NORE/ETH/FER CHW 0.MG Added to the 07 //07 ALYACEN TAB / Added to the 07 //07 AMETHIA LO TAB Added to the 07 //07 ERGOT/CAFFEN TAB 00MG Added to the 07 //07 NORETH/ETHIN TAB /0 Added to the 07 //07 LORCET HD TAB 0 MG Added to the 07 Quantity Limit (60 per 0 //07 PERTZYE CAP Added to the 07 //07 ALA CORT CRE.% Added to the 07 //07 FEMYNOR TAB 0. Added to the 07 //07 BYVALSON TAB 80MG Added to the 07 //07 August, 07 Revised July, 07 Page
ADRIAMYCIN INJ 0MG Added to the 07 B vs D Prior Auth //07 XIIDRA DRO % ADLYXIN INJ 0MCG ADLYXIN INJ 0/0MCG GAMASTAN S/D INJ GAMASTAN S/D INJ MICORT HC CRE.% VASCEPA CAP 0.GM YOSPRALA TAB 0MG YOSPRALA TAB 8 0MG Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Quantity Limit ( pens per 8 Quantity Limit ( pens per 8 //07 //07 //07 B vs D Prior Auth //07 B vs D Prior Auth //07 //07 //07 //07 //07 August, 07 Revised July, 07 Page
NAMZARIC CAP Added to the 07 //07 SOLIQUA INJ 00/ Added to the 07 Quantity Limit (0 pens per 0 //07 NYATA POW 00000 AFREZZA POW FLURANDRENOL LOT 0.0% ALLOPURINOL INJ 00MG MYCOPHENOLAT INJ 00MG OSELTAMIVIR CAP 7MG EZETIMIBE TAB 0MG APREPITANT CAP 80MG Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 //07 //07 //07 //07 B vs D Prior Auth //07 //07 //07 B vs D Prior Auth //07 August, 07 Revised July, 07 Page
APREPITANT CAP MG Added to the 07 B vs D Prior Auth //07 RASAGILINE TAB MG RASAGILINE TAB 0.MG APREPITANT CAP 0MG OSELTAMIVIR CAP 0MG OSELTAMIVIR CAP MG AZITHROMYCIN TAB 00MG APREPITANT PAK 80 & ALTOPREV TAB 60MG ER LOPIN/RITON SOL 80 0/ML Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 //07 //07 B vs D Prior Auth //07 //07 //07 //07 B vs D Prior Auth //07 //07 //07 August, 07 Revised July, 07 Page
FLUOCINONIDE CRE E 0.0% Added to the 07 //07 TIGECYCLINE INJ 0MG Added to the 07 //07 LEVETIRACETA INJ MG/ML Added to the 07 //07 EPANED SOL MG/ML DORIPENEM INJ 0MG Added to the 07 Added to the 07 //07 //07 DOCETAXEL INJ 80MG/ML Added to the 07 B vs D Prior Auth //07 DORIPENEM INJ 00MG Added to the 07 //07 TAYTULLA CAP Added to the 07 //07 TILIA FE TAB Added to the 07 //07 METFORMIN ER TAB 000MG Added to the 07 Quantity Limit (7 per 0 //07 August, 07 Revised July, 07 Page
LEVALBUTEROL NEB./0. LEVETIRACETA INJ MG/ML ETHYNODIOL TAB 0 FLUOXETINE TAB 0MG BROMSITE DRO 0.07% GENGRAF CAP 0MG LEVETIRACETA INJ 0MG/ML OMECLAMOX MIS PAK CERVARIX INJ Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 B vs D Prior Auth //07 //07 //07 //07 //07 B vs D Prior Auth //07 //07 //07 //07 Amoxicillin cap Clarithro tab Lansopraz cap dr Therapy Pack GARDASIL INJ August, 07 Revised July, 07 Page 6
