZOYL DERMA-SMOOTH FS SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE DERMASORB HC SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

29 DERMASORB TA SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE DERMATOP SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE DESONATE SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE

30 DESOWEN SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE DESVENLAFAXINE ER DEPRESSION REQUIRES USE OF ANY ONE (BRAND OR GENERIC SSRI) OR (GENERIC SNRI): SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD; SNRIS: VENLAFAXINE IR OR ER VENLAFAXINE IMMEDIATE-RELEASE TABLETS DESVENLAFAXINE FUMARATE ER DEPRESSION REQUIRES USE OF ANY ONE (BRAND OR GENERIC SSRI) OR (GENERIC SNRI): SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD; SNRIS: VENLAFAXINE IR OR ER VENLAFAXINE IMMEDIATE-RELEASE

31 TABLETS DETROL OVERACTIVE BLADDER DARIFENACIN ER, GELNIQUE, MYRBETRIQ, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TOVIAZ, TROSPIUM, TROSPIUM ER, VESICARE DETROL LA OVERACTIVE BLADDER DARIFENACIN ER, GELNIQUE, MYRBETRIQ, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TOVIAZ, TROSPIUM, TROSPIUM ER, VESICARE DEXEDRINE ADHD GENERIC STIMULANT MEDICATIONS AMPHETAMINE/DEXTROAMPHETAM INE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED- RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED- RELEASE CAPSULES, METHYLPHENIDATE EXTENDED- RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED- RELEASE TABLETS 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

32 DICLOFENAC SODIUM 1% GEL PAIN GENERIC NSAIDS (MUST USE TWO) RULE 1: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL DIFFERIN SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL DIOVAN HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, AND VALSARTAN/AMLODIPINE/HYDROCH LOROTHIAZIDE DIOVAN HCT HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ,

33 VALSARTAN/AMLODIPINE, AND VALSARTAN/AMLODIPINE/HYDROCH LOROTHIAZIDE DIPROLENE SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE DIPROLENE/AF SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE DISKETS PAIN - NARCOTIC N/A DITROPAN XL OVERACTIVE BLADDER DARIFENACIN ER, GELNIQUE, MYRBETRIQ, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TOVIAZ, TROSPIUM, TROSPIUM ER, VESICARE DOLOPHINE PAIN - NARCOTIC N/A

34 DORYX ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE DORYX MPC ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE DOXYCYCLINE 40MG CAPSULES ANTI-INFECTIVE GENERIC AVIDOXY, DEMECLOCYCLINE, DOXYCYCLINE, DOXYCYCLINE DR, MINOCYCLINE, MINOCYCLINE ER, GENERIC MORGIDOX, GENERIC OCUDOX CONVENIENCE KIT, TETRACYCLINE DUAC SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL DUETACT DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN- CONTAINING PRODUCT (BRAND OR GENERIC) DUEXIS PAIN RULE 2 : MUST USE ONE OF BOTH OF THE FOLLOWING (BRAND OR GENERIC): PRESCRIPTION ORAL IBUPROFEN AND PRESCRIPTION ORAL FAMOTIDINE, CIMETIDINE, NIZATIDINE, OR RANITIDINE DURAGESIC PAIN - NARCOTIC N/A DURLAZA BLOOD MODIFYING TWO OTHER ASPIRIN PRODUCTS DUTASTERIDE BPH FINASTERIDE 5 MG DUTASTERIDE/TAMSULOSIN BPH FINASTERIDE 5 MG DYMISTA ALLERGIES BUDESONIDE (RX AND OTC), FLUNISOLIDE, FLUTICASONE, MOMETASONE, QNASL, TRIAMCINOLONE (RX AND OTC)

35 DYNAVEL XR ADHD GENERIC STIMULANT MEDICATIONS AMPHETAMINE/DEXTROAMPHETAM INE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED- RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED- RELEASE CAPSULES, METHYLPHENIDATE EXTENDED- RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED- RELEASE TABLETS EC-NAPROSYN PAIN GENERIC NSAIDS (MUST USE TWO) RULE 1: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL EDARBI HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, AND VALSARTAN/AMLODIPINE/HYDROCH LOROTHIAZIDE

