DAY VAGINL CRE CLOTRIMAZOLE VAGINAL CREAM Azoles by liaoqinmei

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									                                                                                                                 Max Qty
                                                                                                                   Limit   Max Max Age
                                                                                                                 (Liquids Days    Limit    Step        Step Therapy     Specialty
    Drug/Product Name                        Generic Name                             Therapy Class               in mLs) Supply (Years) Required?     Requirement        Drug         Coverage Status
     3 DAY VAGINL CRE 2%             CLOTRIMAZOLE VAGINAL CREAM 2%                          Azoles                  23     30
   8 HOUR PAIN TAB 650MG               ACETAMINOPHEN TAB CR 650 MG           Analgesics and Antipyretics, Misc     120     30
       A + D PERSON LOT                     *EMOLLIENT - LOTION**               Basic Lotions and Liniments                30                                                       Prior Authorization Req'd
        A/B OTIC SOL            BENZOCAINE-ANTIPYRINE OTIC SOLN 1.4-5.4%             Local Anesthetics                     30
A/BETA CAROT CAP 25000UNT              BETA CAROTENE CAP 25000 UNIT                       Vitamin A                        30
      A-200     AER 0.5%                  PERMETHRIN AEROSOL 0.5%              Scabicides and Pediculicides        142     30
       A-200 MAX ST LIQ         PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.33-4%      Scabicides and Pediculicides        120     30
 A-CARO-25 CAP 25000UNT                BETA CAROTENE CAP 25000 UNIT                       Vitamin A                        30
    ACCOLATE TAB 20MG                       ZAFIRLUKAST TAB 20 MG                  Leukotriene Modifiers                   30                                                       Prior Authorization Req'd
    ACCU-CHEK KIT ACTIVE           *BLOOD GLUCOSE MONITORING KIT***                        Devices                         30
 ACCU-CHEK KIT ADVANTAG       *BLOOD GLUCOSE MONITORING KIT W/ DEVICE***                   Devices                         30
  ACCU-CHEK KIT COMPACT            *BLOOD GLUCOSE MONITORING KIT***                        Devices                         30
 ACCU-CHEK KIT VOICEMAT       *BLOOD GLUCOSE MONITORING KIT W/ DEVICE***                   Devices                         30
 ACCU-CHEK LIQ CPT/GLUC          *BLOOD GLUCOSE CALIBRATION - LIQUID***                    Devices                         30
 ACCU-CHEK MIS TRANSFER          *BLOOD GLUCOSE MONITORING DEVICES***                      Devices                         30
   ACETAMIN CAP 500MG                    ACETAMINOPHEN CAP 500 MG            Analgesics and Antipyretics, Misc     250     30
  ACETAMIN CHW 160MG                 ACETAMINOPHEN CHEW TAB 160 MG           Analgesics and Antipyretics, Misc      60     30
   ACETAMIN CHW 80MG                 ACETAMINOPHEN CHEW TAB 80 MG            Analgesics and Antipyretics, Misc      60     30
 ACETAMIN CHW 80MG FRT               ACETAMINOPHEN CHEW TAB 80 MG            Analgesics and Antipyretics, Misc      60     30
ACETAMIN DRO 100MG/ML                ACETAMINOPHEN SOLN 100 MG/ML            Analgesics and Antipyretics, Misc      30     30
 ACETAMIN DRO 80/0.8ML              ACETAMINOPHEN SUSP 80 MG/0.8ML           Analgesics and Antipyretics, Misc      30     30
  ACETAMIN ELX 160/5ML              ACETAMINOPHEN ELIXIR 160 MG/5ML          Analgesics and Antipyretics, Misc     240     30
  ACETAMIN LIQ 160/5ML              ACETAMINOPHEN LIQUID 160 MG/5ML          Analgesics and Antipyretics, Misc     240     30
  ACETAMIN LIQ 500/15ML             ACETAMINOPHEN LIQUID 167 MG/5ML          Analgesics and Antipyretics, Misc     240     30
  ACETAMIN SOL 160/5ML               ACETAMINOPHEN SOLN 160 MG/5ML           Analgesics and Antipyretics, Misc     240     30
   ACETAMIN TAB 325MG                    ACETAMINOPHEN TAB 325 MG            Analgesics and Antipyretics, Misc     250     30
   ACETAMIN TAB 500MG                    ACETAMINOPHEN TAB 500 MG            Analgesics and Antipyretics, Misc     250     30
 ACETAMIN TAB 500MG ES                   ACETAMINOPHEN TAB 500 MG            Analgesics and Antipyretics, Misc     250     30
 ACETAMIN TAB 650MG CR                 ACETAMINOPHEN TAB CR 650 MG           Analgesics and Antipyretics, Misc     120     30
ACETAMIN JR CHW 160MG FR             ACETAMINOPHEN CHEW TAB 160 MG           Analgesics and Antipyretics, Misc      60     30
ACETAMINOPHN SUS 160/5ML             ACETAMINOPHEN SUSP 160 MG/5ML           Analgesics and Antipyretics, Misc     240     30
 ACETAMINOPHN SUS 325MG              ACETAMINOPHEN SUSP 160 MG/5ML           Analgesics and Antipyretics, Misc     240     30
 ACETAMINOPHN SUS 650MG              ACETAMINOPHEN SUSP 160 MG/5ML           Analgesics and Antipyretics, Misc     240     30
    ACETASOL HC SOL OTIC      HYDROCORTISONE W/ ACETIC ACID OTIC SOLN 1-2%             Corticosteroids                     30
 ACETAZOLAMID CAP 500MG             ACETAZOLAMIDE CAP SR 12HR 500 MG         CARBONIC ANYDRASE INHIBITORS                  30
 ACETAZOLAMID TAB 125MG                  ACETAZOLAMIDE TAB 125 MG            CARBONIC ANYDRASE INHIBITORS                  30
 ACETAZOLAMID TAB 250MG                  ACETAZOLAMIDE TAB 250 MG            CARBONIC ANYDRASE INHIBITORS                  30
  ACETIC ACID DRO /HC OTIC    HYDROCORTISONE W/ ACETIC ACID OTIC SOLN 1-2%             Corticosteroids                     30
   ACETIC ACID SOL /HC EAR    HYDROCORTISONE W/ ACETIC ACID OTIC SOLN 1-2%             Corticosteroids                     30
  ACETIC ACID SOL /HC OTIC    HYDROCORTISONE W/ ACETIC ACID OTIC SOLN 1-2%             Corticosteroids                     30
   ACETIC ACID SOL 2% OTIC                 ACETIC ACID OTIC SOLN 2%             EENT Drugs, Miscellaneous                  30
   ACID CONTROL TAB 75MG                  RANITIDINE HCL TAB 75 MG               Histamine H2-Antagonists          60      30
   ACID REDUCER TAB 75MG                  RANITIDINE HCL TAB 75 MG               Histamine H2-Antagonists          60      30
    ACLOVATE OIN 0.05%           ALCLOMETASONE DIPROPIONATE OINT 0.05%           Anti-inflammatory Agents                  30                                                       Prior Authorization Req'd
        A-COF DH SYP         HYDROCODONE-GUAIFENESIN SYRUP 3.5-300 MG/5ML               Antitussives               178     30
   ACT FLUORIDE SOL 0.05%               SODIUM FLUORIDE RINSE 0.05%          Miscellaneous Therapeutic Agents              30      18
ACT FLUORIDE SOL CINNAMON               SODIUM FLUORIDE RINSE 0.05%          Miscellaneous Therapeutic Agents              30      18
    ACT FLUORIDE SOL MINT               SODIUM FLUORIDE RINSE 0.05%          Miscellaneous Therapeutic Agents              30      18
    ACT FOR KIDS SOL RINSE              SODIUM FLUORIDE RINSE 0.05%          Miscellaneous Therapeutic Agents              30      18
    ACT TOTAL SOL 0.05%                 SODIUM FLUORIDE RINSE 0.05%          Miscellaneous Therapeutic Agents              30      18
       ACTICIN CRE 5%                       PERMETHRIN CREAM 5%                Scabicides and Pediculicides        60      30
    ACTONEL TAB 150MG                 RISEDRONATE SODIUM TAB 150 MG             Bone Resorption Inhibitors                 30                                                       Prior Authorization Req'd
     ACTONEL TAB 30MG                 RISEDRONATE SODIUM TAB 30 MG              Bone Resorption Inhibitors                 30                                                       Prior Authorization Req'd
     ACTONEL TAB 35MG                 RISEDRONATE SODIUM TAB 35 MG              Bone Resorption Inhibitors                 30                                                       Prior Authorization Req'd
     ACTONEL TAB 5MG                   RISEDRONATE SODIUM TAB 5 MG              Bone Resorption Inhibitors                 30                                                       Prior Authorization Req'd
     ACTONEL TAB 75MG                 RISEDRONATE SODIUM TAB 75 MG              Bone Resorption Inhibitors                 30                                                       Prior Authorization Req'd




                                                                                                                                                      USE METFORMIN
                                                                                                                                                          AND/OR
    ACTOS    TAB 15MG            PIOGLITAZONE HCL TAB 15 MG (BASE EQUIV)            Thiazolidinediones                     30                Y       SULFONYLUREA 1ST
                                                                                                                                           Max Qty
                                                                                                                                             Limit   Max Max Age
                                                                                                                                           (Liquids Days    Limit    Step        Step Therapy     Specialty
    Drug/Product Name                                 Generic Name                                         Therapy Class                    in mLs) Supply (Years) Required?     Requirement        Drug         Coverage Status




                                                                                                                                                                                USE METFORMIN
                                                                                                                                                                                    AND/OR
    ACTOS    TAB 30MG                    PIOGLITAZONE HCL TAB 30 MG (BASE EQUIV)                          Thiazolidinediones                         30                Y       SULFONYLUREA 1ST




                                                                                                                                                                                USE METFORMIN
                                                                                                                                                                                    AND/OR
     ACTOS      TAB 45MG                   PIOGLITAZONE HCL TAB 45 MG (BASE EQUIV)                        Thiazolidinediones                         30                Y       SULFONYLUREA 1ST
     ACUVAIL SOL 0.45%                   KETOROLAC TROMETHAMINE OPHTH SOLN 0.45%                Nonsteroidal Anti-inflammatory Agents        10      30
   ACYCLOVIR CAP 200MG                                 ACYCLOVIR CAP 200 MG                          Nucleosides and Nucleotides                     30
  ACYCLOVIR SUS 200/5ML                             ACYCLOVIR SUSP 200 MG/5ML                        Nucleosides and Nucleotides                     30      12
   ACYCLOVIR TAB 400MG                                 ACYCLOVIR TAB 400 MG                          Nucleosides and Nucleotides                     30
   ACYCLOVIR TAB 800MG                                 ACYCLOVIR TAB 800 MG                          Nucleosides and Nucleotides                     30
 ADC/FLUORIDE DRO 0.25MG          *PEDIATRIC VITAMINS ACD W/ FLUORIDE SOLN 0.25 MG/ML***              Multivitamin Preparations                      30      18
   ADDAPRIN TAB 200MG                                  IBUPROFEN TAB 200 MG                   Other Nonsteroidal Anti-inflammtory Agents             30
   ADLT ASA LOW TAB 81MG                       ASPIRIN TAB DELAYED RELEASE 81 MG                               Salicylates                   31      30
 ADLT ASA LOW TAB 81MG EC                      ASPIRIN TAB DELAYED RELEASE 81 MG                               Salicylates                   31      30
    ADPRIN B TAB 325MG              ASPIRIN BUFFERED (CA CARB-MG CARB-MG OX) TAB 325 MG                        Salicylates                   31      30
      ADV NATALCAR TAB             *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***               Multivitamin Preparations                      30
  ADVAIR DISKU AER 100/50         FLUTICASONE-SALMETEROL AER POWDER BA 100-50 MCG/DOSE           Selective beta-2-Adrenergic Agonists        60      30                                                       Prior Authorization Req'd
  ADVAIR DISKU AER 250/50         FLUTICASONE-SALMETEROL AER POWDER BA 250-50 MCG/DOSE           Selective beta-2-Adrenergic Agonists        60      30                                                       Prior Authorization Req'd
  ADVAIR DISKU AER 500/50         FLUTICASONE-SALMETEROL AER POWDER BA 500-50 MCG/DOSE           Selective beta-2-Adrenergic Agonists        60      30                                                       Prior Authorization Req'd
   ADVAIR HFA AER 115/21           FLUTICASONE-SALMETEROL INHAL AEROSOL 115-21 MCG/ACT           Selective beta-2-Adrenergic Agonists        60      30                                                       Prior Authorization Req'd
   ADVAIR HFA AER 230/21           FLUTICASONE-SALMETEROL INHAL AEROSOL 230-21 MCG/ACT           Selective beta-2-Adrenergic Agonists        60      30                                                       Prior Authorization Req'd
    ADVAIR HFA AER 45/21            FLUTICASONE-SALMETEROL INHAL AEROSOL 45-21 MCG/ACT           Selective beta-2-Adrenergic Agonists        60      30                                                       Prior Authorization Req'd
  ADVANCED TAB CARE PLS        *PRENATAL WITHOUT A W/ FE ASPARTO GLY-DOC-FA TAB 30-1MG***             Multivitamin Preparations                      30      40
ADVANCED-RF TAB NATALCAR      *PRENATAL WITHOUT A W/ FE CARBONYL-DOCUSATE-FA TAB 90-1MG***            Multivitamin Preparations                      30      40
    ADVIL JR ST TAB 100MG                              IBUPROFEN TAB 100 MG                   Other Nonsteroidal Anti-inflammtory Agents             30
   ADVIL JR STR CHW 100MG                          IBUPROFEN CHEW TAB 100 MG                  Other Nonsteroidal Anti-inflammtory Agents             30
 AEROCHAMBER KIT ACTION                  PEAK FLOW METER W/INHALER ASSIST DEVICE KIT                            Devices                              30
 AF-APAP INFA DRO 80/0.8ML                     ACETAMINOPHEN SUSP 80 MG/0.8ML                      Analgesics and Antipyretics, Misc         30      30
 AF-ASPIRIN CHW CHILDREN                              ASPIRIN CHEW TAB 81 MG                                   Salicylates                   31      30
   AFEDITAB TAB 30MG CR                            NIFEDIPINE TAB SR 24HR 30 MG                            Dihydropyridines                          30
   AFEDITAB TAB 60MG CR                            NIFEDIPINE TAB SR 24HR 60 MG                            Dihydropyridines                          30
 AF-IBUPROFEN DRO INFANT                             IBUPROFEN SUSP 40 MG/ML                  Other Nonsteroidal Anti-inflammtory Agents             30      18
  AF-IBUPROFEN TAB 200MG                               IBUPROFEN TAB 200 MG                   Other Nonsteroidal Anti-inflammtory Agents             30
    AFLURIA INJ 2007-08                         INFLUENZA VIRUS VACCINE SPLIT INJ                               Vaccines                             30
    AFLURIA INJ 2008-09                         INFLUENZA VIRUS VACCINE SPLIT INJ                               Vaccines                             30
    AFLURIA INJ 2009-10                         INFLUENZA VIRUS VACCINE SPLIT INJ                               Vaccines                             30
    AFLURIA INJ PF 07-08              INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                       Vaccines                             30
    AFLURIA INJ PF 08-09              INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                       Vaccines                             30
    AFLURIA INJ PF 10-11              INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                       Vaccines                             30
AF-PSEUDOEPH CAP NON-DRSY                PSEUDOEPHEDRINE-GUAIFENESIN CAP 30-200 MG                           Expectorants                            30
  AF-PSEUDOEPH TAB 30MG                          PSEUDOEPHEDRINE HCL TAB 30 MG                   alpha- and beta-Adrenergic Agonists         120     30
 AF-TUSSIN DM LIQ 100-10/5         DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                          Antitussives                   180     30
 AF-TUSSIN DM SYP 100-10/5          DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                          Antitussives                   180     30
    AGRIFLU INJ 2009-10           INFLUENZA VIRUS VACCINE TYPES A & B PRESERVATIVE FREE INJ                     Vaccines                             30
    AGRIFLU INJ 2010-11           INFLUENZA VIRUS VACCINE TYPES A & B PRESERVATIVE FREE INJ                     Vaccines                             30
   AIMSCO      MIS LUBRICAT                         CONDOMS LATEX LUBRICATED                                Contraceptives                           30
     AK-POLY-BAC OIN OP                       BACITRACIN-POLYMYXIN B OPHTH OINT                              Antibacterials                          30
    AK-TOB     SOL 0.3% OP                   TOBRAMYCIN SULFATE OPHTH SOLN 0.3%                              Antibacterials                          30
   AL/MAG/SIMET SUS X-STR       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML                Antacids and Adsorbents               480     30
      ALA CORT CRE 1%                               HYDROCORTISONE CREAM 1%                           Anti-inflammatory Agents                       30
       ALA DERM LOT                                    *EMOLLIENT - LOTION**                         Basic Lotions and Liniments                     30                                                       Prior Authorization Req'd
      ALA-CORT LOT 1%                               HYDROCORTISONE LOTION 1%                          Anti-inflammatory Agents                       30
        ALAGESIC CAP                BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-325-40 MG             Analgesics and Antipyretics, Misc          20     30
       ALAMAG       SUS          ALUMINUM & MAGNESIUM HYDROXIDES SUSP 225-200 MG/5ML                   Antacids and Adsorbents               480     30
      ALAMAG PLUS SUS           ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 225-200-25 MG/5ML                Antacids and Adsorbents               480     30
        ALAVERT SYP                                LORATADINE SYRUP 5 MG/5ML                      Second Generation Antihistamines                   30
     ALAVERT TAB 10MG                                  LORATADINE TAB 10 MG                       Second Generation Antihistamines                   30
    ALBUMIN HUM INJ 25%                               ALBUMIN HUMAN INJ 25%                                Blood Derivatives                         30                                                       Prior Authorization Req'd
                                                                                                                              Max Qty
                                                                                                                                Limit   Max Max Age
                                                                                                                              (Liquids Days    Limit    Step      Step Therapy   Specialty
   Drug/Product Name                             Generic Name                                    Therapy Class                 in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
   ALBUMINAR-25 INJ 25%                         ALBUMIN HUMAN INJ 25%                            Blood Derivatives                      30                                                   Prior Authorization Req'd
   ALBUMIN-ZLB SOL 25%                          ALBUMIN HUMAN INJ 25%                            Blood Derivatives                      30                                                   Prior Authorization Req'd
     ALBUTEIN INJ 25%                           ALBUMIN HUMAN INJ 25%                            Blood Derivatives                      30                                                   Prior Authorization Req'd
  ALBUTEROL NEB 0.083%            ALBUTEROL SULFATE SOLN NEBU 0.083% (2.5 MG/3ML)      Selective beta-2-Adrenergic Agonists     180     30
   ALBUTEROL NEB 0.5%               ALBUTEROL SULFATE SOLN NEBU 0.5% (5 MG/ML)         Selective beta-2-Adrenergic Agonists     180     30
ALBUTEROL NEB 0.63MG/3         ALBUTEROL SULFATE SOLN NEBU 0.63 MG/3ML (BASE EQUIV)    Selective beta-2-Adrenergic Agonists     180     30
ALBUTEROL NEB 1.25MG/3         ALBUTEROL SULFATE SOLN NEBU 1.25 MG/3ML (BASE EQUIV)    Selective beta-2-Adrenergic Agonists     180     30