STAVUDINE SOL MG/ML PLASMA LYTE INJ 6/DW A HYDROCORT INJ 00MG RAPIVAB INJ 00MG/0 MOXATAG TAB 77MG ALTABAX OIN % TRETIN X CRE 0.07% GONITRO POW 00MCG Added to the 07 //07 Zerit mg/ml Sol //07 PLASMA LYTE INJ 8 //07 Dexamethasone sod phosphate inj 00 mg/0ml //07 TAMIFLU CAP 7MG //07 Amoxicillin 00mg //07 Mupirocin Oint % //07 Tretin X Cream 0.07% //07 August, 07 Revised July, 07 Page 7
RUBRACA TAB 00MG Added to the 07 Prior Auth required //07 RUBRACA TAB 00MG Added to the 07 Prior Auth required //07 PRIMSOL SOL 0MG/ML Added to the 07 //07 SELZENTRY TAB MG Added to the 07 //07 SELZENTRY TAB 7MG Added to the 07 //07 FLUOXETINE TAB 0MG Added to the 07 //07 POT CL MICRO TAB 0MEQ ER Added to the 07 //07 POT CL MICRO TAB 0MEQ ER Added to the 07 //07 RAYALDEE CAP 0MCG Added to the 07 //07 August, 07 Revised July, 07 Page 8
POT CHLORIDE TAB 0MEQ ER POT CHLORIDE TAB 0MEQ ER NUTROPIN AQ INJ 0MG/ML CLAFORAN/DW INJ GM CLAFORAN INJ GM CLAFORAN INJ GM AMMONIUM CHL INJ MEQ/ML CAPITAL/COD SUS 0 / //07 POT CL MICRO TAB 0MEQ ER //07 POT CL MICRO TAB 0MEQ ER //07 NUTROPIN AQ INJ NUSPIN //07 CEFTAZIDIME/ SOL DW GM //07 //07 //07 //07 CEFOTAXIME SODIUM FOR INJ GM CEFOTAXIME SODIUM FOR INJ GM acetaminophen w/ codeine soln 0 mg/ml August, 07 Revised July, 07 Page 9
ONIVYDE INJ.MG/ML Added to the 07 B vs D Prior Auth //07 VEMLIDY TAB MG Added to the 07 //07 EUCRISA OIN % Added to the 07 Prior Auth Required //07 PIPER/TAZOBA INJ.GM Added to the 07 //07 LINZESS CAP 7MCG Added to the 07 //07 METHERGINE TAB 0.MG Added to the 07 //07 METHYLPHENID CAP 60MG LA Added to the 07 Quantity Limit (0 per 0 //07 DESVENLAFAX TAB MG ER Added to the 07 //07 DESVENLAFAX TAB 0MG ER Added to the 07 //07 August, 07 Revised July, 07 Page 0
DESVENLAFAX TAB 00MG ER PREDNISOLONE SOL 0MG/ML PREDNISOLONE SOL 0MG/ML MIBELAS CHW FE Added to the 07 Added to the 07 Added to the 07 Added to the 07 //07 B vs D Prior Auth //07 B vs D Prior Auth //07 //07 METHYLPR SS INJ MG Added to the 07 B vs D Prior Auth //07 METHYLPR SS INJ 000MG //07 METHYLPR SS INJ MG METFORMIN ER TAB 000MG DOCETAXEL INJ 0/7ML //07 metformin hcl tab sr hr osmotic 000 mg //07 DOCETAXEL INJ 60/8ML August, 07 Revised July, 07 Page
NUTROPIN AQ INJ 0MG/ML VITEKTA TAB 8MG VITEKTA TAB 0MG ATROPINE SUL INJ 0.MG/ML LEVOLEUCOVOR INJ 7MG FLURANDRENOL OIN 0.0% VYVANSE CHW 0MG VYVANSE CHW 0MG VYVANSE CHW 0MG VYVANSE CHW 0MG VYVANSE CHW 0MG Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 //07 NUTROPIN AQ INJ 0MG/ML //07 TIVICAY TAB MG //07 TIVICAY TAB 0MG 6//07 B vs D Prior Auth 6//07 Quantity Limit (60 per 0 Quantity Limit (60 per 0 Quantity Limit (60 per 0 Quantity Limit (0 per 0 Quantity Limit (0 per 0 6//07 6//07 6//07 6//07 6//07 6//07 August, 07 Revised July, 07 Page