36 EDARBYCLOR HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, AND VALSARTAN/AMLODIPINE/HYDROCH LOROTHIAZIDE EDLUAR SLEEP DISORDER ESZOPICLONE, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER EFFEXOR DEPRESSION REQUIRES USE OF ANY ONE (BRAND OR GENERIC SSRI) OR (GENERIC SNRI): SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD; SNRIS: VENLAFAXINE IR OR ER VENLAFAXINE IMMEDIATE-RELEASE TABLETS EFFEXOR XR DEPRESSION REQUIRES USE OF ANY ONE (BRAND OR GENERIC SSRI) OR (GENERIC SNRI): SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD;

37 SNRIS: VENLAFAXINE IR OR ER VENLAFAXINE IMMEDIATE-RELEASE TABLETS ELELYSO METABOLIC, IMMUNE VPRIV DISORDERS OR INHERITED RARE DISEASE ELESTAT EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE ELIDEL SKIN CONDITIONS REQUIRES USE OF ONE PRESCRIPTION TOPICAL CORTICOSTEROID FIRST (BRAND OR GENERIC): ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE ELOCON SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE,

38 MOMETASONE, PREDNICARBATE, TRIAMCINOLONE EMADINE EYE CONDITIONS AZELASTINE, EPINASTINE, OLOPATADINE EMBEDA PAIN - NARCOTIC N/A ENABLEX OVERACTIVE BLADDER DARIFENACIN ER, GELNIQUE, MYRBETRIQ, OXYBUTYNIN IR, OXYBUTYNIN ER, TOLTERODINE, TOLTERODINE ER, TOVIAZ, TROSPIUM, TROSPIUM ER, VESICARE ENBREL INFLAMMATORY CONDITIONS - SC & ORAL RHEUMATOID ARTHRITIS: ACTEMRA SC, ENBREL, HUMIRA, XELJANZ/XR ANKYLOSING SPONDYLITIS: COSENTYX, ENBREL, HUMIRA JUVENILE IDIOPATHIC ARTHRITIS: ENBREL, HUMIRA PSORIATIC ARTHRITIS: COSENTYX, ENBREL, HUMIRA, STELARA PSORIASIS: COSENTYX, HUMIRA, OTEZLA, STELARA CROHN'S DISEASE: HUMIRA ULCERATIVE COLITIS: HUMIRA ENVARSUS XR TRANSPLANT GENERIC TACROLIMUS EPCLUSA HEPATITIS C HARVONI, VIEKIRA PAK, VIEKIRA XR EPIDUO SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL EPIDUO FORTE SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL EPOGEN BLOOD CELL DEFICIENCY PROCRIT ESGIC PAIN GENERIC PRODUCT WITH BUTALBITAL ESOMEPRAZOLE STRONTIUM ULCER ESOMEPRAZOLE, LANSOPRAZOLE (RX AND OTC), OMEPRAZOLE (RX OR OTC), PANTOPRAZOLE,

39 RABEPRAZOLE EUCRISA SKIN CONDITIONS REQUIRES USE OF ONE PRESCRIPTION TOPICAL CORTICOSTEROID FIRST (BRAND OR GENERIC): ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE EVOCLIN SKIN CONDITIONS GENERIC PRESCRIPTION TOPICAL EVZIO PAIN-NARCOTIC NALOXONE 0.4 MG/ML VIAL, NALOXONE 0.4 MG/ML SYRINGE, NALOXONE 2 MG/2 ML SYRINGE EXALGO PAIN - NARCOTIC N/A EXELON PATCH EXELON TABLET NEUROLOGICAL DISORDERS NEUROLOGICAL DISORDERS GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS) GALANTAMINE, GALANTAMINE ER, RIVASTIGMINE, DONEPEZIL (DOES NOT INCLUDE DONEPEZIL 23 MG TABLETS) EXFORGE HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN,