ALBUTEROL SYP 2MG/5ML                    ALBUTEROL SULFATE SYRUP 2 MG/5ML              Selective beta-2-Adrenergic Agonists             30      18
   ALBUTEROL TAB 2MG                          ALBUTEROL SULFATE TAB 2 MG               Selective beta-2-Adrenergic Agonists             30
   ALBUTEROL TAB 4MG                          ALBUTEROL SULFATE TAB 4 MG               Selective beta-2-Adrenergic Agonists             30
ALCLOMETASON CRE 0.05%               ALCLOMETASONE DIPROPIONATE CREAM 0.05%                 Anti-inflammatory Agents                    30                                                   Prior Authorization Req'd
ALCLOMETASON OIN 0.05%                ALCLOMETASONE DIPROPIONATE OINT 0.05%                 Anti-inflammatory Agents                    30                                                   Prior Authorization Req'd
    ALCOHOL PAD PREP                              *ALCOHOL SWABS***                                   Devices                           30
  ALCOHOL PAD SWABS                               *ALCOHOL SWABS***                                   Devices                           30
     ALCOHOL PREP PAD                             *ALCOHOL SWABS***                                   Devices                           30
     ALCOHOL SWAB PAD                             *ALCOHOL SWABS***                                   Devices                           30
     ALCOHOL WIPE PAD                             *ALCOHOL SWABS***                                   Devices                           30
     ALDROXICON SUS II      ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML          Antacids and Adsorbents            480     30
      ALDROXICON I SUS      ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML          Antacids and Adsorbents            480     30
 ALENDRONATE TAB 10MG                      ALENDRONATE SODIUM TAB 10 MG                     Bone Resorption Inhibitors                  30                                                   Prior Authorization Req'd
 ALENDRONATE TAB 35MG                      ALENDRONATE SODIUM TAB 35 MG                     Bone Resorption Inhibitors                  30                                                   Prior Authorization Req'd
 ALENDRONATE TAB 40MG                      ALENDRONATE SODIUM TAB 40 MG                     Bone Resorption Inhibitors                  30                                                   Prior Authorization Req'd
  ALENDRONATE TAB 5MG                       ALENDRONATE SODIUM TAB 5 MG                     Bone Resorption Inhibitors                  30                                                   Prior Authorization Req'd
 ALENDRONATE TAB 70MG                      ALENDRONATE SODIUM TAB 70 MG                     Bone Resorption Inhibitors                  30                                                   Prior Authorization Req'd
   ALER-CAP CAP 25MG                       DIPHENHYDRAMINE HCL CAP 25 MG                    Ethanolamine Derivatives                    30
   ALER-DRYL TAB 50MG                      DIPHENHYDRAMINE HCL TAB 50 MG                    Ethanolamine Derivatives                    30
    ALERTAB TAB 25MG                       DIPHENHYDRAMINE HCL TAB 25 MG                    Ethanolamine Derivatives                    30
   ALER-TAB TAB 25MG                       DIPHENHYDRAMINE HCL TAB 25 MG                    Ethanolamine Derivatives                    30
 ALFERON N INJ 5MU/ML                  INTERFERON ALFA-N3 INJ 5000000 UNIT/ML                  Antineoplastic Agents                    30                                       Specialty   Prior Authorization Req'd
   ALFURIA INJ PF 09-10          INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                 Vaccines                           30
    ALKERAN TAB 2MG                               MELPHALAN TAB 2 MG                           Antineoplastic Agents                    30
 ALL DAY ALLG SOL 1MG/ML               CETIRIZINE HCL SYRUP 1 MG/ML (5 MG/5ML)          Second Generation Antihistamines                30      9
ALL DAY ALLG SOL 5MG/5ML               CETIRIZINE HCL SYRUP 1 MG/ML (5 MG/5ML)          Second Generation Antihistamines                30      9
 ALL DAY ALLG SYP 1MG/ML               CETIRIZINE HCL SYRUP 1 MG/ML (5 MG/5ML)          Second Generation Antihistamines                30      9
ALL DAY ALLG SYP 5MG/5ML               CETIRIZINE HCL SYRUP 1 MG/ML (5 MG/5ML)          Second Generation Antihistamines                30      9
  ALL DAY ALLG TAB 10MG                         CETIRIZINE HCL TAB 10 MG                Second Generation Antihistamines                30
  ALLERCLEAR TAB 10MG                            LORATADINE TAB 10 MG                   Second Generation Antihistamines                30
    ALLERGEN SOL OTIC                 BENZOCAINE-ANTIPYRINE OTIC SOLN 1.4-5.4%                   Local Anesthetics                      30
    ALLERGY CAP 25MG                       DIPHENHYDRAMINE HCL CAP 25 MG                    Ethanolamine Derivatives                    30
    ALLERGY TAB 10MG                             LORATADINE TAB 10 MG                   Second Generation Antihistamines                30
    ALLERGY TAB 25MG                       DIPHENHYDRAMINE HCL TAB 25 MG                    Ethanolamine Derivatives                    30
  ALLERGY MED CAP 25MG                     DIPHENHYDRAMINE HCL CAP 25 MG                    Ethanolamine Derivatives                    30
ALLERGY MEDI LIQ 12.5/5ML             DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                Ethanolamine Derivatives                    30
  ALLERGY RELF CAP 25MG                    DIPHENHYDRAMINE HCL CAP 25 MG                    Ethanolamine Derivatives                    30
ALLERGY RELF LIQ 12.5/5ML             DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                Ethanolamine Derivatives                    30
ALLERGY RELF LIQ CHILDREN             DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                Ethanolamine Derivatives                    30
ALLERGY RELF SOL 5MG/5ML               CETIRIZINE HCL SYRUP 1 MG/ML (5 MG/5ML)          Second Generation Antihistamines                30      9
ALLERGY RELF SYP 5MG/5ML                      LORATADINE SYRUP 5 MG/5ML                 Second Generation Antihistamines                30
  ALLERGY RELF SYP CHILD                      LORATADINE SYRUP 5 MG/5ML                 Second Generation Antihistamines                30
  ALLERGY RELF TAB 10MG                         CETIRIZINE HCL TAB 10 MG                Second Generation Antihistamines                30
  ALLERGY RELF TAB 25MG                    DIPHENHYDRAMINE HCL TAB 25 MG                    Ethanolamine Derivatives                    30
   ALLERMAX TAB 25MG                       DIPHENHYDRAMINE HCL TAB 25 MG                    Ethanolamine Derivatives                    30
 ALLER-TEC SOL CHILDREN                CETIRIZINE HCL SYRUP 1 MG/ML (5 MG/5ML)          Second Generation Antihistamines                30      9
   ALLER-TEC TAB 10MG                           CETIRIZINE HCL TAB 10 MG                Second Generation Antihistamines                30
       ALLFEN DM TAB          DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 58-1000 MG                   Antitussives                31      30
ALLFEN DM TAB 400-20MG             DEXTROMETHORPHAN-GUAIFENESIN TAB 20-400 MG                       Antitussives                31      30
 ALLOPURINOL TAB 100MG                          ALLOPURINOL TAB 100 MG                  Miscellaneous Therapeutic Agents                30
 ALLOPURINOL TAB 300MG                          ALLOPURINOL TAB 300 MG                  Miscellaneous Therapeutic Agents                30
      ALMACONE CHW          ALUM & MAG HYDROXIDE-SIMETHICONE CHEW TAB 200-200-20 MG          Antacids and Adsorbents            120     30
      ALMACONE SUS          ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML          Antacids and Adsorbents            480     30
    ALMACONE MLT CHW        ALUM & MAG HYDROXIDE-SIMETHICONE CHEW TAB 200-200-20 MG          Antacids and Adsorbents            120     30
    ALMACONE-II SUS DS      ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML          Antacids and Adsorbents            480     30
      ALOE AFTERSU LOT                           *EMOLLIENT - LOTION**                     Basic Lotions and Liniments                  30                                                   Prior Authorization Req'd
   ALORA      DIS 0.025MG            ESTRADIOL TD PATCH BIWEEKLY 0.025 MG/24HR                       Estrogens                          30
   ALPHAGAN P SOL 0.1%                 BRIMONIDINE TARTRATE OPHTH SOLN 0.1%               ALPHA ADRENERGIC AGONISTS                     30
                                                                                                                              Max Qty
                                                                                                                                Limit   Max Max Age
                                                                                                                              (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                             Generic Name                                   Therapy Class                 in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
    ALPHATREX GEL 0.05%          BETAMETHASONE DIPROPIONATE AUGMENTED GEL 0.05%              Anti-inflammatory Agents                   30                                                   Prior Authorization Req'd
   ALPROSTADIL INJ 500MCG                     ALPROSTADIL INJ 500 MCG/ML                Vasodilating Agents, Miscellaneous              30                                                   Prior Authorization Req'd
    ALSUMA     KIT 6MG/0.5             SUMATRIPTAN SUCCINATE INJ KIT 6 MG/0.5ML            Selective Serotonin Agonists          2      30
  ALTARUSSIN LIQ 100-10/5       DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                    Antitussives               180     30
  ALTARUSSIN SYP 100/5ML                    GUAIFENESIN SYRUP 100 MG/5ML                            Expectorants                        30
      ALTARUSSIN SYP -PE          PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 30-100 MG/5ML                   Expectorants                        30
 ALTARUSSN DM SYP 100-10/5      DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                     Antitussives               180     30
   ALTOPREV TAB 60MG ER                      LOVASTATIN TAB SR 24HR 60 MG                 HMG-CoA Reductase Inhibitors                  30
 ALUM/MAGNES/ SUS SIMETH     ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML         Antacids and Adsorbents            480     30
  ALUPENT INH AER 0.65/ACT    METAPROTERENOL SULFATE INHAL AEROSOL POW 0.65 MG/ACT     Selective beta-2-Adrenergic Agonists      28     30
  AMANTADINE CAP 100MG                        AMANTADINE HCL CAP 100 MG                   Central Nervous System Agents                 30
AMANTADINE SYP 50MG/5ML                    AMANTADINE HCL SYRUP 50 MG/5ML                 Central Nervous System Agents                 30      18
  AMANTADINE TAB 100MG                        AMANTADINE HCL TAB 100 MG                   Central Nervous System Agents                 30
       AMBI 1000/55 TAB        DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 55-1000 MG                   Antitussives               31      30
       AMBI 45/800 TAB           PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 45-800 MG                  Expectorants                31      30
       AMBI 60/1000 TAB         PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 60-1000 MG                  Expectorants                31      30
       AMBI 60/580 TAB           PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 60-580 MG                  Expectorants                31      30
   AMBI 60PSE/ TAB 400GFN             PSEUDOEPHEDRINE-GUAIFENESIN TAB 60-400 MG                     Expectorants                        30
       AMBI 80/700 TAB           PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 80-700 MG                  Expectorants                31      30
       AMBI 80/780 TAB           PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 80-780 MG                  Expectorants                31      30
 AMBI ESSNTLS LOT MOISTURZ                       *EMOLLIENT - LOTION**                      Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
    AMBI EVEN & LOT CLEAR                        *EMOLLIENT - LOTION**                      Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
  AMBI SOFT & LOT EVEN OIL                       *EMOLLIENT - LOTION**                      Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
  AMIBID DM TAB 30-600CR       DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 30-600 MG                    Antitussives               31      30
        AMIDRINE CAP         ACETAMINOPHEN-ISOMETHEPTENE-DICHLORAL CAP 325-65-100 MG    Antimigraine Agents, Miscellaneous      6       30
    AMIFOSTINE INJ 500MG                 AMIFOSTINE CRYSTALLINE FOR INJ 500 MG           Miscellaneous Therapeutic Agents               30                                                   Prior Authorization Req'd
    AMIGESIC TAB 500MG                           SALSALATE TAB 500 MG                                 Salicylates                       30
    AMIGESIC TAB 750MG                           SALSALATE TAB 750 MG                                 Salicylates                       30
    AMINATE FE TAB 90MG        *PRENATAL VIT W/ DSS-FE FUMARATE-FA TAB CR 90-1 MG***        Multivitamin Preparations                   30
   AMINOFEN TAB 325MG                         ACETAMINOPHEN TAB 325 MG                   Analgesics and Antipyretics, Misc      250     30
   AMINOFEN TAB 500MG                         ACETAMINOPHEN TAB 500 MG                   Analgesics and Antipyretics, Misc      250     30
  AMINOPHYLLIN TAB 100MG                       AMINOPHYLLINE TAB 100 MG                Respiratory Smooth Muscle Relaxants              30
  AMINOPHYLLIN TAB 200MG                       AMINOPHYLLINE TAB 200 MG                Respiratory Smooth Muscle Relaxants              30
  AMIODARONE TAB 200MG                        AMIODARONE HCL TAB 200 MG                       Class III Antiarrhythmics                 30
  AMIODARONE TAB 400MG                        AMIODARONE HCL TAB 400 MG                       Class III Antiarrhythmics                 30
       AMLACTIN XL LOT                           *EMOLLIENT - LOTION**                      Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
AMLOD/BENAZP CAP 10-20MG           AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-20 MG               Dihydropyridines                       30
AMLOD/BENAZP CAP 10-40MG           AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-40 MG               Dihydropyridines                       30
AMLOD/BENAZP CAP 2.5-10MG          AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 2.5-10 MG              Dihydropyridines                       30
 AMLOD/BENAZP CAP 5-10MG            AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-10 MG               Dihydropyridines                       30
 AMLOD/BENAZP CAP 5-20MG            AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-20 MG               Dihydropyridines                       30
 AMLOD/BENAZP CAP 5-40MG            AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-40 MG               Dihydropyridines                       30
    AMLODIPINE TAB 10MG                     AMLODIPINE BESYLATE TAB 10 MG                        Dihydropyridines                       30
   AMLODIPINE TAB 2.5MG                     AMLODIPINE BESYLATE TAB 2.5 MG                       Dihydropyridines                       30
     AMLODIPINE TAB 5MG                      AMLODIPINE BESYLATE TAB 5 MG                        Dihydropyridines                       30
  AMOCLAN SUS 200/5ML           AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML              Aminopenicillins                      14      18
  AMOCLAN SUS 400/5ML            AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML               Aminopenicillins                      14      18
   AMOCLAN SUS 600-42.9         AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML              Aminopenicillins                      14      18
  AMOX/K CLAV CHW 200MG           AMOXICILLIN & K CLAVULANATE CHEW TAB 200-28.5 MG                Aminopenicillins                      14
  AMOX/K CLAV CHW 400MG            AMOXICILLIN & K CLAVULANATE CHEW TAB 400-57 MG                 Aminopenicillins                      14
 AMOX/K CLAV SUS 200/5ML        AMOXICILLIN & K CLAVULANATE FOR SUSP 200-28.5 MG/5ML              Aminopenicillins                      14      18
 AMOX/K CLAV SUS 250/5ML        AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML              Aminopenicillins                      14      18
 AMOX/K CLAV SUS 400/5ML         AMOXICILLIN & K CLAVULANATE FOR SUSP 400-57 MG/5ML               Aminopenicillins                      14      18
 AMOX/K CLAV SUS 600/5ML        AMOXICILLIN & K CLAVULANATE FOR SUSP 600-42.9 MG/5ML              Aminopenicillins                      14      18
  AMOX/K CLAV TAB 250MG               AMOXICILLIN & K CLAVULANATE TAB 250-125 MG                  Aminopenicillins                      14
  AMOX/K CLAV TAB 500MG               AMOXICILLIN & K CLAVULANATE TAB 500-125 MG                  Aminopenicillins                      14
  AMOX/K CLAV TAB 875MG               AMOXICILLIN & K CLAVULANATE TAB 875-125 MG                  Aminopenicillins                      14
   AMOXICILLIN CAP 250MG                  AMOXICILLIN (TRIHYDRATE) CAP 250 MG                     Aminopenicillins                      30
   AMOXICILLIN CAP 500MG                  AMOXICILLIN (TRIHYDRATE) CAP 500 MG                     Aminopenicillins                      30
  AMOXICILLIN CHW 125MG                AMOXICILLIN (TRIHYDRATE) CHEW TAB 125 MG                   Aminopenicillins                      30
  AMOXICILLIN CHW 200MG                AMOXICILLIN (TRIHYDRATE) CHEW TAB 200 MG                   Aminopenicillins                      30
  AMOXICILLIN CHW 250MG                AMOXICILLIN (TRIHYDRATE) CHEW TAB 250 MG                   Aminopenicillins                      30
  AMOXICILLIN CHW 400MG                AMOXICILLIN (TRIHYDRATE) CHEW TAB 400 MG                   Aminopenicillins                      30
  AMOXICILLIN SUS 125/5ML            AMOXICILLIN (TRIHYDRATE) FOR SUSP 125 MG/5ML                 Aminopenicillins                      30      18
  AMOXICILLIN SUS 200/5ML            AMOXICILLIN (TRIHYDRATE) FOR SUSP 200 MG/5ML                 Aminopenicillins                      30      18
                                                                                                                              Max Qty
                                                                                                                                Limit   Max Max Age
                                                                                                                              (Liquids Days    Limit    Step      Step Therapy   Specialty
   Drug/Product Name                               Generic Name                                    Therapy Class               in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
 AMOXICILLIN SUS 250/5ML             AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML                  Aminopenicillins                     30      18
 AMOXICILLIN SUS 400/5ML             AMOXICILLIN (TRIHYDRATE) FOR SUSP 400 MG/5ML                  Aminopenicillins                     30      18
  AMOXICILLIN TAB 500MG                   AMOXICILLIN (TRIHYDRATE) TAB 500 MG                      Aminopenicillins                     30
  AMOXICILLIN TAB 875MG                   AMOXICILLIN (TRIHYDRATE) TAB 875 MG                      Aminopenicillins                     30
    AMOXIL      CAP 500MG                 AMOXICILLIN (TRIHYDRATE) CAP 500 MG                      Aminopenicillins                     30
   AMOXIL      SUS 250/5ML           AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML                  Aminopenicillins                     30      18
AMPHETAMINE CAP 10MG ER          AMPHETAMINE-DEXTROAMPHETAMINE CAP SR 24HR 10 MG                   Amphetamines                 30      30      20
AMPHETAMINE CAP 15MG ER          AMPHETAMINE-DEXTROAMPHETAMINE CAP SR 24HR 15 MG                   Amphetamines                 30      30      20
AMPHETAMINE CAP 20MG ER          AMPHETAMINE-DEXTROAMPHETAMINE CAP SR 24HR 20 MG                   Amphetamines                 30      30      20
AMPHETAMINE CAP 25MG ER          AMPHETAMINE-DEXTROAMPHETAMINE CAP SR 24HR 25 MG                   Amphetamines                 30      30      20
AMPHETAMINE CAP 30MG ER          AMPHETAMINE-DEXTROAMPHETAMINE CAP SR 24HR 30 MG                   Amphetamines                 30      30      20