VYVANSE CHW 60MG ZILEUTON ER TAB 600MG BUSULFAN INJ 6MG/ML MG SO/DW INJ 0MG/ML GAMMAPLEX INJ 0/00ML GAMMAPLEX INJ 0/00 GAMMAPLEX INJ G/0ML TAZAROTENE CRE 0.% RIVELSA TAB FAYOSIM TAB AZOR TAB 0 0MG Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Quantity Limit (0 per 0 6//07 6//07 B vs D Prior Auth 6//07 6//07 Prior Auth Required 6//07 Prior Auth Required 6//07 Prior Auth Required 6//07 Prior Auth Required 6//07 6//07 6//07 6//07 AMLOD/OLMES A TAB 0 0MG August, 07 Revised July, 07 Page
AZOR TAB 0 0MG AZOR TAB 0MG AZOR TAB 0MG TAMIFLU CAP MG TAMIFLU CAP 0MG TAMIFLU CAP 7MG XOPENEX HFA AER VAGIFEM TAB 0MCG 6//07 AMLOD/OLMES A TAB 0 0MG 6//07 AMLOD/OLMES A TAB 0MG 6//07 AMLOD/OLMES A TAB 0MG 6//07 OSELTAMIVIR CAP MG 6//07 OSELTAMIVIR CAP 0MG 6//07 OSELTAMIVIR CAP 7MG 6//07 LEVALBUTEROL AER /ACT 6//07 YUVAFEM TAB 0MCG August, 07 Revised July, 07 Page
ILOTYCIN OIN OP NITROSTAT SUB 0.6MG NITROSTAT SUB 0.MG NITROSTAT SUB 0.MG BENICAR TAB MG BENICAR TAB 0MG BENICAR TAB 0MG BENICAR HCT TAB 0. 6//07 ERYTHROMYCIN OIN OP 6//07 NITROGLYCERI SUB 0.6MG 6//07 NITROGLYCERN SUB 0.MG 6//07 NITROGLYCERN SUB 0.MG 6//07 6//07 6//07 OLMESA MEDOX TAB MG OLMESA MEDOX TAB 0MG OLMESA MEDOX TAB 0MG 6//07 OLM MED/HCTZ TAB 0. August, 07 Revised July, 07 Page
BENICAR HCT TAB 0 MG BENICAR HCT TAB 0. NILANDRON TAB 0MG CAFERGOT TAB 00MG ASACOL HD TAB 800MG AMETHYST TAB 90 0MCG ZETIA TAB 0MG SEROQUEL XR TAB 0MG 6//07 OLM MED/HCTZ TAB 0 MG 6//07 OLM MED/HCTZ TAB 0. 6//07 NILUTAMIDE TAB 0MG 6//07 ERGOT/CAFFEN TAB 00MG 6//07 MESALAMINE TAB 800MG DR 6//07 LEVO ETH EST TAB 90 0MCG 6//07 EZETIMIBE TAB 0MG 6//07 QUETIAPINE TAB 0MG ER August, 07 Revised July, 07 Page 6
SEROQUEL XR TAB 0MG SEROQUEL XR TAB 00MG SEROQUEL XR TAB 00MG SEROQUEL XR TAB 00MG TRIBENZOR0 TAB.MG TRIBENZOR0 TAB 0 MG TRIBENZOR0 TAB 0. TRIBENZOR0 TAB.MG 6//07 QUETIAPINE TAB 0MG ER 6//07 QUETIAPINE TAB 00MG ER 6//07 QUETIAPINE TAB 00MG ER 6//07 QUETIAPINE TAB 00MG ER 6//07 6//07 6//07 6//07 OLM MED/AMLO TAB /HCTZ OLM MED/AMLO TAB /HCTZ OLM MED/AMLO TAB /HCTZ OLM MED/AMLO TAB /HCTZ August, 07 Revised July, 07 Page 7
TRIBENZOR0 TAB MG AZILECT TAB 0.MG AZILECT TAB MG EPZICOM TAB 600 00 ALOGLIPTIN TAB MG ALOGLIPTIN TAB 6.MG ALOGLIPTIN TAB.MG ALOGLIPTIN/ TAB METFORM ALOGLIPTIN/ TAB METFORM ALOG/PIOGLIP TAB. Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Quantity Limit (0 per 0 Quantity Limit (0 per 0 Quantity Limit (60 per 0 Quantity Limit (60 per 0 Quantity Limit (60 per 0 Quantity Limit (60 per 0 6//07 OLM MED/AMLO TAB /HCTZ 6//07 RASAGILINE TAB 0.MG 6//07 RASAGILINE TAB MG 6//07 ABACA/LAMIVU TAB 600 00 7//07 7//07 7//07 7//07 7//07 7//07 August, 07 Revised July, 07 Page 8