40 VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, AND VALSARTAN/AMLODIPINE/HYDROCH LOROTHIAZIDE EXFORGE HCT HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, AND VALSARTAN/AMLODIPINE/HYDROCH LOROTHIAZIDE FARXIGA DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN- CONTAINING PRODUCT (BRAND OR GENERIC) FELDENE PAIN GENERIC NSAIDS (MUST USE TWO) RULE 1: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL FENOFIBRATE CAPSULES HIGH BLOOD CHOLESTEROL FENOFIBRATE, FENOFIBRIC ACID

41 FENOGLIDE HIGH BLOOD FENOFIBRATE, FENOFIBRIC ACID CHOLESTEROL FENOPROFEN(BRAND) PAIN GENERIC NSAIDS (MUST USE TWO) RULE 1: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL FETZIMA DEPRESSION REQUIRES USE OF ANY ONE (BRAND OR GENERIC SSRI) OR (GENERIC SNRI): SSRIS: CITALOPRAM (CELEXA), DULOXETINE (CYMBALTA), ESCITALOPRAM (LEXAPRO), FLUOXETINE (PROZAC, SARAFEM), FLUVOXAMINE IR OR ER (LUVOX CR), PAROXETINE IR OR ER (PAXIL, PAXIL CR), PEXEVA, SERTRALINE (ZOLOFT), TRINTELLIX (FORMERLY KNOWN AS BRINTELLIX), VIIBRYD; SNRIS: VENLAFAXINE IR OR ER VENLAFAXINE IMMEDIATE-RELEASE TABLETS FEXMID MUSCLE RELAXANT GENERIC CYCLOBENZAPRINE FIBRICOR HIGH BLOOD FENOFIBRATE, FENOFIBRIC ACID CHOLESTEROL FINACEA FOAM SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL FINACEA GEL SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL

42 FINACEA PLUS KIT SKIN CONDITIONS METRONIDAZOLE CREAM 0.75%, METRONIDAZOLE GEL 0.75% AND 1%, METRONIDAZOLE LOTION 0.75%, ROSADAN CREAM, ROSADAN GEL FIORICET PAIN GENERIC PRODUCT WITH BUTALBITAL FIORINAL PAIN GENERIC PRODUCT WITH BUTALBITAL FIORINAL WITH CODEINE PAIN GENERIC PRODUCT WITH BUTALBITAL FIRMAGON ELIGARD FLECTOR PATCH PAIN GENERIC NSAIDS (MUST USE TWO) RULE 1: DICLOFENAC (IR AND ER), DICLOFENAC TOPICAL SOLUTION 1.5%, ETODOLAC (IR AND ER), FENOPROFEN, FLURBIPROFEN, IBUPROFEN, INDOMETHACIN (IR AND ER), KETOPROFEN (IR AND ER), KETOROLAC (ORAL), MECLOFENAMATE, MEFENAMIC ACID, MELOXICAM, NABUMETONE, NAPROXEN (IR AND ER), OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN, DICLOFENAC SODIUM/MISOPROSTOL FLONASE ALLERGIES BUDESONIDE (RX AND OTC), FLUNISOLIDE, FLUTICASONE, MOMETASONE, QNASL, TRIAMCINOLONE (RX AND OTC) FLOWTUSS COUGH AND COLD GENERIC COUGH/COLD LIQUID FLUOXETINE 60MG TABLETS DEPRESSION REQUIRES USE OF ANY ONE GENERIC SSRI : CITALOPRAM, ESCITALOPRAM, FLUOXETINE, FLUOXETINE DR, FLUVOXAMINE, FLUVOXAMINE ER, PAROXETINE, PAROXETINE CR, SERTRALINE FOCALIN XR ADHD GENERIC STIMULANT MEDICATIONS AMPHETAMINE/DEXTROAMPHETAM INE EXTENDED-RELEASE CAPSULES, DEXMETHYLPHENIDATE EXTENDED- RELEASE CAPSULES, DEXTROAMPHETAMINE EXTENDED- RELEASE CAPSULES, METHYLPHENIDATE EXTENDED-