AMPHETAMINE CAP 5MG ER            AMPHETAMINE-DEXTROAMPHETAMINE CAP SR 24HR 5 MG                   Amphetamines                 30      30      20
 AMPHETAMINE TAB 10MG                AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG                       Amphetamines                 60      30      20
AMPHETAMINE TAB 12.5MG              AMPHETAMINE-DEXTROAMPHETAMINE TAB 12.5 MG                      Amphetamines                 60      30      20
 AMPHETAMINE TAB 15MG                AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG                       Amphetamines                 60      30      20
 AMPHETAMINE TAB 20MG                AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG                       Amphetamines                 90      30      20
 AMPHETAMINE TAB 30MG                AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG                       Amphetamines                 60      30      20
  AMPHETAMINE TAB 5MG                 AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG                       Amphetamines                 60      30      20
 AMPHETAMINE TAB 7.5MG               AMPHETAMINE-DEXTROAMPHETAMINE TAB 7.5 MG                      Amphetamines                 60      30      20
   AMPICILLIN CAP 250MG                          AMPICILLIN CAP 250 MG                             Aminopenicillins                     14
   AMPICILLIN CAP 500MG                          AMPICILLIN CAP 500 MG                             Aminopenicillins                     14
  AMPICILLIN SUS 125/5ML                    AMPICILLIN FOR SUSP 125 MG/5ML                         Aminopenicillins                     14      18
  AMPICILLIN SUS 250/5ML                    AMPICILLIN FOR SUSP 250 MG/5ML                         Aminopenicillins                     14      18
    AMPYRA       TAB 10MG                  DALFAMPRIDINE TAB SR 12HR 10 MG                 Other Misc Therapeutic Agents                30                                                   Prior Authorization Req'd
  ANACIN       TAB 81MG EC                 ASPIRIN TAB DELAYED RELEASE 81 MG                          Salicylates                31     30
   ANACIN AF TAB 500MG                        ACETAMINOPHEN TAB 500 MG                    Analgesics and Antipyretics, Misc     250     30
   ANASTROZOLE TAB 1MG                           ANASTROZOLE TAB 1 MG                           Antineoplastic Agents                   30
    ANDEHIST DM SYP NR             PSEUDOEPHED-BROMPHEN-DM SYRUP 45-4-15 MG/5ML                      Antitussives               178     30
ANDEHIST NR SYP 4-45MG/M       BROMPHENIRAMINE & PSEUDOEPHEDRINE SYRUP 4-45 MG/5ML             Proplamine Derivatives           178     30
    ANDROID CAP 10MG                        METHYLTESTOSTERONE CAP 10 MG                             Androgens                          30                                                   Prior Authorization Req'd
    ANDROXY TAB 10MG                         FLUOXYMESTERONE TAB 10 MG                               Androgens                          30
  ANEXSIA TAB 5-325MG                 HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG                       Opiate Agonists              150     30
   ANEXSIA TAB 7.5-325               HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG                      Opiate Agonists              150     30
       ANOLOR 300 CAP            BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-325-40 MG       Analgesics and Antipyretics, Misc      20     30
   ANTABUSE TAB 250MG                            DISULFIRAM TAB 250 MG                    Miscellaneous Therapeutic Agents              30
   ANTABUSE TAB 500MG                            DISULFIRAM TAB 500 MG                    Miscellaneous Therapeutic Agents              30
        ANTACID SUS            ALUMINUM & MAGNESIUM HYDROXIDES SUSP 225-200 MG/5ML            Antacids and Adsorbents           480     30
  ANTACID SUS ANTI-GAS        ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML         Antacids and Adsorbents           480     30
     ANTACID SUS EX ST        ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML         Antacids and Adsorbents           480     30
 ANTACID SUS LEMON CM          ALUMINUM & MAGNESIUM HYDROXIDES SUSP 225-200 MG/5ML            Antacids and Adsorbents           480     30
   ANTACID SUS MAX ST         ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML         Antacids and Adsorbents           480     30
     ANTACID SUS MINT          ALUMINUM & MAGNESIUM HYDROXIDES SUSP 225-200 MG/5ML            Antacids and Adsorbents           480     30
      ANTACID SUS REG         ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML         Antacids and Adsorbents           480     30
  ANTACID SUS ULTRA ST        ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 500-450-40 MG/5ML         Antacids and Adsorbents           480     30
       ANTACID DS SUS         ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML         Antacids and Adsorbents           480     30
  ANTACID FAST SUS RELIEF     ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML         Antacids and Adsorbents           480     30
        ANTACID I SUS         ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML         Antacids and Adsorbents           480     30
        ANTACID III SUS       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML         Antacids and Adsorbents           480     30
       ANTACID LIQ SUS         ALUMINUM & MAGNESIUM HYDROXIDES SUSP 225-200 MG/5ML            Antacids and Adsorbents           480     30
 ANTACID LIQ SUS FAST REL     ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML         Antacids and Adsorbents           480     30
       ANTACID M SUS          ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML         Antacids and Adsorbents           480     30
  ANTACID M SUS MAX ST        ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML         Antacids and Adsorbents           480     30
       ANTACID PLUS SUS       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 225-200-25 MG/5ML         Antacids and Adsorbents           480     30
ANTACID PLUS SUS ANTI-GAS     ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML         Antacids and Adsorbents           480     30
 ANTACID PLUS SUS GAS REL     ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML         Antacids and Adsorbents           480     30
 ANTACID PLUS SUS LEMON       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 500-450-40 MG/5ML         Antacids and Adsorbents           480     30
   ANTACID/ SUS SIMETH        ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML         Antacids and Adsorbents           480     30
 ANTACID/ANTI SUS -GAS DS     ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML         Antacids and Adsorbents           480     30
 ANTACID/GAS SUS REL MAX      ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML         Antacids and Adsorbents           480     30
    ANTACID/SIME SUS DS       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML         Antacids and Adsorbents           480     30
 ANTIBIOT EAR SOL 1% OTIC                NEOMYCIN-POLYMYXIN-HC OTIC SOLN 1%                        Corticosteroids                      30
 ANTIBIOT EAR SUS 1% OTIC    NEOMYCIN-POLYMYXIN-HC OTIC SUSP 3.5 MG/ML-10000 UNIT/ML-1%            Corticosteroids                      30
        ANTIBIOTIC CRE           NEOMYCIN-POLYMYXIN CREAM 3.5 MG/GM-10000 UNIT/GM                   Antibacterials               15     30
    ANTIBIOTIC CRE PLUS              NEOMYCIN-POLYMYXIN W/ PRAMOXINE CREAM 1%                       Antibacterials               15     30
ANTI-DIARRHE LIQ 1MG/5ML               LOPERAMIDE HCL LIQ 1 MG/5ML (0.2 MG/ML)                   Antidiarrhea Agents            180     30
                                                                                                                                    Max Qty
                                                                                                                                      Limit   Max Max Age
                                                                                                                                    (Liquids Days    Limit    Step        Step Therapy    Specialty
    Drug/Product Name                              Generic Name                                      Therapy Class                   in mLs) Supply (Years) Required?     Requirement       Drug         Coverage Status
    ANTI-DIARRHE TAB 2MG                       LOPERAMIDE HCL TAB 2 MG                             Antidiarrhea Agents                31      30
     ANTI-FUNGAL CRE 1%                         CLOTRIMAZOLE CREAM 1%                                     Azoles                      30      30
     ANTI-HIST CAP 25MG                    DIPHENHYDRAMINE HCL CAP 25 MG                        Ethanolamine Derivatives                      30
     ANTI-HIST TAB 25MG                    DIPHENHYDRAMINE HCL TAB 25 MG                        Ethanolamine Derivatives                      30
   ANTIHISTAMIN CAP 25MG                   DIPHENHYDRAMINE HCL CAP 25 MG                        Ethanolamine Derivatives                      30
   ANTI-ITCH CRE /ALOE/E                      HYDROCORTISONE CREAM 1%                           Anti-inflammatory Agents                      30
  ANTI-ITCH CRE /OATMEAL                      HYDROCORTISONE CREAM 1%                           Anti-inflammatory Agents                      30
  ANTI-ITCH CRE 1%MAX ST                      HYDROCORTISONE CREAM 1%                           Anti-inflammatory Agents                      30
    ANTI-ITCH OIN MAX ST                       HYDROCORTISONE OINT 1%                           Anti-inflammatory Agents                      30
   ANTIPY/BENZO DRO OTIC               BENZOCAINE-ANTIPYRINE OTIC SOLN 1.4-5.4%                     Local Anesthetics                         30
    ANTIPY/BENZO SOL OTIC              BENZOCAINE-ANTIPYRINE OTIC SOLN 1.4-5.4%                     Local Anesthetics                         30
      ANTISPASMOD ELX          BELLADONNA ALKALOIDS-PHENOBARBITAL ELIXIR 16 MG/5ML           Antimuscarinics/Antispasmodics           60      30      18
     ANTIVERT TAB 50MG                          MECLIZINE HCL TAB 50 MG                               Antihistamines                          30
     APAP      CAP 500MG                     ACETAMINOPHEN CAP 500 MG                        Analgesics and Antipyretics, Misc        250     30
     APAP       CHW 80MG                   ACETAMINOPHEN CHEW TAB 80 MG                      Analgesics and Antipyretics, Misc         60     30
   APAP      DRO 80/0.8ML                  ACETAMINOPHEN SOLN 100 MG/ML                      Analgesics and Antipyretics, Misc         30     30
    APAP      SOL 80MG/2.5                ACETAMINOPHEN SOLN 160 MG/5ML                      Analgesics and Antipyretics, Misc        240     30
     APAP       TAB 325MG                    ACETAMINOPHEN TAB 325 MG                        Analgesics and Antipyretics, Misc        250     30
     APAP       TAB 500MG                    ACETAMINOPHEN TAB 500 MG                        Analgesics and Antipyretics, Misc        250     30
  APAP ARTHRIT TAB 650MG                    ACETAMINOPHEN TAB CR 650 MG                      Analgesics and Antipyretics, Misc        120     30
   APAP CHILD CHW 80MG                     ACETAMINOPHEN CHEW TAB 80 MG                      Analgesics and Antipyretics, Misc         60     30
  APAP CHILD ELX 160/5ML                  ACETAMINOPHEN ELIXIR 160 MG/5ML                    Analgesics and Antipyretics, Misc        240     30
  APAP CHILD SUS 160/5ML                  ACETAMINOPHEN SUSP 160 MG/5ML                      Analgesics and Antipyretics, Misc        240     30
   APAP EX STR TAB 500MG                     ACETAMINOPHEN TAB 500 MG                        Analgesics and Antipyretics, Misc        250     30
      APAP/BUT/CAF TAB          BUTALBITAL-ACETAMINOPHEN-CAFFEINE TAB 50-500-40 MG           Analgesics and Antipyretics, Misc         20     30
 APAP/CODEINE SOL 120-12/5         ACETAMINOPHEN W/ CODEINE SOLN 120-12 MG/5ML                       Opiate Agonists                  480     30
APAP/CODEINE TAB 300-15MG             ACETAMINOPHEN W/ CODEINE TAB 300-15 MG                         Opiate Agonists                  120     30
APAP/CODEINE TAB 300-30MG             ACETAMINOPHEN W/ CODEINE TAB 300-30 MG                         Opiate Agonists                  120     30
APAP/CODEINE TAB 300-60MG             ACETAMINOPHEN W/ CODEINE TAB 300-60 MG                         Opiate Agonists                  120     30
APAP/HYDROCO TAB 500-5MG             HYDROCODONE-ACETAMINOPHEN TAB 5-500 MG                          Opiate Agonists                  150     30
APAP/OXYCOD TAB 325-5MG              OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG                         Opiate Agonists                  120     30
    APARA      SOL 160/5ML                ACETAMINOPHEN SOLN 160 MG/5ML                      Analgesics and Antipyretics, Misc        240     30
    APEXICON OIN 0.05%                    DIFLORASONE DIACETATE OINT 0.05%                      Anti-inflammatory Agents                      30                                                      Prior Authorization Req'd
    APEXICON E CRE 0.05%         DIFLORASONE DIACETATE EMOLLIENT BASE CREAM 0.05%               Anti-inflammatory Agents                      30                                                      Prior Authorization Req'd
        APOKYN       INJ              APOMORPHINE HYDROCHLORIDE INJ 10 MG/ML                  Dopamine Receptor Agonists                      30                                                      Prior Authorization Req'd
    APRA       ELX 160/5ML                ACETAMINOPHEN ELIXIR 160 MG/5ML                    Analgesics and Antipyretics, Misc        240     30
         APRI      TAB           DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG                   Contraceptives                          30



                                                                                                                                                                         USE AT LEAST 1
                                                                                                                                                                        OTHER PROTEASE
   APTIVUS   CAP 250MG                        TIPRANAVIR CAP 250 MG                               HIV Protease Inhibitors                     30                Y          INHIB 1ST



                                                                                                                                                                         USE AT LEAST 1
                                                                                                                                                                        OTHER PROTEASE
       APTIVUS SOL                       TIPRANAVIR ORAL SOLN 100 MG/ML                           HIV Protease Inhibitors                     30                Y          INHIB 1ST
AQUA GLYCOL LOT HND/BDY                        *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                   30                                                      Prior Authorization Req'd
     AQUA LACTEN LOT                           *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                   30                                                      Prior Authorization Req'd
AQUABID-DM TAB 30-600CR        DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 30-600 MG                       Antitussives                  31      30
AQUADERM LOT MOISTURE                          *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                   30                                                      Prior Authorization Req'd
      AQUAMED LOT                              *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                   30                                                      Prior Authorization Req'd
    AQUANIL HC LOT 1%                       HYDROCORTISONE LOTION 1%                             Anti-inflammatory Agents                     30
 AQUASOL A INJ 50000/ML                     VITAMIN A INJ 50000 UNIT/ML                                   Vitamin A                           30
     AQUATAB DM TAB            DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 28-835 MG                       Antitussives                  31      30
      ARANELLE TAB           NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG                 Contraceptives                         30
   ARICEPT TAB 23MG                    DONEPEZIL HYDROCHLORIDE TAB 23 MG                 Parasympathomimetic (Cholinergic) Agents             30                                                      Prior Authorization Req'd
   ARIMIDEX TAB 1MG                            ANASTROZOLE TAB 1 MG                               Antineoplastic Agents                       30
   ARIXTRA SOL 2.5/0.5                FONDAPARINUX SODIUM INJ 2.5 MG/0.5ML                     Miscellaneous Anticoagulants                   30                                                      Prior Authorization Req'd
ARMOUR THYRO TAB 120MG                     THYROID TAB 120 MG (2 GRAIN)                                Thyroid Agents                         30
 ARMOUR THYRO TAB 15MG                     THYROID TAB 15 MG (1/4 GRAIN)                               Thyroid Agents                         30
ARMOUR THYRO TAB 180MG                     THYROID TAB 180 MG (3 GRAIN)                                Thyroid Agents                         30
ARMOUR THYRO TAB 240MG                     THYROID TAB 240 MG (4 GRAIN)                                Thyroid Agents                         30
ARMOUR THYRO TAB 300MG                     THYROID TAB 300 MG (5 GRAIN)                                Thyroid Agents                         30
 ARMOUR THYRO TAB 30MG                     THYROID TAB 30 MG (1/2 GRAIN)                               Thyroid Agents                         30
                                                                                                                                    Max Qty
                                                                                                                                      Limit   Max Max Age
                                                                                                                                    (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                                Generic Name                                      Therapy Class                 in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
  ARMOUR THYRO TAB 60MG                         THYROID TAB 60 MG (1 GRAIN)                             Thyroid Agents                        30
  ARMOUR THYRO TAB 90MG                       THYROID TAB 90 MG (1 1/2 GRAIN)                           Thyroid Agents                        30
    AROMASIN TAB 25MG                              EXEMESTANE TAB 25 MG                             Antineoplastic Agents                     30
   ARTHRITIS TAB PAIN REL                      ACETAMINOPHEN TAB CR 650 MG                    Analgesics and Antipyretics, Misc       120     30
   ARTHRTS PAIN TAB 650MG                      ACETAMINOPHEN TAB CR 650 MG                    Analgesics and Antipyretics, Misc       120     30
  ASA FREE CHW 160MG JR                      ACETAMINOPHEN CHEW TAB 160 MG                    Analgesics and Antipyretics, Misc        60     30
  ASA LO-DOSE TAB 81MG EC                   ASPIRIN TAB DELAYED RELEASE 81 MG                             Salicylates                  31     30
 ASA LOW DOSE TAB 81MG EC                   ASPIRIN TAB DELAYED RELEASE 81 MG                             Salicylates                  31     30
  ASA LOW STR TAB 81MG EC                   ASPIRIN TAB DELAYED RELEASE 81 MG                             Salicylates                  31     30
ASA/BUT/CAFF CAP COD 30MG         BUTALBITAL-ASPIRIN-CAFF W/ CODEINE CAP 50-325-40-30 MG               Opiate Agonists                 20     30
 ASA/CAFF/BUT CAP 325-40-5             BUTALBITAL-ASPIRIN-CAFFEINE CAP 50-325-40 MG                       Salicylates                  20     30
 ASA/CODEINE TAB 325-30MG                    ASPIRIN W/ CODEINE TAB 325-30 MG                          Opiate Agonists                120     30
 ASA/CODEINE TAB 325-60MG                    ASPIRIN W/ CODEINE TAB 325-60 MG                          Opiate Agonists                120     30
   ASACOL     TAB 400MG DR               MESALAMINE TAB DELAYED RELEASE 400 MG                    Anti-inflammatory Agents                    30                                                   Prior Authorization Req'd
    ASACOL HD TAB 800MG                  MESALAMINE TAB DELAYED RELEASE 800 MG                    Anti-inflammatory Agents                    30                                                   Prior Authorization Req'd
   ASCOMP/COD CAP 30MG            BUTALBITAL-ASPIRIN-CAFF W/ CODEINE CAP 50-325-40-30 MG               Opiate Agonists                20      30