ALOG/PIOGLIP TAB. 0 ALOG/PIOGLIT TAB. ALOG/PIOGLIT TAB MG ALOG/PIOGLIT TAB 0MG ALOG/PIOGLIT TAB MG VIBATIV INJ 70MG ESBRIET TAB 67MG ESBRIET TAB 80MG KISQALI TAB 00DOSE KISQALI TAB 00DOSE KISQALI TAB 600DOSE KINRIX INJ Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Quantity Limit (0 per 0 Quantity Limit (0 per 0 Quantity Limit (0 per 0 Quantity Limit (0 per 0 Quantity Limit (0 per 0 Prior Auth required Prior Auth required New Start Prior Auth required New Start Prior Auth required New Start Prior Auth required 7//07 7//07 7//07 7//07 7//07 7//07 7//07 7//07 7//07 7//07 7//07 7//07 August, 07 Revised July, 07 Page 9
SYNJARDY XR TAB 000MG SYNJARDY XR TAB 000 ROWEEPRA TAB 000MG EZETIM/SIMVA TAB 0 0MG NORETH/ETHIN CHW FE /0 EZETIM/SIMVA TAB 0 80MG ROWEEPRA TAB 70MG ZEJULA CAP 00MG SYNJARDY XR TAB 0 000 EZETIM/SIMVA TAB 0 0MG SYNJARDY XR TAB ZYTIGA TAB 00MG Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Quantity Limit (60 per 0 Quantity Limit (0 per 0 New Start Prior Auth required Quantity Limit (60 per 0 Quantity Limit (60 per 0 New Start Prior Auth required 7//07 7//07 7//07 7//07 7//07 7//07 7//07 7//07 7//07 7//07 7//07 7//07 August, 07 Revised July, 07 Page 0
HERCEPTIN INJ 0MG DOCETAXEL INJ 00/0 EZETIM/SIMVA TAB 0 0MG UVADEX INJ 0MCG/ML Added to the 07 Added to the 07 Added to the 07 New Start Prior Auth 7//07 required B vs D Prior Auth 7//07 7//07 7//07 AUSTEDO TAB 6MG AUSTEDO TAB 9MG AUSTEDO TAB MG Added to the 07 Added to the 07 Added to the 07 Prior Auth Required; Quantity Limit (60 per 0 Prior Auth Required; Quantity Limit (0 per 0 Prior Auth Required; Quantity Limit (0 per 0 8//07 8//07 8//07 RYDAPT CAP MG Added to the 07 New Start Prior Auth Required 8//07 ALUNBRIG TAB 0MG XATMEP SOL.MG/ML Added to the 07 Added to the 07 New Start Prior Auth Required B vs D Prior Auth 8//07 8//07 August, 07 Revised July, 07 Page
KISQALI 00 PAK FEMARA KISQALI 00 PAK FEMARA KISQALI 600 PAK FEMARA CLOFARABINE INJ 0/0ML ATOMOXETINE CAP 0MG ATOMOXETINE CAP 8MG ATOMOXETINE CAP MG ATOMOXETINE CAP 0MG ATOMOXETINE CAP 60MG ATOMOXETINE CAP 80MG ATOMOXETINE CAP 00MG RUBRACA TAB 0MG Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 Added to the 07 New Start Prior Auth Required New Start Prior Auth Required New Start Prior Auth Required B vs D Prior Auth Quantity Limit (0 per 0 Quantity Limit (0 per 0 Quantity Limit (0 per 0 Quantity Limit (60 per 0 Quantity Limit (0 per 0 Quantity Limit (0 per 0 Quantity Limit (0 per 0 New Start Prior Auth 8//07 8//07 8//07 8//07 8//07 8//07 8//07 8//07 8//07 8//07 8//07 8//07 August, 07 Revised July, 07 Page
ZUBSOLV SUB 0.7 0.8 OLOPATADINE SOL 0.% POT CHLORIDE POW 0MEQ ATROPINE SUL INJ 0.MG/ML AMINOSYN II INJ 7% DOCETAXEL INJ 00MG/0 KLOR CON POW 0MEQ Added to the 07 Added to the 07 Added to the 07 Prior Auth Required; Quantity Limit (90 per 0 8//07 8//07 8//07 8//07 ATROPINE SULFATE SOLN PREFILL SYR MG/0ML (0. MG/ML) 8//07 AMINOSYN HBC INJ 7% 8//07 DOCETAXEL INJ 00/0 8//07 POT CHLORIDE POW 0MEQ August, 07 Revised July, 07 Page