43 RELEASE CAPSULES, METADATE ER, METHYLPHENIDATE SUSTAINED- RELEASE TABLETS, METHYLPHENIDATE EXTENDED- RELEASE TABLETS FOLLISTIM AQ INFERTILITY FIRST: CLOMIPHENE CITRATE; SECOND: GONAL-F, GONAL-F RFF FORFIVO XL DEPRESSION BUPROPION SR, BUPROPION ER FORTAMET (BRAND AND GENERIC) DIABETES METFORMIN ER (GENERIC TO GLUCOPHAGE XR ONLY) FOSAMAX PLUS D BONE CONDITIONS ALENDRONATE, IBANDRONATE, RISEDRONATE FOSAMAX TABLETS BONE CONDITIONS ALENDRONATE, IBANDRONATE, RISEDRONATE FROVA MIGRAINE HEADACHES ALMOTRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN GANIRELIX INFERTILITY CETROTIDE GILENYA MULTIPLE SCLEROSIS AVONEX, BETASERON, COPAXONE 40 MG, EXTAVIA, GLATOPA, PLEGRIDY, REBIF GLASSIA METABOLIC, IMMUNE ARALAST NP DISORDERS OR INHERITED RARE DISEASE GLUCOPHAGE DIABETES METFORMIN IR GLUCOPHAGE XR (Brand) DIABETES METFORMIN ER (GENERIC TO GLUCOPHAGE XR ONLY) GLUMETZA (Brand and Generic) DIABETES STEP 1: METFORMIN ER (GENERIC TO GLUCOPHAGE XR ONLY) STEP 2: GLUCOPHAGE XR (BRAND), FORTAMET (BRAND AND GENERIC) GLYXAMBI DIABETES REQUIRES USE OF ANY ONE METFORMIN OR METFORMIN- CONTAINING PRODUCT (BRAND OR GENERIC) GONAL INFERTILITY FIRST: CLOMIPHENE CITRATE; SECOND: GONAL-F, GONAL-F RFF GONAL - F INFERTILITY FIRST: CLOMIPHENE CITRATE; SECOND: GONAL-F, GONAL-F RFF GRALISE NEUROLOGICAL GABAPENTIN

44 DISORDERS HALOG SKIN CONDITIONS REQUIRES USE OF TWO PRESCRIPTION GENERIC TOPICAL CORTICOSTEROIDS FIRST: ALCLOMETASONE, AMCINONIDE, BETAMETHASONE DIPROPIONATE (AUGMENTED), BETAMETHASONE DIPROPIONATE, BETAMETHASONE VALERATE, CLOBETASOL, DESONIDE, DESOXIMETASONE, DIFLORASONE, FLUOCINOLONE, FLUOCINONIDE, FLURANDRENOLIDE, FLUTICASONE, HALOBETASOL, HYDROCORTISONE, MOMETASONE, PREDNICARBATE, TRIAMCINOLONE HORIZANT NEUROLOGICAL GABAPENTIN DISORDERS HYCOFENIX COUGH AND COLD GENERIC COUGH/COLD LIQUID HYDROMORPHONE ER PAIN - NARCOTIC N/A HYSINGLA ER PAIN - NARCOTIC N/A HYZAAR HIGH BLOOD PRESSURE CANDESARTAN, CANDESARTAN/HCTZ, EPROSARTAN, IRBESARTAN, IRBESARTAN/HCTZ, LOSARTAN, LOSARTAN/HCTZ, OLMESARTAN TABLETS, OLMESARTAN/HCTZ TABLETS, OLMESARTAN/AMLODIPINE TABLETS, OLMESARTAN/AMLODIPINE/HCTZ TABLETS, TELMISARTAN, TELMISARTAN/AMLODIPINE, TELMISARTAN/HCTZ, VALSARTAN, VALSARTAN/HCTZ, VALSARTAN/AMLODIPINE, AND VALSARTAN/AMLODIPINE/HYDROCH LOROTHIAZIDE IMITREX (ORAL) MIGRAINE HEADACHES ALMOTRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN IMITREX INJECTION MIGRAINE HEADACHES ALMOTRIPTAN, FROVATRIPTAN, NARATRIPTAN, RIZATRIPTAN, SUMATRIPTAN, SUMATRIPTAN INJECTION, SUMATRIPTAN NASAL SPRAY, ZOLMITRIPTAN