     ASMALPRED SOL PLUS       PREDNISOLONE SOD PHOSPHATE ORAL SOLN 15 MG/5ML (BASE EQUIV)                  Adrenals                           30
    ASPIR-81 TAB 81MG EC                    ASPIRIN TAB DELAYED RELEASE 81 MG                             Salicylates                  31     30
    ASPIRIN    TAB 81MG EC                  ASPIRIN TAB DELAYED RELEASE 81 MG               Nonsteroidal Anti-inflammatory Agents      31     30
     ASPIRIN CHW 81MG                             ASPIRIN CHEW TAB 81 MG                                  Salicylates                  31     30
     ASPIRIN TAB 325MG                               ASPIRIN TAB 325 MG                     Nonsteroidal Anti-inflammatory Agents      31     30
       ASPIRIN TAB 5GR                               ASPIRIN TAB 325 MG                                   Salicylates                  31     30
      ASPIRIN TAB 81MG                               ASPIRIN TAB 81 MG                                    Salicylates                  31     30
    ASPIRIN TAB 81MG EC                     ASPIRIN TAB DELAYED RELEASE 81 MG                             Salicylates                  31     30
    ASPIRIN ADLT TAB 81MG                            ASPIRIN TAB 81 MG                                    Salicylates                  31     30
    ASPIRIN CHIL CHW 81MG                         ASPIRIN CHEW TAB 81 MG                                  Salicylates                  31     30
   ASPIRIN CHLD CHW 81MG                          ASPIRIN CHEW TAB 81 MG                                  Salicylates                  31     30
    ASPIRIN CHLD TAB 81MG                            ASPIRIN TAB 81 MG                                    Salicylates                  31     30
     ASPIRIN DR TAB 81MG                    ASPIRIN TAB DELAYED RELEASE 81 MG                             Salicylates                  31     30
  ASPIRIN FREE DRO 80/0.8ML                 ACETAMINOPHEN SUSP 80 MG/0.8ML                    Analgesics and Antipyretics, Misc        30     30
   ASPIRIN FREE TAB 325MG                       ACETAMINOPHEN TAB 325 MG                      Analgesics and Antipyretics, Misc       250     30
   ASPIRIN FREE TAB 500MG                       ACETAMINOPHEN TAB 500 MG                      Analgesics and Antipyretics, Misc       250     30
   ASPIRIN LOW CHW 81MG                           ASPIRIN CHEW TAB 81 MG                                  Salicylates                  31     30
    ASPIRIN LOW TAB 81MG                    ASPIRIN TAB DELAYED RELEASE 81 MG                             Salicylates                  31     30
  ASPIRIN LOW TAB 81MG EC                   ASPIRIN TAB DELAYED RELEASE 81 MG                             Salicylates                  31     30
  ASPIR-LOW TAB 81MG EC                     ASPIRIN TAB DELAYED RELEASE 81 MG                             Salicylates                  31     30
 ASTRAMORPH INJ 0.5MG/ML                    MORPHINE SULFATE INJ PF 0.5 MG/ML                          Opiate Agonists                        30                                                   Prior Authorization Req'd
  ASTRAMORPH INJ 10/10ML                     MORPHINE SULFATE INJ PF 1 MG/ML                           Opiate Agonists                        30                                                   Prior Authorization Req'd
 ASTRAMORPH INJ 1MG/2ML                     MORPHINE SULFATE INJ PF 0.5 MG/ML                          Opiate Agonists                        30                                                   Prior Authorization Req'd
  ASTRAMORPH INJ 1MG/ML                      MORPHINE SULFATE INJ PF 1 MG/ML                           Opiate Agonists                        30                                                   Prior Authorization Req'd
 ASTRAMORPH INJ 2MG/2ML                      MORPHINE SULFATE INJ PF 1 MG/ML                           Opiate Agonists                        30                                                   Prior Authorization Req'd
ASTRAMORPH INJ 5MG/10ML                     MORPHINE SULFATE INJ PF 0.5 MG/ML                          Opiate Agonists                        30                                                   Prior Authorization Req'd
  ATAMET       TAB 25-250MG                CARBIDOPA & LEVODOPA TAB 25-250 MG                  Central Nervous System Agents                  30
    ATENOLOL TAB 100MG                              ATENOLOL TAB 100 MG                       Beta-Adrenergic Blocking Agents                 30
     ATENOLOL TAB 25MG                              ATENOLOL TAB 25 MG                        Beta-Adrenergic Blocking Agents                 30
     ATENOLOL TAB 50MG                              ATENOLOL TAB 50 MG                        Beta-Adrenergic Blocking Agents                 30
     ATHLETE FOOT CRE 1%                         TERBINAFINE HCL CREAM 1%                                 Allylamines                 30      30
      ATHLETE FOOT CRE AF                        TERBINAFINE HCL CREAM 1%                                 Allylamines                 30      30
ATLAS CONDOM MIS COLR/SPM                     CONDOMS LATEX NON-LUBRICATED                              Contraceptives                        30
ATLAS CONDOM MIS LUB/COLR                       CONDOMS LATEX LUBRICATED                                Contraceptives                        30
ATLAS CONDOM MIS LUB/SPMC                       CONDOMS LATEX LUBRICATED                                Contraceptives                        30
ATLAS CONDOM MIS LUBRICAT                       CONDOMS LATEX LUBRICATED                                Contraceptives                        30
         ATRIPLA TAB             EFAVIRENZ-EMTRICITABINE-TENOFOVIR DF TAB 600-200-300 MG        Miscellaneous Antiretrovirals                 30
   ATROPIN-CARE SOL 1% OP                    ATROPINE SULFATE OPHTH SOLN 1%                               Mydriatics                          30
   ATROPINE SUL SOL 1% OP                    ATROPINE SULFATE OPHTH SOLN 1%                               Mydriatics                          30
  ATROVENT HFA AER 17MCG           IPRATROPIUM BROMIDE HFA INHAL AEROSOL 17 MCG/ACT           Antimuscarinics/Antispasmodics          26      30
   AUG BETAMET CRE 0.05%          BETAMETHASONE DIPROPIONATE AUGMENTED CREAM 0.05%                Anti-inflammatory Agents            45      30
   AUG BETAMET GEL 0.05%            BETAMETHASONE DIPROPIONATE AUGMENTED GEL 0.05%                Anti-inflammatory Agents                    30                                                   Prior Authorization Req'd
   AUG BETAMET LOT 0.05%          BETAMETHASONE DIPROPIONATE AUGMENTED LOTION 0.05%               Anti-inflammatory Agents                    30                                                   Prior Authorization Req'd
   AUG BETAMET OIN 0.05%           BETAMETHASONE DIPROPIONATE AUGMENTED OINT 0.05%                Anti-inflammatory Agents            45      30
  AUGMENTIN SUS 125/5ML           AMOXICILLIN & K CLAVULANATE FOR SUSP 125-31.25 MG/5ML                Aminopenicillins                       14      18
      AURODEX SOL OTIC                   BENZOCAINE-ANTIPYRINE OTIC SOLN 1.4-5.4%                     Local Anesthetics                       30
       AUROGUARD SOL                     BENZOCAINE-ANTIPYRINE OTIC SOLN 1.4-5.4%                     Local Anesthetics                       30
      AUROTO      SOL OTIC               BENZOCAINE-ANTIPYRINE OTIC SOLN 1.4-5.4%                     Local Anesthetics                       30
                                                                                                                            Max Qty
                                                                                                                              Limit   Max Max Age
                                                                                                                            (Liquids Days    Limit    Step        Step Therapy     Specialty
    Drug/Product Name                                Generic Name                                  Therapy Class             in mLs) Supply (Years) Required?     Requirement        Drug         Coverage Status




                                                                                                                                                                 USE METFORMIN
                                                                                                                                                                     AND/OR
AVANDAMET TAB 2-1000MG            ROSIGLITAZONE MALEATE-METFORMIN HCL TAB 2-1000 MG               Thiazolidinediones                  30                Y       SULFONYLUREA 1ST




                                                                                                                                                                 USE METFORMIN
                                                                                                                                                                     AND/OR
AVANDAMET TAB 2-500MG             ROSIGLITAZONE MALEATE-METFORMIN HCL TAB 2-500 MG                Thiazolidinediones                  30                Y       SULFONYLUREA 1ST




                                                                                                                                                                 USE METFORMIN
                                                                                                                                                                     AND/OR
AVANDAMET TAB 4-1000MG            ROSIGLITAZONE MALEATE-METFORMIN HCL TAB 4-1000 MG               Thiazolidinediones                  30                Y       SULFONYLUREA 1ST




                                                                                                                                                                 USE METFORMIN
                                                                                                                                                                     AND/OR
AVANDAMET TAB 4-500MG             ROSIGLITAZONE MALEATE-METFORMIN HCL TAB 4-500 MG                Thiazolidinediones                  30                Y       SULFONYLUREA 1ST




                                                                                                                                                                 USE METFORMIN
                                                                                                                                                                     AND/OR
   AVANDIA    TAB 2MG                 ROSIGLITAZONE MALEATE TAB 2 MG (BASE EQUIV)                 Thiazolidinediones                  30                Y       SULFONYLUREA 1ST




                                                                                                                                                                 USE METFORMIN
                                                                                                                                                                     AND/OR
   AVANDIA    TAB 4MG                 ROSIGLITAZONE MALEATE TAB 4 MG (BASE EQUIV)                 Thiazolidinediones                  30                Y       SULFONYLUREA 1ST




                                                                                                                                                                 USE METFORMIN
                                                                                                                                                                     AND/OR
     AVANDIA TAB 8MG                  ROSIGLITAZONE MALEATE TAB 8 MG (BASE EQUIV)                 Thiazolidinediones                  30                Y       SULFONYLUREA 1ST
  AVEENO     CRE 1%MAX ST                      HYDROCORTISONE CREAM 1%                         Anti-inflammatory Agents               30
   AVEENO    LOT NOURISH                          *EMOLLIENT - LOTION**                       Basic Lotions and Liniments             30                                                       Prior Authorization Req'd
    AVEENO     LOT SPF 15                         *EMOLLIENT - LOTION**                       Basic Lotions and Liniments             30                                                       Prior Authorization Req'd
AVEENO CONTI LOT RADIANCE                         *EMOLLIENT - LOTION**                       Basic Lotions and Liniments             30                                                       Prior Authorization Req'd
 AVEENO DAILY LOT FIRMING                         *EMOLLIENT - LOTION**                       Basic Lotions and Liniments             30                                                       Prior Authorization Req'd
 AVEENO POSIT LOT AGELESS                         *EMOLLIENT - LOTION**                       Basic Lotions and Liniments             30                                                       Prior Authorization Req'd
 AVEENO POSIT LOT RADIANT                         *EMOLLIENT - LOTION**                       Basic Lotions and Liniments             30                                                       Prior Authorization Req'd
 AVEENO POSIT LOT SMOOTH                          *EMOLLIENT - LOTION**                       Basic Lotions and Liniments             30                                                       Prior Authorization Req'd
   AVEENO STRES LOT RELIEF                        *EMOLLIENT - LOTION**                       Basic Lotions and Liniments             30                                                       Prior Authorization Req'd
       AVIANE     TAB            LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG                Contraceptives                   30
    AZASAN    TAB 100MG                         AZATHIOPRINE TAB 100 MG                       Immunosuppressive Agents                30
    AZASAN    TAB 75 MG                          AZATHIOPRINE TAB 75 MG                       Immunosuppressive Agents                30
   AZATHIOPRINE INJ 100MG                 AZATHIOPRINE SODIUM FOR INJ 100 MG                  Immunosuppressive Agents                30                                                       Prior Authorization Req'd
     AZATHIOPRINE POW                             AZATHIOPRINE POWDER                            Pharmaceutical Aids                  30
   AZATHIOPRINE TAB 50MG                         AZATHIOPRINE TAB 50 MG                       Immunosuppressive Agents                30
AZITHROMYCIN POW 1GM PAK                AZITHROMYCIN POWD PACK FOR SUSP 1 GM                       Other Macrolides                   14                                                       Prior Authorization Req'd
 AZITHROMYCIN SUS 100/5ML                 AZITHROMYCIN FOR SUSP 100 MG/5ML                         Other Macrolides                   30
 AZITHROMYCIN SUS 200/5ML                 AZITHROMYCIN FOR SUSP 200 MG/5ML                         Other Macrolides                   30
  AZITHROMYCIN TAB 250MG                        AZITHROMYCIN TAB 250 MG                            Other Macrolides                   30
  AZITHROMYCIN TAB 500MG                        AZITHROMYCIN TAB 500 MG                            Other Macrolides                   30
  AZITHROMYCIN TAB 600MG                        AZITHROMYCIN TAB 600 MG                            Other Macrolides                   30
   AZMACORT AER 75MCG        TRIAMCINOLONE ACETONIDE INHAL AEROSOL 75 MCG/ACT (200/VALVE)               Adrenals                      30
     AZOPT    SUS 1% OP                       BRINZOLAMIDE OPHTH SUSP 1%                    CARBONIC ANYDRASE INHIBITORS              30
                                                                                                                                            Max Qty
                                                                                                                                              Limit   Max Max Age
                                                                                                                                            (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                                Generic Name                                           Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
    AZURETTE TAB 28 DAY        DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)                    Contraceptives                        30
       B-6      TAB 100MG                        PYRIDOXINE HCL TAB 100 MG                                  Vitamin B Complex                        30
       B-6      TAB 250MG                        PYRIDOXINE HCL TAB 250 MG                                  Vitamin B Complex                        30
       B-6       TAB 50MG                         PYRIDOXINE HCL TAB 50 MG                                  Vitamin B Complex                        30
   BABY ASPIRIN CHW 81MG                           ASPIRIN CHEW TAB 81 MG                                         Salicylates                 31     30
       BABY VITAMIN DRO             *PEDIATRIC MULTIPLE VITAMIN W/ C SOLN 35 MG/ML**                    Multivitamin Preparations                    30       1
   BABY VITAMIN DRO /IRON        *PEDIATRIC MULTIPLE VITAMINS W/ IRON DROPS 10 MG/ML**                  Multivitamin Preparations                    30      0.5
     BAC/NEO/POLY OIN OP     NEOMYCIN-BACITRAC ZN-POLYMYX 5(3.5)MG-400UNT-10000UNT OP OIN                       Antibacterials                       30
BAC/POLY/NEO OIN /HC 1%OP           BACITRACIN-POLYMYXIN-NEOMYCIN-HC OPHTH OINT 1%                             Corticosteroids                       30
       BACIT/POLYMY OIN                      *BACITRACIN-POLYMYXIN B OINT***                                    Antibacterials                       30
     BACIT/POLYMY OIN OP                    BACITRACIN-POLYMYXIN B OPHTH OINT                                   Antibacterials                       30
    BACLOFEN TAB 10MG                                BACLOFEN TAB 10 MG                       GABA DERIVATIVE SKELETAL MUSCLE RELAXANTS              30                                                    Prior Authorization Req'd
    BACLOFEN TAB 20MG                                BACLOFEN TAB 20 MG                       GABA DERIVATIVE SKELETAL MUSCLE RELAXANTS              30                                                    Prior Authorization Req'd
      BACTROBAN CRE 2%                         MUPIROCIN CALCIUM CREAM 2%                                       Antibacterials                       30
     BACTROBAN OIN 2%                                 MUPIROCIN OINT 2%                                         Antibacterials                       30
 BACTROBAN OIN NASAL 2%                      MUPIROCIN CALCIUM NASAL OINT 2%                                    Antibacterials                       30
   BALAGAN SOL 1.4-5.4%                  BENZOCAINE-ANTIPYRINE OTIC SOLN 1.4-5.4%                            Local Anesthetics                       30
     BALNEOL LOT 0.25%                         HYDROCORTISONE LOTION 0.25%                               Anti-inflammatory Agents                    30
          BALZIVA TAB             NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG                          Contraceptives                        30
    BANOPHEN CAP 25MG                         DIPHENHYDRAMINE HCL CAP 25 MG                              Ethanolamine Derivatives                    30
  BANOPHEN LIQ 12.5/5ML                  DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                          Ethanolamine Derivatives                    30
    BANOPHEN TAB 25MG                         DIPHENHYDRAMINE HCL TAB 25 MG                              Ethanolamine Derivatives                    30
           BARC      LIQ               PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.18-2.2%                     Scabicides and Pediculicides           120    30
  BAYCADRON ELX 0.5/5ML                      DEXAMETHASONE ELIXIR 0.5 MG/5ML                                       Adrenals                          30
    BAYER ASA TAB 325MG                               ASPIRIN TAB 325 MG                                          Salicylates                 31     30
  BAYER LOW TAB 81MG EC                      ASPIRIN TAB DELAYED RELEASE 81 MG                                    Salicylates                 31     30
     B-CARO-T CAP 15MG                            BETA CAROTENE CAP 15 MG                                         Vitamin A                          30
 BD SWAB BFLY PAD SNGL USE                           *ALCOHOL SWABS***                                             Devices                           30
 BD SWAB REG PAD SNGL USE                            *ALCOHOL SWABS***                                             Devices                           30
    BEDDING SPRA AER 0.5%                         PERMETHRIN AEROSOL 0.5%                              Scabicides and Pediculicides           142    30
         BELLA ALK/PB ELX         BELLADONNA ALKALOIDS-PHENOBARBITAL ELIXIR 16 MG/5ML                Antimuscarinics/Antispasmodics            60    30       18
  BELLA ALK/PB TAB 16.2MG           BELLADONNA ALKALOIDS-PHENOBARBITAL TAB 16.2 MG                   Antimuscarinics/Antispasmodics            20    30
  BELLA/OPIUM SUP 16.2-60           BELLADONNA ALKALOIDS & OPIUM SUPPOS 16.2-60 MG                   Antimuscarinics/Antispasmodics            1     180
  BENAZEP/HCTZ TAB 10-12.5          BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG              Angiotensin-Converting Enzyme Inhibitors            30
  BENAZEP/HCTZ TAB 20-12.5          BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG              Angiotensin-Converting Enzyme Inhibitors            30
 BENAZEP/HCTZ TAB 20-25MG            BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG               Angiotensin-Converting Enzyme Inhibitors            30
  BENAZEP/HCTZ TAB 5-6.25            BENAZEPRIL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG              Angiotensin-Converting Enzyme Inhibitors            30
    BENAZEPRIL TAB 10MG                           BENAZEPRIL HCL TAB 10 MG                       Angiotensin-Converting Enzyme Inhibitors            30
    BENAZEPRIL TAB 20MG                           BENAZEPRIL HCL TAB 20 MG                       Angiotensin-Converting Enzyme Inhibitors            30
    BENAZEPRIL TAB 40MG                           BENAZEPRIL HCL TAB 40 MG                       Angiotensin-Converting Enzyme Inhibitors            30
     BENAZEPRIL TAB 5MG                            BENAZEPRIL HCL TAB 5 MG                       Angiotensin-Converting Enzyme Inhibitors            30
  BENZONATATE CAP 100MG                           BENZONATATE CAP 100 MG                                         Antitussives                 31     30
  BENZONATATE CAP 200MG                           BENZONATATE CAP 200 MG                                         Antitussives                 31     30
     BENZOTIC DRO OTIC                   BENZOCAINE-ANTIPYRINE OTIC SOLN 1.4-5.4%                            Local Anesthetics                       30
   BENZTROPINE TAB 0.5MG                     BENZTROPINE MESYLATE TAB 0.5 MG                          Central Nervous System Agents                  30
    BENZTROPINE TAB 1MG                       BENZTROPINE MESYLATE TAB 1 MG                           Central Nervous System Agents                  30
    BENZTROPINE TAB 2MG                       BENZTROPINE MESYLATE TAB 2 MG                           Central Nervous System Agents                  30
         BETA CARE LOT                              *EMOLLIENT - LOTION**                               Basic Lotions and Liniments                  30                                                    Prior Authorization Req'd
BETA CAROTEN CAP 10000UNT                      BETA CAROTENE CAP 10000 UNIT                                       Vitamin A                          30
BETA CAROTEN CAP 25000UNT                      BETA CAROTENE CAP 25000 UNIT                                       Vitamin A                          30
    BETA DIPROP GEL 0.05%          BETAMETHASONE DIPROPIONATE AUGMENTED GEL 0.05%                        Anti-inflammatory Agents                    30                                                    Prior Authorization Req'd
        BETA HC LOT 1%                           HYDROCORTISONE LOTION 1%                                Anti-inflammatory Agents                    30
   BETAMETH DIP CRE 0.05%               BETAMETHASONE DIPROPIONATE CREAM 0.05%                           Anti-inflammatory Agents             45     30
   BETAMETH DIP LOT 0.05%              BETAMETHASONE DIPROPIONATE LOTION 0.05%                           Anti-inflammatory Agents                    30                                                    Prior Authorization Req'd
   BETAMETH DIP OIN 0.05%                BETAMETHASONE DIPROPIONATE OINT 0.05%                           Anti-inflammatory Agents             45     30
   BETAMETH VAL CRE 0.1%                   BETAMETHASONE VALERATE CREAM 0.1%                             Anti-inflammatory Agents             60     30
   BETAMETH VAL LOT 0.1%                   BETAMETHASONE VALERATE LOTION 0.1%                            Anti-inflammatory Agents             60     30
   BETAMETH VAL OIN 0.1%                    BETAMETHASONE VALERATE OINT 0.1%                             Anti-inflammatory Agents             60     30
      BETAMETH VAL POW                       BETAMETHASONE VALERATE POWDER                                 Pharmaceutical Aids                       30                                                    Prior Authorization Req'd
BETAMETH VAL POW MICRONIZ                    BETAMETHASONE VALERATE POWDER                                 Pharmaceutical Aids                       30                                                    Prior Authorization Req'd
 BETAMETH VAL POW USP NF                     BETAMETHASONE VALERATE POWDER                                 Pharmaceutical Aids                       30                                                    Prior Authorization Req'd
    BETATEMP SUS CHILD                       ACETAMINOPHEN SUSP 160 MG/5ML                           Analgesics and Antipyretics, Misc        240    30
      BETA-VAL CRE 0.1%                    BETAMETHASONE VALERATE CREAM 0.1%                             Anti-inflammatory Agents              60    30
      BETA-VAL LOT 0.1%                    BETAMETHASONE VALERATE LOTION 0.1%                            Anti-inflammatory Agents              60    30
  BETAXOLOL SOL 0.5% OP                       BETAXOLOL HCL OPHTH SOLN 0.5%                       BETA ADRENERGIC BLOCKING AGENTS                    30
                                                                                                                                         Max Qty
                                                                                                                                           Limit   Max Max Age
                                                                                                                                         (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                               Generic Name                                         Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
  BETHANECHOL TAB 10MG                      BETHANECHOL CHLORIDE TAB 10 MG                  Parasympathomimetic (Cholinergic) Agents               30
  BETHANECHOL TAB 25MG                      BETHANECHOL CHLORIDE TAB 25 MG                  Parasympathomimetic (Cholinergic) Agents               30
  BETHANECHOL TAB 50MG                      BETHANECHOL CHLORIDE TAB 50 MG                  Parasympathomimetic (Cholinergic) Agents               30
   BETHANECHOL TAB 5MG                       BETHANECHOL CHLORIDE TAB 5 MG                  Parasympathomimetic (Cholinergic) Agents               30
     BETIMOL SOL 0.25%                           TIMOLOL OPHTH SOLN 0.25%                     BETA ADRENERGIC BLOCKING AGENTS                      30
     BETIMOL SOL 0.5%                             TIMOLOL OPHTH SOLN 0.5%                     BETA ADRENERGIC BLOCKING AGENTS                      30
  BETOPTIC-S SUS 0.25% OP                    BETAXOLOL HCL OPHTH SUSP 0.25%                   BETA ADRENERGIC BLOCKING AGENTS                      30
         BEYAZ     TAB       DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB 3-0.02-0.451 MG                 Contraceptives                           30
  BICALUTAMIDE TAB 50MG                            BICALUTAMIDE TAB 50 MG                              Antineoplastic Agents                       30
 BIDEX-DMI TAB 20-400MG              DEXTROMETHORPHAN-GUAIFENESIN TAB 20-400 MG                             Antitussives                    31     30
 BIOCOTRON LIQ 100-10/5          DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                          Antitussives                   180     30
  BIOFED      LIQ 30MG/5ML                 PSEUDOEPHEDRINE HCL LIQ 30 MG/5ML                   alpha- and beta-Adrenergic Agonists         240     30
 BIOTUSS DM LIQ 100-10/5         DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                          Antitussives                   180     30
  BIOTUSS PE SYP 30-100/5          PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 30-100 MG/5ML                         Expectorants                            30
      BIOTUSSIN SYP AC                  GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML                              Antitussives                           30
  BISMATROL CHW 262MG                   BISMUTH SUBSALICYLATE CHEW TAB 262 MG                           Antidiarrhea Agents               120      30
 BISMATROL SUS 262/15ML                 BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                          Antidiarrhea Agents               1800     30
 BISMATROL SUS 525/15ML                 BISMUTH SUBSALICYLATE SUSP 525 MG/15ML                          Antidiarrhea Agents               1800     30
   BISMUTH CHW 262MG                    BISMUTH SUBSALICYLATE CHEW TAB 262 MG                           Antidiarrhea Agents               120      30
BISMUTH MS SUS 525/15ML                 BISMUTH SUBSALICYLATE SUSP 525 MG/15ML                          Antidiarrhea Agents               1800     30
 BISMUTH SUBS CHW 300MG                 BISMUTH SUBSALICYLATE CHEW TAB 300 MG                           Antidiarrhea Agents               120      30
BISMUTH SUBS SUS 262/15ML               BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                          Antidiarrhea Agents               1800     30
  BISOPRL/HCTZ TAB 10/6.25         BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 10-6.25 MG               Beta-Adrenergic Blocking Agents                   30
 BISOPRL/HCTZ TAB 2.5/6.25         BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 2.5-6.25 MG              Beta-Adrenergic Blocking Agents                   30
BISOPRL/HCTZ TAB 5/6.25MG           BISOPROLOL & HYDROCHLOROTHIAZIDE TAB 5-6.25 MG               Beta-Adrenergic Blocking Agents                   30
  BISOPROL FUM TAB 10MG                      BISOPROLOL FUMARATE TAB 10 MG                       Beta-Adrenergic Blocking Agents                   30
   BISOPROL FUM TAB 5MG                       BISOPROLOL FUMARATE TAB 5 MG                       Beta-Adrenergic Blocking Agents                   30
  BL ADULT ASA CHW 81MG                            ASPIRIN CHEW TAB 81 MG                                    Salicylates                   31      30
    BL ASPIRIN TAB 325MG                              ASPIRIN TAB 325 MG                                     Salicylates                   31      30
   BL DIPHEDRYL CAP 25MG                     DIPHENHYDRAMINE HCL CAP 25 MG                          Ethanolamine Derivatives                       30
    BL HYDROCORT CRE 1%                    HYDROCORTISONE ACETATE CREAM 1%                          Anti-inflammatory Agents               30      30
  BL IBUPROFEN TAB 200MG                            IBUPROFEN TAB 200 MG                    Other Nonsteroidal Anti-inflammtory Agents             30
   BL NIACIN TR TAB 250MG                            NIACIN TAB CR 250 MG                               Vitamin B Complex                  62      30
 BL NICOTINE DIS 11MG/24H                  NICOTINE TD PATCH 24HR 11 MG/24HR                     Autonomic Drugs, Miscellaneous                    30
 BL NICOTINE DIS 22MG/24H                  NICOTINE TD PATCH 24HR 22 MG/24HR                     Autonomic Drugs, Miscellaneous                    30
   BL PAIN RELI CHW 80MG                     ACETAMINOPHEN CHEW TAB 80 MG                        Analgesics and Antipyretics, Misc         60      30
        BL PEDIATRIC SOL                     *ORAL ELECTROLYTE SOLUTION***                          Replacement Preparations                       30      18
     BL PERMETHRI LIQ 1%                        PERMETHRIN CREME RINSE 1%                          Scabicides and Pediculicides           120      30
 BL PINK BISM SUS 525/15ML              BISMUTH SUBSALICYLATE SUSP 525 MG/15ML                          Antidiarrhea Agents               1800     30
 BL TRIACTING SYP CHST CON          PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 15-50 MG/5ML                         Expectorants                            30
    BL VIT B-6 TAB 100MG                         PYRIDOXINE HCL TAB 100 MG                              Vitamin B Complex                          30
     BL VIT B-6 TAB 50MG                          PYRIDOXINE HCL TAB 50 MG                              Vitamin B Complex                          30
  BP FOLINATAL TAB PLUS B       *PRENATAL W/ CALCIUM CARBONATE-B6-B12-FA TAB 1 MG***                Multivitamin Preparations                      30      40
  BP MULTINATL CHW PLUS          *PRENATAL W/O A VIT W/ FE FUM-FA TAB CHEW 40-1 MG***               Multivitamin Preparations                      30
   BP MULTINATL TAB PLUS         *PRENATAL W/O A VIT W/ FE FUMARATE-FA TAB 30-1 MG***               Multivitamin Preparations                      30
       BPM/DM/PSE SYP               PSEUDOEPHED-BROMPHEN-DM SYRUP 30-2-10 MG/5ML                            Antitussives                   178     30
   BRIMONIDINE SOL 0.15%                 BRIMONIDINE TARTRATE OPHTH SOLN 0.15%                    ALPHA ADRENERGIC AGONISTS                        30
 BRIMONIDINE SOL 0.2% OP                 BRIMONIDINE TARTRATE OPHTH SOLN 0.2%                     ALPHA ADRENERGIC AGONISTS                        30
    BROM/PSEUD/ SYP DM              PSEUDOEPHED-BROMPHEN-DM SYRUP 60-4-30 MG/5ML                            Antitussives                   178     30
      BROMATANE DX SYP              PSEUDOEPHED-BROMPHEN-DM SYRUP 30-2-10 MG/5ML                            Antitussives                   178     30
  BROMAXEFED SYP DM RF             PSEUDOEPHED-BROMPHEN-DM SYRUP 45-4-15 MG/5ML                             Antitussives                   178     30
     BROMAXEFED SYP RF         BROMPHENIRAMINE & PSEUDOEPHEDRINE SYRUP 4-45 MG/5ML                    Proplamine Derivatives               178     30
        BROMDEX D SYP               PSEUDOEPHED-BROMPHEN-DM SYRUP 50-3-30 MG/5ML                            Antitussives                   178     30
      BROMETANE DX SYP              PSEUDOEPHED-BROMPHEN-DM SYRUP 30-2-10 MG/5ML                            Antitussives                   178     30
       BROMFED DM SYP               PSEUDOEPHED-BROMPHEN-DM SYRUP 30-2-10 MG/5ML                            Antitussives                   178     30
  BROMOCRIPTIN CAP 5MG                      BROMOCRIPTINE MESYLATE CAP 5 MG                        Dopamine Receptor Agonists                      30                                                   Prior Authorization Req'd
 BROMOCRIPTIN TAB 2.5MG                    BROMOCRIPTINE MESYLATE TAB 2.5 MG                       Dopamine Receptor Agonists                      30                                                   Prior Authorization Req'd
      BROMOPHED DX SYP              PSEUDOEPHED-BROMPHEN-DM SYRUP 30-2-10 MG/5ML                            Antitussives                   178     30
   BROMPHEN/DM/ SYP PSE             PSEUDOEPHED-BROMPHEN-DM SYRUP 45-4-15 MG/5ML                            Antitussives                   178     30
    BROMPHENEX SYP DM               PSEUDOEPHED-BROMPHEN-DM SYRUP 60-4-30 MG/5ML                            Antitussives                   178     30
   BROMPHENIRAM SYP PSE        BROMPHENIRAMINE & PSEUDOEPHEDRINE SYRUP 4-45 MG/5ML                    Proplamine Derivatives               178     30
      BROMPLEX DM SYP               PSEUDOEPHED-BROMPHEN-DM SYRUP 60-4-30 MG/5ML                            Antitussives                   178     30
BRONCOTRON LIQ 10-100/5          DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                          Antitussives                   180     30
       BRONTUSS LA TAB          DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 60-1000 MG                         Antitussives                    31     30
BUDESONIDE SUS 0.25MG/2                 BUDESONIDE INHALATION SUSP 0.25 MG/2ML                                Adrenals                             30
                                                                                                                                      Max Qty
                                                                                                                                        Limit   Max Max Age
                                                                                                                                      (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                               Generic Name                                       Therapy Class                   in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
  BUDESONIDE SUS 0.5MG/2                 BUDESONIDE INHALATION SUSP 0.5 MG/2ML                               Adrenals                           30
     BUFFASAL TAB 324MG                         ASPIRIN BUFFERED TAB 325 MG                                 Salicylates                 31      30
   BUFFERED ASA TAB 325MG        ASPIRIN BUFFERED (CA CARB-MG CARB-MG OX) TAB 325 MG                        Salicylates                 31      30
  BUFFERIN TAB LOW DOSE                     ASPIRIN TAB DELAYED RELEASE 81 MG                               Salicylates                 31      30
     BUFPIRIN TAB 325MG                         ASPIRIN BUFFERED TAB 325 MG                                 Salicylates                 31      30
      BUMINATE INJ 25%                             ALBUMIN HUMAN INJ 25%                                Blood Derivatives                       30                                                   Prior Authorization Req'd
   BUPRENORPHIN SUB 2MG               BUPRENORPHINE HCL SL TAB 2 MG (BASE EQUIV)                     Opiate Partial Agonists                    30                                                   Prior Authorization Req'd
   BUPRENORPHIN SUB 8MG               BUPRENORPHINE HCL SL TAB 8 MG (BASE EQUIV)                     Opiate Partial Agonists                    30                                                   Prior Authorization Req'd
    BUPROBAN TAB 150MG          BUPROPION HCL (SMOKING DETERRENT) TAB SR 12HR 150 MG             Miscellaneous Antidepressants                  30                                                   Prior Authorization Req'd
   BUPROPION TAB 150MG          BUPROPION HCL (SMOKING DETERRENT) TAB SR 12HR 150 MG             Miscellaneous Antidepressants                  30                                                   Prior Authorization Req'd
       BUT/APAP/CAF CAP          BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-325-40 MG             Analgesics and Antipyretics, Misc       20      30
        BUT/APAP/CAF TAB         BUTALBITAL-ACETAMINOPHEN-CAFFEINE TAB 50-325-40 MG             Analgesics and Antipyretics, Misc       20      30
BUT/ASA/CAF/ CAP COD 30MG       BUTALBITAL-ASPIRIN-CAFF W/ CODEINE CAP 50-325-40-30 MG                   Opiate Agonists                20      30
        BUT/ASA/CAFF CAP             BUTALBITAL-ASPIRIN-CAFFEINE CAP 50-325-40 MG                           Salicylates                 20      30
        BUT/ASA/CAFF TAB             BUTALBITAL-ASPIRIN-CAFFEINE TAB 50-325-40 MG                           Salicylates                         30
   BUTAL CPD/ CAP CODEINE       BUTALBITAL-ASPIRIN-CAFF W/ CODEINE CAP 50-325-40-30 MG                   Opiate Agonists                20      30
    BUTAL/APAP TAB 50-325               BUTALBITAL-ACETAMINOPHEN TAB 50-325 MG                  Analgesics and Antipyretics, Misc       20      30
      BUTALBITAL CAP CPD             BUTALBITAL-ASPIRIN-CAFFEINE CAP 50-325-40 MG                           Salicylates                 20      30
      BUTALBITAL TAB CPD             BUTALBITAL-ASPIRIN-CAFFEINE TAB 50-325-40 MG                           Salicylates                         30
      BYETTA    INJ 10MCG                       EXENATIDE INJ 10 MCG/0.04ML                             Incretin Mimetics                       30                                                   Prior Authorization Req'd
       BYETTA    INJ 5MCG                        EXENATIDE INJ 5 MCG/0.02ML                             Incretin Mimetics                       30                                                   Prior Authorization Req'd
   CALC ACETATE CAP 667MG     CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA)            Replacement Preparations                     30
   CALCITONIN SPR 200/ACT            CALCITONIN (SALMON) NASAL SOLN 200 UNIT/ACT                           Parathyroid                          30                                                   Prior Authorization Req'd
   CALCITRIOL CAP 0.25MCG                          CALCITRIOL CAP 0.25 MCG                                   Vitamin D                          30
    CALCITRIOL CAP 0.5MCG                           CALCITRIOL CAP 0.5 MCG                                   Vitamin D                          30
   CALCITRIOL INJ 1MCG/ML                          CALCITRIOL INJ 1 MCG/ML                                   Vitamin D                          30                                                   Prior Authorization Req'd
  CALCITRIOL SOL 1MCG/ML                      CALCITRIOL ORAL SOLN 1 MCG/ML                                  Vitamin D                          30      18
      CALDECORT CRE 1%                           HYDROCORTISONE CREAM 1%                            Anti-inflammatory Agents                    30
         CAL-NATE TAB        *PRENATAL W/O A W/ FE CARBONYL-FE GLUC-DSS-FA TAB 27-1MG***           Multivitamin Preparations                    30      40
          CAM      LOT                              *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                  30                                                   Prior Authorization Req'd
     CAMILA    TAB 0.35MG                       NORETHINDRONE TAB 0.35 MG                                 Contraceptives                        30
   CAMPATH INJ 10MG/ML                ALEMTUZUMAB IV INJ 10 MG/ML (FOR INFUSION)                      Antineoplastic Agents                     30                                                   Prior Authorization Req'd
  CAMPTOSAR INJ 20MG/ML                IRINOTECAN HCL INJ 300 MG/15ML (20 MG/ML)                      Antineoplastic Agents                     30                                                   Prior Authorization Req'd
    CANASA     SUP 1000MG                       MESALAMINE SUPPOS 1000 MG                           Anti-inflammatory Agents                    30
 CAPTOPR/HCTZ TAB 25-15MG           CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 25-15 MG           Angiotensin-Converting Enzyme Inhibitors             30
 CAPTOPR/HCTZ TAB 25-25MG           CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 25-25 MG           Angiotensin-Converting Enzyme Inhibitors             30
 CAPTOPR/HCTZ TAB 50-15MG           CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 50-15 MG           Angiotensin-Converting Enzyme Inhibitors             30
 CAPTOPR/HCTZ TAB 50-25MG           CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 50-25 MG           Angiotensin-Converting Enzyme Inhibitors             30
    CAPTOPRIL TAB 100MG                             CAPTOPRIL TAB 100 MG                   Angiotensin-Converting Enzyme Inhibitors             30
    CAPTOPRIL TAB 12.5MG                            CAPTOPRIL TAB 12.5 MG                  Angiotensin-Converting Enzyme Inhibitors             30
     CAPTOPRIL TAB 25MG                              CAPTOPRIL TAB 25 MG                   Angiotensin-Converting Enzyme Inhibitors             30
     CAPTOPRIL TAB 50MG                              CAPTOPRIL TAB 50 MG                   Angiotensin-Converting Enzyme Inhibitors             30
       CARAC     CRE 0.5%                         FLUOROURACIL CREAM 0.5%                  Skin and Mucous Membrane Agents, Misc                30
  CARB/LEVO TAB 10-100MG                  CARBIDOPA & LEVODOPA TAB 10-100 MG                     Central Nervous System Agents                  30
  CARB/LEVO TAB 25-100MG                  CARBIDOPA & LEVODOPA TAB 25-100 MG                     Central Nervous System Agents                  30
  CARB/LEVO TAB 25-250MG                  CARBIDOPA & LEVODOPA TAB 25-250 MG                     Central Nervous System Agents                  30
CARB/LEVO ER TAB 25-100MG                CARBIDOPA & LEVODOPA TAB CR 25-100 MG                   Central Nervous System Agents                  30
CARB/LEVO ER TAB 50-200MG                CARBIDOPA & LEVODOPA TAB CR 50-200 MG                   Central Nervous System Agents                  30
 CARB/LEVO SR TAB 25-100MG               CARBIDOPA & LEVODOPA TAB CR 25-100 MG                   Central Nervous System Agents                  30
 CARB/LEVO SR TAB 50-200MG               CARBIDOPA & LEVODOPA TAB CR 50-200 MG                   Central Nervous System Agents                  30
 CARBAMAZEPIN CHW 100MG                     CARBAMAZEPINE CHEW TAB 100 MG                        Anticonvulsants, Miscellaneous                 30
 CARBAMAZEPIN SUS 100/5ML                    CARBAMAZEPINE SUSP 100 MG/5ML                       Anticonvulsants, Miscellaneous                 30      12
  CARBAMAZEPIN TAB 200MG                         CARBAMAZEPINE TAB 200 MG                        Anticonvulsants, Miscellaneous                 30
CARBAMAZEPIN TAB 200MG ER                  CARBAMAZEPINE TAB SR 12HR 200 MG                      Anticonvulsants, Miscellaneous                 30                                                   Prior Authorization Req'd
CARBAMAZEPIN TAB 400MG ER                  CARBAMAZEPINE TAB SR 12HR 400 MG                      Anticonvulsants, Miscellaneous                 30                                                   Prior Authorization Req'd
    CARBATROL CAP 100MG                    CARBAMAZEPINE CAP SR 12HR 100 MG                      Anticonvulsants, Miscellaneous                 30                                                   Prior Authorization Req'd
    CARBATROL CAP 200MG                    CARBAMAZEPINE CAP SR 12HR 200 MG                      Anticonvulsants, Miscellaneous                 30                                                   Prior Authorization Req'd
    CARBATROL CAP 300MG                    CARBAMAZEPINE CAP SR 12HR 300 MG                      Anticonvulsants, Miscellaneous                 30                                                   Prior Authorization Req'd
       CARBODEX DM SYP            PSEUDOEPHED-BROMPHEN-DM SYRUP 45-4-15 MG/5ML                             Antitussives                 178     30
        CARBOFED DM SYP           PSEUDOEPHED-BROMPHEN-DM SYRUP 45-4-15 MG/5ML                             Antitussives                 178     30
CARDIZEM CD CAP 360MG/24            DILTIAZEM HCL COATED BEADS CAP SR 24HR 360 MG           Calcium-Channel Blocking Agents, Misc               30
    CAROGUARD CAP 15MG                            BETA CAROTENE CAP 15 MG                                    Vitamin A                          30
    CARTEOLOL SOL 1% OP                        CARTEOLOL HCL OPHTH SOLN 1%                   BETA ADRENERGIC BLOCKING AGENTS                    30
   CARTIA XT CAP 120/24HR           DILTIAZEM HCL COATED BEADS CAP SR 24HR 120 MG           Calcium-Channel Blocking Agents, Misc               30
   CARTIA XT CAP 180/24HR           DILTIAZEM HCL COATED BEADS CAP SR 24HR 180 MG           Calcium-Channel Blocking Agents, Misc               30
                                                                                                                                     Max Qty
                                                                                                                                       Limit   Max Max Age
                                                                                                                                     (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                               Generic Name                                        Therapy Class                 in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
  CARTIA XT CAP 240/24HR            DILTIAZEM HCL COATED BEADS CAP SR 24HR 240 MG            Calcium-Channel Blocking Agents, Misc             30
  CARTIA XT CAP 300/24HR            DILTIAZEM HCL COATED BEADS CAP SR 24HR 300 MG            Calcium-Channel Blocking Agents, Misc             30
  CARVEDILOL TAB 12.5MG                          CARVEDILOL TAB 12.5 MG                         Beta-Adrenergic Blocking Agents                30
    CARVEDILOL TAB 25MG                           CARVEDILOL TAB 25 MG                          Beta-Adrenergic Blocking Agents                30
  CARVEDILOL TAB 3.125MG                         CARVEDILOL TAB 3.125 MG                        Beta-Adrenergic Blocking Agents                30
  CARVEDILOL TAB 6.25MG                          CARVEDILOL TAB 6.25 MG                         Beta-Adrenergic Blocking Agents                30
      CAUT CONDOMS MIS                         CONDOMS LATEX LUBRICATED                                   Contraceptives                       30
CAUT CONDOMS MIS SPERMICI                      CONDOMS LATEX LUBRICATED                                   Contraceptives                       30
   CAVAN      TAB PRENATAL     *PRENATAL W/O A VIT W/ FE FUMARATE-FA TAB DR 30-1 MG***             Multivitamin Preparations                   30      40
  CAVAN ONE CAP OMEGA        *PRENATAL VIT W/ FE CBN-FE ASP GLYC-FA-OMEGA 3 CAP 27-1MG***          Multivitamin Preparations                   30      40
    CAVAN-EC SOD MIS DHA     *PRENATAL W/ SOD FEREDETATE-FA TAB 30-1 & OMEGA 3 CAP DR***           Multivitamin Preparations                   30      40
     CAVAREST GEL 1.1%                     SODIUM FLUORIDE GEL 1.1% (0.5% F)                   Miscellaneous Therapeutic Agents                30      18
    CAVERJECT INJ 20MCG                        ALPROSTADIL FOR INJ 20 MCG                      Vasodilating Agents, Miscellaneous              30                                                   Prior Authorization Req'd
    CAVERJECT INJ 40MCG                        ALPROSTADIL FOR INJ 40 MCG                      Vasodilating Agents, Miscellaneous              30                                                   Prior Authorization Req'd
    CAVERJECT KIT 10MCG                      ALPROSTADIL FOR INJ KIT 10 MCG                    Vasodilating Agents, Miscellaneous              30                                                   Prior Authorization Req'd
    CAVERJECT KIT 20MCG                      ALPROSTADIL FOR INJ KIT 20 MCG                    Vasodilating Agents, Miscellaneous              30                                                   Prior Authorization Req'd
     CAVIRINSE SOL 0.2%                        SODIUM FLUORIDE RINSE 0.2%                      Miscellaneous Therapeutic Agents                30      18
        CAZIANT PAK           DESOGEST-ETHIN EST TAB 0.1-0.025/0.125-0.025/0.15-0.025MG-MG                Contraceptives                       30
    CEDAX      SUS 180/5ML                  CEFTIBUTEN FOR SUSP 180 MG/5ML                      Third Generation Cephalosporins                14      18
  CEDAX      SUS 90MG/5ML                    CEFTIBUTEN FOR SUSP 90 MG/5ML                      Third Generation Cephalosporins                14      18
     CEENU      CAP 100MG                         LOMUSTINE CAP 100 MG                                Antineoplastic Agents                    30
     CEENU      CAP 10MG                           LOMUSTINE CAP 10 MG                                Antineoplastic Agents                    30
     CEENU      CAP 40MG                           LOMUSTINE CAP 40 MG                                Antineoplastic Agents                    30
  CEENU       PAK DOSEPACK                      LOMUSTINE CAP DOSE PACK                               Antineoplastic Agents                    30
  CEFADROXIL SUS 250/5ML                    CEFADROXIL FOR SUSP 250 MG/5ML                      First Generation Cephalosporins                14      18
  CEFADROXIL SUS 500/5ML                    CEFADROXIL FOR SUSP 500 MG/5ML                      First Generation Cephalosporins                14      18
    CEFDINIR CAP 300MG                              CEFDINIR CAP 300 MG                         Third Generation Cephalosporins                14
   CEFDINIR SUS 125/5ML                       CEFDINIR FOR SUSP 125 MG/5ML                      Third Generation Cephalosporins                14      18
   CEFDINIR SUS 250/5ML                       CEFDINIR FOR SUSP 250 MG/5ML                      Third Generation Cephalosporins                14      18
 CEFPODO PROX SUS 100/5ML             CEFPODOXIME PROXETIL FOR SUSP 100 MG/5ML                  Third Generation Cephalosporins                14      18
CEFPODO PROX SUS 50MG/5ML             CEFPODOXIME PROXETIL FOR SUSP 50 MG/5ML                   Third Generation Cephalosporins                14      18
  CEFPODOXIME TAB 100MG                    CEFPODOXIME PROXETIL TAB 100 MG                      Third Generation Cephalosporins                14
  CEFPODOXIME TAB 200MG                    CEFPODOXIME PROXETIL TAB 200 MG                      Third Generation Cephalosporins                14
   CEFPROZIL SUS 125/5ML                     CEFPROZIL FOR SUSP 125 MG/5ML                     Second Generation Cephalosporins                14      18
   CEFPROZIL SUS 250/5ML                     CEFPROZIL FOR SUSP 250 MG/5ML                     Second Generation Cephalosporins                14      18
    CEFPROZIL TAB 250MG                            CEFPROZIL TAB 250 MG                        Second Generation Cephalosporins                14
    CEFPROZIL TAB 500MG                            CEFPROZIL TAB 500 MG                        Second Generation Cephalosporins                14
    CEFTIN     SUS 125/5ML              CEFUROXIME AXETIL FOR SUSP 125 MG/5ML                  Second Generation Cephalosporins                14      18
    CEFTIN     SUS 250/5ML              CEFUROXIME AXETIL FOR SUSP 250 MG/5ML                  Second Generation Cephalosporins                14      18
 CEFUROXIME SUS 125/5ML                 CEFUROXIME AXETIL FOR SUSP 125 MG/5ML                  Second Generation Cephalosporins                14      18
 CEFUROXIME SUS 250/5ML                 CEFUROXIME AXETIL FOR SUSP 250 MG/5ML                  Second Generation Cephalosporins                14      18
  CEFUROXIME TAB 250MG                        CEFUROXIME AXETIL TAB 250 MG                     Second Generation Cephalosporins                14
  CEFUROXIME TAB 500MG                        CEFUROXIME AXETIL TAB 500 MG                     Second Generation Cephalosporins                14
    CELONTIN CAP 300MG                          METHSUXIMIDE CAP 300 MG                                    Succinimides                        30
      CENTANY OIN 2%                                MUPIROCIN OINT 2%                                     Antibacterials                       30
   CENTEX-PSE TAB 600-120        PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-600 MG                        Expectorants                31      30
   CEPHALEXIN CAP 250MG                           CEPHALEXIN CAP 250 MG                         First Generation Cephalosporins                14
   CEPHALEXIN CAP 500MG                           CEPHALEXIN CAP 500 MG                         First Generation Cephalosporins                14
  CEPHALEXIN SUS 125/5ML                    CEPHALEXIN FOR SUSP 125 MG/5ML                      First Generation Cephalosporins                14      18
  CEPHALEXIN SUS 250/5ML                    CEPHALEXIN FOR SUSP 250 MG/5ML                      First Generation Cephalosporins                14      18
   CEPHALEXIN TAB 250MG                           CEPHALEXIN TAB 250 MG                         First Generation Cephalosporins                14
   CEPHALEXIN TAB 500MG                           CEPHALEXIN TAB 500 MG                         First Generation Cephalosporins                14
        CERAVE      LOT                           *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
    CERAVE AM LOT SPF 30                          *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
       CERAVE PM LOT                              *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
         CESIA     PAK        DESOGEST-ETHIN EST TAB 0.1-0.025/0.125-0.025/0.15-0.025MG-MG                Contraceptives                       30
      CETACORT LOT 1%                          HYDROCORTISONE LOTION 1%                             Anti-inflammatory Agents                   30
       CETA-KLENZ LOT                             *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
  CETAPHIL LOT CLEANSER                           *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
  CETAPHIL LOT MOISTURE                           *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
  CETAPHIL LOT RESTORAD                           *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
 CETAPHIL DAY LOT ADVANCE                         *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
   CETAPHIL FAC LOT SPF 15                        *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
   CETIRIZINE SOL 1MG/ML                CETIRIZINE HCL SYRUP 1 MG/ML (5 MG/5ML)                Second Generation Antihistamines                30      9
  CETIRIZINE SOL 5MG/5ML                CETIRIZINE HCL SYRUP 1 MG/ML (5 MG/5ML)                Second Generation Antihistamines                30      9
                                                                                                                                         Max Qty
                                                                                                                                           Limit   Max Max Age
                                                                                                                                         (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                                Generic Name                                        Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
    CETIRIZINE SYP 1MG/ML                 CETIRIZINE HCL SYRUP 1 MG/ML (5 MG/5ML)               Second Generation Antihistamines                   30      9
   CETIRIZINE SYP 5MG/5ML                 CETIRIZINE HCL SYRUP 1 MG/ML (5 MG/5ML)               Second Generation Antihistamines                   30      9
      CETIRIZINE TAB 10MG                           CETIRIZINE HCL TAB 10 MG                    Second Generation Antihistamines                   30
      CGH CONTROL SYP PE            PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 30-100 MG/5ML                         Expectorants                           30
  CGH RELIEVER LIQ DOUBL ST       DEXTROMETHORPHAN-GUAIFENESIN LIQUID 30-200 MG/5ML                          Antitussives                  180     30
     CHELATED K TAB 99MG                              POTASSIUM TAB 99 MG                           Replacement Preparations                       30
         CHEMSTRIP K TES                          ACETONE (URINE) TEST STRIP                                   Ketones                             30
      CHERATUSSIN SYP AC                 GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML                              Antitussives                  180     30
 CHEST CONGES TAB 20-400MG            DEXTROMETHORPHAN-GUAIFENESIN TAB 20-400 MG                             Antitussives                   31     30
  CHEST/NASAL SYP CONGEST           PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 15-50 MG/5ML                          Expectorants                           30
    CHILD APAP CHW 80MG                       ACETAMINOPHEN CHEW TAB 80 MG                       Analgesics and Antipyretics, Misc          60     30
 CHILD APAP CHW 80MG GRP                      ACETAMINOPHEN CHEW TAB 80 MG                       Analgesics and Antipyretics, Misc          60     30
 CHILD APAP CHW 80MG GUM                      ACETAMINOPHEN CHEW TAB 80 MG                       Analgesics and Antipyretics, Misc          60     30
   CHILD APAP ELX 160/5ML                    ACETAMINOPHEN ELIXIR 160 MG/5ML                     Analgesics and Antipyretics, Misc         240     30
     CHILD ASA CHW 81MG                             ASPIRIN CHEW TAB 81 MG                                    Salicylates                   31     30
    CHILD ASA LS CHW 81MG                           ASPIRIN CHEW TAB 81 MG                                    Salicylates                   31     30
 CHILD COMPLE CHW ALLERGY                 DIPHENHYDRAMINE HCL CHEW TAB 12.5 MG                       Ethanolamine Derivatives                      30
   CHILD NONASA CHW 80MG                      ACETAMINOPHEN CHEW TAB 80 MG                       Analgesics and Antipyretics, Misc          60     30
 CHILD NONASA CHW PAIN/REL                    ACETAMINOPHEN CHEW TAB 80 MG                       Analgesics and Antipyretics, Misc          60     30
   CHILD PAIN LIQ RELIEVER                   ACETAMINOPHEN LIQUID 160 MG/5ML                     Analgesics and Antipyretics, Misc         240     30
    CHILD PN REL CHW 80MG                     ACETAMINOPHEN CHEW TAB 80 MG                       Analgesics and Antipyretics, Misc          60     30
   CHILD PN REL ELX 160/5ML                  ACETAMINOPHEN ELIXIR 160 MG/5ML                     Analgesics and Antipyretics, Misc         240     30
  CHILD PN/FEV DRO 80/0.8ML                  ACETAMINOPHEN SUSP 80 MG/0.8ML                      Analgesics and Antipyretics, Misc          30     30
  CHILD SILFED LIQ 15MG/5ML                 PSEUDOEPHEDRINE HCL LIQ 15 MG/5ML                  alpha- and beta-Adrenergic Agonists         480     30
    CHILDRENS CHW 80MG                        ACETAMINOPHEN CHEW TAB 80 MG                       Analgesics and Antipyretics, Misc          60     30
   CHILDRENS LIQ 5-100MG           DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML                          Antitussives                  180     30
   CHILDS APAP SUS 160/5ML                    ACETAMINOPHEN SUSP 160 MG/5ML                      Analgesics and Antipyretics, Misc         240     30
  CHILDS APAP SUS 320/10ML                    ACETAMINOPHEN SUSP 160 MG/5ML                      Analgesics and Antipyretics, Misc         240     30
    CHILDS APAP SUS 325MG                     ACETAMINOPHEN SUSP 160 MG/5ML                      Analgesics and Antipyretics, Misc         240     30
  CHILDS APAP SUS 640/20ML                    ACETAMINOPHEN SUSP 160 MG/5ML                      Analgesics and Antipyretics, Misc         240     30
    CHILDS APAP SUS 650MG                     ACETAMINOPHEN SUSP 160 MG/5ML                      Analgesics and Antipyretics, Misc         240     30
    CHILDS PAIN SUS RELIEF                    ACETAMINOPHEN SUSP 160 MG/5ML                      Analgesics and Antipyretics, Misc         240     30
  CHLD ALLERGY LIQ 12.5/5ML              DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                      Ethanolamine Derivatives                      30
  CHLD ASAFREE ELX 80/2.5ML                  ACETAMINOPHEN ELIXIR 160 MG/5ML                     Analgesics and Antipyretics, Misc         240     30
  CHLD ASAFREE SUS 80/2.5ML                   ACETAMINOPHEN SUSP 160 MG/5ML                      Analgesics and Antipyretics, Misc         240     30
CHLD DECONGS LIQ 15MG/5ML                   PSEUDOEPHEDRINE HCL LIQ 15 MG/5ML                  alpha- and beta-Adrenergic Agonists         480     30
 CHLD IBUPRFN DRO 40MG/ML                          IBUPROFEN SUSP 40 MG/ML                  Other Nonsteroidal Anti-inflammtory Agents             30      18
  CHLD IBUPROF SUS 100/5ML                       IBUPROFEN SUSP 100 MG/5ML                  Other Nonsteroidal Anti-inflammtory Agents             30      18
   CHLD MEDITAB CHW 80MG                      ACETAMINOPHEN CHEW TAB 80 MG                       Analgesics and Antipyretics, Misc          60     30
CHLD NON-ASA CHW 80MG GRP                     ACETAMINOPHEN CHEW TAB 80 MG                       Analgesics and Antipyretics, Misc          60     30
 CHLD PN REL CHW 80MG GRP                     ACETAMINOPHEN CHEW TAB 80 MG                       Analgesics and Antipyretics, Misc          60     30
   CHLD SILAPAP LIQ 160/5ML                  ACETAMINOPHEN LIQUID 160 MG/5ML                     Analgesics and Antipyretics, Misc         240     30
  CHLORASEPTIC LIQ SORE THR                  ACETAMINOPHEN LIQUID 167 MG/5ML                     Analgesics and Antipyretics, Misc         240     30
   CHLORHEX GLU SOL 0.12%                  CHLORHEXIDINE GLUCONATE SOLN 0.12%                   EENT Anti-infectives, Miscellaneous                30
  CHLORPHEN HD SYP 5-2-1.67   PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 5-2-1.67 MG/5ML                       Antitussives                  178     30
   CHLORTHALID TAB 100MG                        CHLORTHALIDONE TAB 100 MG                              Thiazide-like Diuretics                     30
    CHLORTHALID TAB 25MG                          CHLORTHALIDONE TAB 25 MG                             Thiazide-like Diuretics                     30
    CHLORTHALID TAB 50MG                          CHLORTHALIDONE TAB 50 MG                             Thiazide-like Diuretics                     30
  CHO MAG TRIS TAB 1000MG             CHOLINE & MAGNESIUM SALICYLATES TAB 1000 MG                             Salicylates                          30
   CHO MAG TRIS TAB 500MG              CHOLINE & MAGNESIUM SALICYLATES TAB 500 MG                             Salicylates                          30
   CHO MAG TRIS TAB 750MG              CHOLINE & MAGNESIUM SALICYLATES TAB 750 MG                             Salicylates                          30
   CHOLESTYRAM POW 4GM                      CHOLESTYRAMINE POWDER 4 GM/DOSE                            Bile Acid Sequestrants                      30
CHOLESTYRAM POW 4GM LITE                 CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE                         Bile Acid Sequestrants                      30
     CICLOPIROX CRE 0.77%              CICLOPIROX OLAMINE CREAM 0.77% (BASE EQUIV)                       Hydroxypyridones                          30                                                   Prior Authorization Req'd
     CICLOPIROX GEL 0.77%                             CICLOPIROX GEL 0.77%                               Hydroxypyridones                          30                                                   Prior Authorization Req'd
       CICLOPIROX SHA 1%                            CICLOPIROX SHAMPOO 1%                                Hydroxypyridones                          30                                                   Prior Authorization Req'd
     CICLOPIROX SUS 0.77%               CICLOPIROX OLAMINE SUSP 0.77% (BASE EQUIV)                       Hydroxypyridones                          30                                                   Prior Authorization Req'd
    CILOSTAZOL TAB 100MG                             CILOSTAZOL TAB 100 MG                        Platelet-Aggregation Inhibitors                  30
     CILOSTAZOL TAB 50MG                             CILOSTAZOL TAB 50 MG                         Platelet-Aggregation Inhibitors                  30
   CIMETIDINE SOL 300/5ML                     CIMETIDINE HCL SOLN 300 MG/5ML                        Histamine H2-Antagonists                       30      6
    CIMETIDINE TAB 200MG                             CIMETIDINE TAB 200 MG                          Histamine H2-Antagonists                       30
    CIMETIDINE TAB 300MG                             CIMETIDINE TAB 300 MG                          Histamine H2-Antagonists                       30
    CIMETIDINE TAB 400MG                             CIMETIDINE TAB 400 MG                          Histamine H2-Antagonists                       30
    CIMETIDINE TAB 800MG                             CIMETIDINE TAB 800 MG                          Histamine H2-Antagonists                       30
   CIPRO (10%) SUS 500MG/5     CIPROFLOXACIN FOR ORAL SUSP 500 MG/5ML (10%) (10 GM/100ML)                    Quinolones                            14      18
                                                                                                                               Max Qty
                                                                                                                                 Limit   Max Max Age
                                                                                                                               (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                               Generic Name                                    Therapy Class               in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
   CIPRO (5%) SUS 250MG/5        CIPROFLOXACIN FOR ORAL SUSP 250 MG/5ML (5%) (5 GM/100ML)               Quinolones                       14      18
   CIPRODEX SUS 0.3-0.1%              CIPROFLOXACIN-DEXAMETHASONE OTIC SUSP 0.3-0.1%                  Corticosteroids                    30                                                   Prior Authorization Req'd
  CIPROFLOXACN TAB 100MG                   CIPROFLOXACIN HCL TAB 100 MG (BASE EQUIV)                    Quinolones                       14
  CIPROFLOXACN TAB 250MG                   CIPROFLOXACIN HCL TAB 250 MG (BASE EQUIV)                    Quinolones                       14
  CIPROFLOXACN TAB 500MG                   CIPROFLOXACIN HCL TAB 500 MG (BASE EQUIV)                    Quinolones                       14
  CIPROFLOXACN TAB 750MG                   CIPROFLOXACIN HCL TAB 750 MG (BASE EQUIV)                    Quinolones                       14
 CLARITHROMYC SUS 125/5ML                     CLARITHROMYCIN FOR SUSP 125 MG/5ML                    Other Macrolides                     14      18
 CLARITHROMYC SUS 250/5ML                     CLARITHROMYCIN FOR SUSP 250 MG/5ML                    Other Macrolides                     14      18
  CLARITHROMYC TAB 250MG                            CLARITHROMYCIN TAB 250 MG                       Other Macrolides                     14
  CLARITHROMYC TAB 500MG                            CLARITHROMYCIN TAB 500 MG                       Other Macrolides                     14
     CLARITIN CAP 10MG                                 LORATADINE CAP 10 MG                 Second Generation Antihistamines             30
     CLARITIN CHW 5MG                               LORATADINE CHEW TAB 5 MG                Second Generation Antihistamines             30
     CLARITIN RDT TAB 5MG                 LORATADINE ORALLY DISINTEGRATING TAB 5 MG         Second Generation Antihistamines             30
   CLASS ACT MIS LUBRICAT                           CONDOMS LATEX LUBRICATED                          Contraceptives                     30
CLEAN&CLEAR LOT MORNING                                *EMOLLIENT - LOTION**                   Basic Lotions and Liniments               30                                                   Prior Authorization Req'd
    CLEAN&CLEAR LOT SOFT                               *EMOLLIENT - LOTION**                   Basic Lotions and Liniments               30                                                   Prior Authorization Req'd
     CLEAR COUGH SYP DM             DEXTROMETHORPHAN-GUAIFENESIN SYRUP 15-100 MG/5ML                    Antitussives             180     30
   CLEAR-ATADIN TAB 10MG                 LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG        Second Generation Antihistamines             30
   CLEMASTINE SYP 0.5/5ML      CLEMASTINE FUMARATE SYRUP 0.67 MG/5ML (0.5 MG/5ML BASE EQ)       Ethanolamine Derivatives                 30      18
   CLEMASTINE TAB 2.68MG                        CLEMASTINE FUMARATE TAB 2.68 MG                 Ethanolamine Derivatives                 30
   CLINDAMAX CRE 2% VAG                    CLINDAMYCIN PHOSPHATE VAGINAL CREAM 2%                      Antibacterials            40      30
  CLINDAMYCIN CAP 150MG                            CLINDAMYCIN HCL CAP 150 MG                           Lincomycins                      30
  CLINDAMYCIN CAP 300MG                            CLINDAMYCIN HCL CAP 300 MG                           Lincomycins                      30
  CLINDAMYCIN CRE 2% VAG                   CLINDAMYCIN PHOSPHATE VAGINAL CREAM 2%                      Antibacterials            40      30
     CLINDAMYCIN SOL 1%                          CLINDAMYCIN PHOSPHATE SOLN 1%                         Antibacterials                    30      18
CLINDAMYCIN SOL 75MG/5ML        CLINDAMYCIN PALMITATE HCL FOR SOLN 75 MG/5ML (BASE EQUIV)               Lincomycins                      30      18
    CLOBETASOL CRE 0.05%                      CLOBETASOL PROPIONATE CREAM 0.05%                 Anti-inflammatory Agents         30      30
    CLOBETASOL GEL 0.05%                        CLOBETASOL PROPIONATE GEL 0.05%                 Anti-inflammatory Agents                 30                                                   Prior Authorization Req'd
    CLOBETASOL OIN 0.05%                       CLOBETASOL PROPIONATE OINT 0.05%                 Anti-inflammatory Agents         30      30
    CLOBETASOL SOL 0.05%                       CLOBETASOL PROPIONATE SOLN 0.05%                 Anti-inflammatory Agents         60      30
   CLOBETASOL E CRE 0.05%            CLOBETASOL PROPIONATE EMOLLIENT BASE CREAM 0.05%           Anti-inflammatory Agents                 30                                                   Prior Authorization Req'd
    CLOBEVATE GEL 0.05%                         CLOBETASOL PROPIONATE GEL 0.05%                 Anti-inflammatory Agents                 30                                                   Prior Authorization Req'd
 CLONAZEP ODT TAB 0.125MG              CLONAZEPAM ORALLY DISINTEGRATING TAB 0.125 MG         Anticonvulsant Benzodiazepines              30                                                   Prior Authorization Req'd
  CLONAZEP ODT TAB 0.25MG               CLONAZEPAM ORALLY DISINTEGRATING TAB 0.25 MG         Anticonvulsant Benzodiazepines              30                                                   Prior Authorization Req'd
  CLONAZEP ODT TAB 0.5MG                CLONAZEPAM ORALLY DISINTEGRATING TAB 0.5 MG          Anticonvulsant Benzodiazepines              30                                                   Prior Authorization Req'd
    CLONAZEP ODT TAB 1MG                 CLONAZEPAM ORALLY DISINTEGRATING TAB 1 MG           Anticonvulsant Benzodiazepines              30                                                   Prior Authorization Req'd
    CLONAZEP ODT TAB 2MG                 CLONAZEPAM ORALLY DISINTEGRATING TAB 2 MG           Anticonvulsant Benzodiazepines              30                                                   Prior Authorization Req'd
   CLONAZEPAM TAB 0.5MG                               CLONAZEPAM TAB 0.5 MG                  Anticonvulsant Benzodiazepines      240     30
    CLONAZEPAM TAB 1MG                                 CLONAZEPAM TAB 1 MG                   Anticonvulsant Benzodiazepines      120     30
    CLONAZEPAM TAB 2MG                                 CLONAZEPAM TAB 2 MG                   Anticonvulsant Benzodiazepines       60     30
   CLONIDINE DIS 0.1/24HR                 CLONIDINE HCL TD PATCH WEEKLY 0.1 MG/24HR              Central Alpha-Agonists                  30                                                   Prior Authorization Req'd
   CLONIDINE DIS 0.2/24HR                 CLONIDINE HCL TD PATCH WEEKLY 0.2 MG/24HR              Central Alpha-Agonists                  30                                                   Prior Authorization Req'd
   CLONIDINE DIS 0.3/24HR                 CLONIDINE HCL TD PATCH WEEKLY 0.3 MG/24HR              Central Alpha-Agonists                  30                                                   Prior Authorization Req'd
    CLONIDINE TAB 0.1MG                              CLONIDINE HCL TAB 0.1 MG                    Central Alpha-Agonists                  30
    CLONIDINE TAB 0.2MG                              CLONIDINE HCL TAB 0.2 MG                    Central Alpha-Agonists                  30
    CLONIDINE TAB 0.3MG                              CLONIDINE HCL TAB 0.3 MG                    Central Alpha-Agonists                  30
  CLORTIMAZOLE CRE A/F 1%                             CLOTRIMAZOLE CREAM 1%                                Azoles                30      30
  CLOTRIM/BETA CRE DIPROP              CLOTRIMAZOLE W/ BETAMETHASONE CREAM 1-0.05%                         Azoles                        30                                                   Prior Authorization Req'd
  CLOTRIM/BETA LOT DIPROP              CLOTRIMAZOLE W/ BETAMETHASONE LOTION 1-0.05%                        Azoles                        30                                                   Prior Authorization Req'd
     CLOTRIMAZOLE CRE 1%                         CLOTRIMAZOLE VAGINAL CREAM 1%                             Azoles                45      30
   CLOTRIMAZOLE CRE 1% AF                             CLOTRIMAZOLE CREAM 1%                                Azoles                30      30
  CLOTRIMAZOLE CRE 1% VAG                        CLOTRIMAZOLE VAGINAL CREAM 1%                             Azoles                45      30
     CLOTRIMAZOLE CRE 2%                         CLOTRIMAZOLE VAGINAL CREAM 2%                             Azoles                23      30
   CLOTRIMAZOLE CRE 3 DAY                        CLOTRIMAZOLE VAGINAL CREAM 2%                             Azoles                23      30
   CLOTRIMAZOLE LOZ 10MG                           CLOTRIMAZOLE TROCHE 10 MG                               Azoles                        30                                                   Prior Authorization Req'd
     CLOTRIMAZOLE SOL 1%                               CLOTRIMAZOLE SOLN 1%                                Azoles                        30                                                   Prior Authorization Req'd
CLOTRIMAZOLE TAB 100MG VA                       CLOTRIMAZOLE VAGINAL TAB 100 MG                         Antifungals               7      30                                                   Prior Authorization Req'd
   CLOTRIMAZOLE TRO 10MG                           CLOTRIMAZOLE TROCHE 10 MG                               Azoles                        30                                                   Prior Authorization Req'd
      COCOA BUTTER LOT                                 *EMOLLIENT - LOTION**                   Basic Lotions and Liniments               30                                                   Prior Authorization Req'd
        CODAL-DH SYP         PHENYLEPH-PYRILAMINE W/ HYDROCODONE SYRUP 5-8.33-1.66 MG/5ML               Antitussives             178     30
       CODAL-DM SYP                 PHENYLEPHRINE-PYRILAMINE-DM SYRUP 5-8.33-10 MG/5ML                  Antitussives             180     30
CODEINE/APAP TAB 15-300MG                  ACETAMINOPHEN W/ CODEINE TAB 300-15 MG                    Opiate Agonists             120     30
CODEINE/APAP TAB 30-300MG                  ACETAMINOPHEN W/ CODEINE TAB 300-30 MG                    Opiate Agonists             120     30
CODEINE/APAP TAB 60-300MG                  ACETAMINOPHEN W/ CODEINE TAB 300-60 MG                    Opiate Agonists             120     30
  CODICLEAR DH SYP 5-100/5              HYDROCODONE-GUAIFENESIN SYRUP 5-100 MG/5ML                      Antitussives             178     30
                                                                                                                                                  Max Qty
                                                                                                                                                    Limit   Max Max Age
                                                                                                                                                  (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                                  Generic Name                                            Therapy Class                       in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
         CODITUSS DH SYP      PHENYLEPH-PYRILAMINE W/ HYDROCODONE SYRUP 5-8.33-1.66 MG/5ML                        Antitussives                      178     30
        CODITUSS DM SYP             PHENYLEPHRINE-PYRILAMINE-DM SYRUP 5-8.33-10 MG/5ML                            Antitussives                      180     30
   COFEX-DM TAB 55-1000            DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 55-1000 MG                            Antitussives                       31     30
    CO-GESIC TAB 500-5MG                 HYDROCODONE-ACETAMINOPHEN TAB 5-500 MG                                 Opiate Agonists                     150     30
    COLCHICINE TAB 0.6MG                               COLCHICINE TAB 0.6 MG                          Miscellaneous Therapeutic Agents                      30
     COLCRYS TAB 0.6MG                                 COLCHICINE TAB 0.6 MG                          Miscellaneous Therapeutic Agents                      30
         COLDEC DM SYP                PSEUDOEPHED-BROMPHEN-DM SYRUP 45-4-15 MG/5ML                                Antitussives                     178      30
     COLDMIST JR TAB 12HR            PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 48-595 MG                            Expectorants                      31      30
     COLDMIST LA TAB 12HR            PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 85-795 MG                            Expectorants                      31      30
    COLFED-A CAP 8-120 CR           CHLORPHENIRAMINE & PSEUDOEPHEDRINE CAP CR 8-120 MG                      Proplamine Derivatives                  31      30
  COLIDROPS DRO 0.125/ML                    HYOSCYAMINE SULFATE SOLN 0.125 MG/ML                       Antimuscarinics/Antispasmodics               30      30      18
    COLYTE/FLAVR SOL PACKS        PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 227.1 GM                  Cathartics and Laxatives               4000     30
          COMBI RX TAB             *PRENATAL W/ CALCIUM CARBONATE-B6-B12-FA TAB 1 MG***                   Multivitamin Preparations                         30      40
   COMBIPATCH DIS .05/.14          ESTRADIOL-NORETHINDRONE ACE TD PTTW 0.05-0.14 MG/DAY                             Estrogens                               30                                                   Prior Authorization Req'd
   COMBIPATCH DIS .05/.25          ESTRADIOL-NORETHINDRONE ACE TD PTTW 0.05-0.25 MG/DAY                             Estrogens                               30                                                   Prior Authorization Req'd
         COMBIVENT AER        IPRATROPIUM-ALBUTEROL AEROSOL 18-103 MCG/ACT (20-120MCG/ACT)           Selective beta-2-Adrenergic Agonists           30      30                                                   Prior Authorization Req'd
          COMBIVIR TAB                      LAMIVUDINE-ZIDOVUDINE TAB 150-300 MG                Nucleoside & Nucleotide Rev Transcriptase Inhib             30
        COMFORT GEL SUS          ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML                   Antacids and Adsorbents                  480     30
 COMFORT GEL SUS ANTI-GAS        ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML                   Antacids and Adsorbents                  480     30
    COMFORT GEL SUS EX ST        ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML                   Antacids and Adsorbents                  480     30
   COMP ALLERGY CAP 25MG                        DIPHENHYDRAMINE HCL CAP 25 MG                              Ethanolamine Derivatives                         30
 COMP ALLERGY LIQ 12.5/5ML                 DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                          Ethanolamine Derivatives                         30
   COMP ALLERGY TAB 25MG                        DIPHENHYDRAMINE HCL TAB 25 MG                              Ethanolamine Derivatives                         30
COMP ALLERGY TAB 25MG MED                       DIPHENHYDRAMINE HCL TAB 25 MG                              Ethanolamine Derivatives                         30
 COMP ALLERGY TAB 25MG RLF                      DIPHENHYDRAMINE HCL TAB 25 MG                              Ethanolamine Derivatives                         30
       COMPLETE KIT LICE      PYRETH-PIPERONYL BUTOX SHAM-PERMETH AERO-NIT REMOVER GEL KIT               Scabicides and Pediculicides                       30
    COMPLETE NAT PAK DHA         *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA 3 CAP 250 PK**             Multivitamin Preparations                         30      40
      COMPLETENATE CHW              *PRENATAL VIT W/ FE FUMARATE-FA CHEW TAB 29-1 MG***                   Multivitamin Preparations                         30      40
         COMPLEX 15 LOT                                *EMOLLIENT - LOTION**                              Basic Lotions and Liniments                       30                                                   Prior Authorization Req'd
     COMPRO       SUP 25MG                      PROCHLORPERAZINE SUPPOS 25 MG                                    Phenothiazines                             30
    COMTAN       TAB 200MG                            ENTACAPONE TAB 200 MG                             Central Nervous System Agents                       30
   CO-NATAL FA TAB 29-1MG              *PRENATAL VIT W/ FE FUMARATE-FA TAB 29-1 MG***                     Multivitamin Preparations                         30      40
     CONCERTA TAB 18MG                      METHYLPHENIDATE HCL TAB SA OSM 18 MG                   Anorexigenics & Resp & Cereb Stim, Misc           30     30      20
     CONCERTA TAB 27MG                      METHYLPHENIDATE HCL TAB SA OSM 27 MG                   Anorexigenics & Resp & Cereb Stim, Misc           30     30      20
     CONCERTA TAB 36MG                      METHYLPHENIDATE HCL TAB SA OSM 36 MG                   Anorexigenics & Resp & Cereb Stim, Misc           60     30      20
     CONCERTA TAB 54MG                      METHYLPHENIDATE HCL TAB SA OSM 54 MG                   Anorexigenics & Resp & Cereb Stim, Misc           30     30      20
          CONDASIN SYP                 HYDROCODONE-GUAIFENESIN SYRUP 3.5-100 MG/5ML                               Antitussives                      178     30
         CONDOMS MIS                                    *CONDOMS - MALE***                                       Contraceptives                             30
CONDOMS-PREM MIS LUBRICAT                           CONDOMS LATEX LUBRICATED                                     Contraceptives                             30
     CONDYLOX GEL 0.5%                                   PODOFILOX GEL 0.5%                       Skin and Mucous Membrane Agents, Misc             3.5     30
    CONGEST AID TAB 30MG                         PSEUDOEPHEDRINE HCL TAB 30 MG                       alpha- and beta-Adrenergic Agonists            120     30
CONGESTA DM TAB 20-400MG                DEXTROMETHORPHAN-GUAIFENESIN TAB 20-400 MG                                Antitussives                       31     30
  CONSTULOSE SOL 10GM/15                        LACTULOSE SOLUTION 10 GM/15ML                                Ammonia Detoxicants                    947     30
     CONTROLRX CRE 1.1%                            SODIUM FLUORIDE CREAM 1.1%                         Miscellaneous Therapeutic Agents                      30      18
     CORMAX       CRE 0.05%                   CLOBETASOL PROPIONATE CREAM 0.05%                            Anti-inflammatory Agents                 30      30
     CORMAX       OIN 0.05%                    CLOBETASOL PROPIONATE OINT 0.05%                            Anti-inflammatory Agents                 30      30
        CORN HUSKERS LOT                               *EMOLLIENT - LOTION**                              Basic Lotions and Liniments                       30                                                   Prior Authorization Req'd
    CORRECTOL CAP 100MG                           DOCUSATE SODIUM CAP 100 MG                                Cathartics and Laxatives                100     30
        CORTAID CRE 1%                              HYDROCORTISONE CREAM 1%                                Anti-inflammatory Agents                         30
   CORTAID CRE 1%MAX ST                             HYDROCORTISONE CREAM 1%                                Anti-inflammatory Agents                         30
   CORTAID OIN 1%MAX ST                         HYDROCORTISONE ACETATE OINT 1%                             Anti-inflammatory Agents                  30     30
        CORTAID SPR 1%                               HYDROCORTISONE SOLN 1%                                Anti-inflammatory Agents                 120     30
  CORTAID ADV CRE 1% 12 HR                          HYDROCORTISONE CREAM 1%                                Anti-inflammatory Agents                         30
     CORTICAINE CRE 0.5%                     HYDROCORTISONE ACETATE CREAM 0.5%                             Anti-inflammatory Agents                 30      30
  CORTISONE CRE 1%MAX ST                            HYDROCORTISONE CREAM 1%                                Anti-inflammatory Agents                         30
 CORTISONE + CRE 1%MAX ST                           HYDROCORTISONE CREAM 1%                                Anti-inflammatory Agents                         30
  CORTIZONE-10 LOT ECZEMA                           HYDROCORTISONE LOTION 1%                               Anti-inflammatory Agents                         30
      CORTIZONE-10 OIN 1%                            HYDROCORTISONE OINT 1%                                Anti-inflammatory Agents                         30
  CORTOMYCIN SOL 1% OTIC                     NEOMYCIN-POLYMYXIN-HC OTIC SOLN 1%                                  Corticosteroids                            30
  CORTOMYCIN SUS 1% OTIC        NEOMYCIN-POLYMYXIN-HC OTIC SUSP 3.5 MG/ML-10000 UNIT/ML-1%                       Corticosteroids                            30
    COUGH       SYP 100/5ML                       GUAIFENESIN SYRUP 100 MG/5ML                                    Expectorants                              30
  COUGH CONT LIQ DM MAX             DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/5ML                             Antitussives                      180     30
   COUGH DM LIQ 100-10/5            DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                             Antitussives                      180     30
  COUGH DM SYP 100-10/5             DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                              Antitussives                      180     30
    COUGHTAB TAB 200MG                                GUAIFENESIN TAB 200 MG                                      Expectorants                      180     30
                                                                                                                                            Max Qty
                                                                                                                                              Limit   Max Max Age
                                                                                                                                            (Liquids Days    Limit    Step      Step Therapy   Specialty
     Drug/Product Name                                 Generic Name                                         Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
      COUGHTUSS LIQ 5-2-5         PHENYLEPH-CHLORPHEN W/ HYDROCODONE LIQD 5-2-5 MG/5ML                          Antitussives                          30
          COVARYX TAB            ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 1.25-2.5 MG                       Estrogens                            30
         COVARYX HS TAB         ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 0.625-1.25 MG                      Estrogens                            30
     COVERA-HS TAB 180MG            VERAPAMIL HCL TAB SR 24HR (CONTROLLED ONSET) 180 MG          Calcium-Channel Blocking Agents, Misc                30
     COVERA-HS TAB 240MG            VERAPAMIL HCL TAB SR 24HR (CONTROLLED ONSET) 240 MG          Calcium-Channel Blocking Agents, Misc                30
    CPM/PSE CAP 8-120 CR            CHLORPHENIRAMINE & PSEUDOEPHEDRINE CAP CR 8-120 MG                    Proplamine Derivatives              31      30
     CPM/PSE CAP 8-120 SR           CHLORPHENIRAMINE & PSEUDOEPHEDRINE CAP CR 8-120 MG                    Proplamine Derivatives              31      30
    CREON       CAP 12000UNT      PANCRELIPASE (LIP-PROT-AMYL) DR CAP 12000-38000-60000 UNIT                     Digestants                           30
    CREON       CAP 24000UNT     PANCRELIPASE (LIP-PROT-AMYL) DR CAP 24000-76000-120000 UNIT                     Digestants                           30
    CREON       CAP 6000UNIT      PANCRELIPASE (LIP-PROT-AMYL) DR CAP 6000-19000-30000 UNIT                      Digestants                           30
        CREON 10 CAP EC              AMY-LIP-PROT DR PARTICLES CAP 33200-10000-37500 UNIT                        Digestants                           30
          CREON 20 CAP               AMY-LIP-PROT DR PARTICLES CAP 66400-20000-75000 UNIT                        Digestants                           30
          CREON 5 CAP                AMY-LIP-PROT DR PARTICLES CAP 16600-5000-18750 UNIT                         Digestants                           30
      CRIXIVAN CAP 100MG                          INDINAVIR SULFATE CAP 100 MG                            HIV Protease Inhibitors                     30
      CRIXIVAN CAP 200MG                          INDINAVIR SULFATE CAP 200 MG                            HIV Protease Inhibitors                     30
      CRIXIVAN CAP 333MG                          INDINAVIR SULFATE CAP 333 MG                            HIV Protease Inhibitors                     30
      CRIXIVAN CAP 400MG                          INDINAVIR SULFATE CAP 400 MG                            HIV Protease Inhibitors                     30
CROMOLYN SOD NEB 20MG/2ML                  CROMOLYN SODIUM SOLN NEBU 20 MG/2ML                             Mast-cell Stabilizers                      30
    CRYSELLE-28 TAB 28 TABS           NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG                         Contraceptives                         30
     CUPRIMINE CAP 125MG                            PENICILLAMINE CAP 125 MG                             Heavy Metal Antagonists                      30
     CUPRIMINE CAP 250MG                            PENICILLAMINE CAP 250 MG                             Heavy Metal Antagonists                      30
   CURITY PREP PAD ALCOHOL                             *ALCOHOL SWABS***                                          Devices                             30
  CURITY SWABS PAD ALCOHOL                             *ALCOHOL SWABS***                                          Devices                             30
          CVS 3-DAY CRE                         CLOTRIMAZOLE VAGINAL CREAM 2%                                      Azoles                      23     30
     CVS 8 HOUR TAB 650MG                         ACETAMINOPHEN TAB CR 650 MG                       Analgesics and Antipyretics, Misc         120     30
     CVS ALLERGY CAP 25MG                       DIPHENHYDRAMINE HCL CAP 25 MG                           Ethanolamine Derivatives                      30
   CVS ALLERGY CHW 12.5MG                   DIPHENHYDRAMINE HCL CHEW TAB 12.5 MG                        Ethanolamine Derivatives                      30
   CVS ALLERGY SYP CHILDREN                        LORATADINE SYRUP 5 MG/5ML                       Second Generation Antihistamines                   30
     CVS ALLERGY TAB 10MG                            CETIRIZINE HCL TAB 10 MG                      Second Generation Antihistamines                   30
     CVS ALLERGY TAB 25MG                       DIPHENHYDRAMINE HCL TAB 25 MG                           Ethanolamine Derivatives                      30
   CVS ANTACID SUS ANTIGAS       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML                 Antacids and Adsorbents             480      30
       CVS ANTACID SUS DS        ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML                 Antacids and Adsorbents             480      30
    CVS ANTACID/ SUS SIMETH      ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML                 Antacids and Adsorbents             480      30
      CVS ANTIBIO CRE PLUS              NEOMYCIN-POLYMYXIN W/ PRAMOXINE CREAM 1%                               Antibacterials                 15      30
     CVS ASPIRIN TAB 325MG                              ASPIRIN TAB 325 MG                                       Salicylates                  31      30
    CVS ASPIRIN TAB 81MG EC                    ASPIRIN TAB DELAYED RELEASE 81 MG                                 Salicylates                  31      30
     CVS ATHLETES CRE FOOT                          TERBINAFINE HCL CREAM 1%                                    Allylamines                   30      30
   CVS BISMUTH CHW 262MG                    BISMUTH SUBSALICYLATE CHEW TAB 262 MG                          Antidiarrhea Agents               120      30
  CVS BISMUTH SUS 262/15ML                 BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                          Antidiarrhea Agents               1800     30
   CVS BISMUTH SUS MAX STR                 BISMUTH SUBSALICYLATE SUSP 525 MG/15ML                          Antidiarrhea Agents               1800     30
    CVS BISMUTH TAB 262MG                      BISMUTH SUBSALICYLATE TAB 262 MG                            Antidiarrhea Agents               120      30
     CVS CHILDS CHW 80MG                        ACETAMINOPHEN CHEW TAB 80 MG                        Analgesics and Antipyretics, Misc         60      30
    CVS CHLD ASA CHW 81MG                            ASPIRIN CHEW TAB 81 MG                                      Salicylates                  31      30
        CVS ELECTROL SOL                         *ORAL ELECTROLYTE SOLUTION***                          Replacement Preparations                      30      18
   CVS FACIAL LOT MOISTURI                            *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
    CVS GENTLE LOT SKIN CLE                           *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
      CVS HYDROCOR OIN 1%                       HYDROCORTISONE ACETATE OINT 1%                          Anti-inflammatory Agents              30      30
    CVS IBUPROF DRO 50/1.25                         IBUPROFEN SUSP 40 MG/ML                    Other Nonsteroidal Anti-inflammtory Agents             30      18
  CVS INFANTS DRO 80/0.8ML                     ACETAMINOPHEN SUSP 80 MG/0.8ML                       Analgesics and Antipyretics, Misc         30      30
      CVS IRON TAB 325MG               FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)                       Iron Preparations                        30
       CVS LICE KIT MAX ST     PYRETH-PIPERONYL BUTOX SHAM-PERMETH AERO-NIT REMOVER GEL KIT            Scabicides and Pediculicides                   30
  CVS NICOTINE DIS 14MG/24H                    NICOTINE TD PATCH 24HR 14 MG/24HR                    Autonomic Drugs, Miscellaneous                    30
  CVS NICOTINE DIS 21MG/24H                    NICOTINE TD PATCH 24HR 21 MG/24HR                    Autonomic Drugs, Miscellaneous                    30
  CVS NICOTINE DIS 7MG/24HR                    NICOTINE TD PATCH 24HR 7 MG/24HR                     Autonomic Drugs, Miscellaneous                    30
 CVS NICOTINE GUM 2MG CINN                       NICOTINE POLACRILEX GUM 2 MG                       Autonomic Drugs, Miscellaneous                    30
 CVS NICOTINE GUM 2MG MINT                       NICOTINE POLACRILEX GUM 2 MG                       Autonomic Drugs, Miscellaneous                    30
 CVS NICOTINE GUM 2MG ORIG                       NICOTINE POLACRILEX GUM 2 MG                       Autonomic Drugs, Miscellaneous                    30
 CVS NICOTINE GUM 2MGFRUIT                       NICOTINE POLACRILEX GUM 2 MG                       Autonomic Drugs, Miscellaneous                    30
 CVS NICOTINE GUM 4MG MINT                       NICOTINE POLACRILEX GUM 4 MG                       Autonomic Drugs, Miscellaneous                    30
 CVS NICOTINE GUM 4MG ORIG                       NICOTINE POLACRILEX GUM 4 MG                       Autonomic Drugs, Miscellaneous                    30
 CVS NICOTINE GUM 4MGFRUIT                       NICOTINE POLACRILEX GUM 4 MG                       Autonomic Drugs, Miscellaneous                    30
  CVS NON-ASA DRO 80/0.8ML                     ACETAMINOPHEN SUSP 80 MG/0.8ML                       Analgesics and Antipyretics, Misc         30      30
       CVS NTS DIS STEP 1                      NICOTINE TD PATCH 24HR 21 MG/24HR                    Autonomic Drugs, Miscellaneous                    30
       CVS NTS DIS STEP 2                      NICOTINE TD PATCH 24HR 14 MG/24HR                    Autonomic Drugs, Miscellaneous                    30
  CVS PAIN REL TAB 500MG/RR                        ACETAMINOPHEN TAB 500 MG                         Analgesics and Antipyretics, Misc         250     30
                                                                                                                                         Max Qty
                                                                                                                                           Limit   Max Max Age
                                                                                                                                         (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                               Generic Name                                         Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
     CVS PERMETHR LOT 1%                           PERMETHRIN LOTION 1%                              Scabicides and Pediculicides                  30
CVS REPAIRNG SOL MOUTHWSH                      SODIUM FLUORIDE RINSE 0.05%                        Miscellaneous Therapeutic Agents                 30      18
   CVS TRIPLE OIN ANTIBIOT        NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%                            Antibacterials                15      30
   CVS TUSSIN SYP 100/5ML                     GUAIFENESIN SYRUP 100 MG/5ML                                   Expectorants                          30
    CVS VIT B-6 TAB 100MG                       PYRIDOXINE HCL TAB 100 MG                                 Vitamin B Complex                        30
     CVS VIT B-6 TAB 50MG                        PYRIDOXINE HCL TAB 50 MG                                 Vitamin B Complex                        30
     CYCLAFEM TAB 1/35            NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG                         Contraceptives                         30
     CYCLAFEM TAB 7/7/7       NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG                    Contraceptives                         30
   CYCLOBENZAPR TAB 10MG                     CYCLOBENZAPRINE HCL TAB 10 MG                 CENTRALLY ACTING SKELETAL MUSCLE RELAXANTS      30      30
   CYCLOPHOSPH TAB 25MG                       CYCLOPHOSPHAMIDE TAB 25 MG                                Antineoplastic Agents                      30
   CYCLOPHOSPH TAB 50MG                       CYCLOPHOSPHAMIDE TAB 50 MG                                Antineoplastic Agents                      30
  CYCLOSPORINE CAP 100MG                         CYCLOSPORINE CAP 100 MG                             Immunosuppressive Agents                      30
CYCLOSPORINE CAP 100MG MD                  CYCLOSPORINE MODIFIED CAP 100 MG                          Immunosuppressive Agents                      30
   CYCLOSPORINE CAP 25MG                          CYCLOSPORINE CAP 25 MG                             Immunosuppressive Agents                      30
CYCLOSPORINE CAP 25MG MOD                   CYCLOSPORINE MODIFIED CAP 25 MG                          Immunosuppressive Agents                      30
CYCLOSPORINE CAP 50MG MOD                   CYCLOSPORINE MODIFIED CAP 50 MG                          Immunosuppressive Agents                      30
 CYCLOSPORINE INJ 50MG/ML                    CYCLOSPORINE IV SOLN 50 MG/ML                           Immunosuppressive Agents                      30                                                   Prior Authorization Req'd
CYCLOSPORINE SOL 100MG/ML                  CYCLOSPORINE ORAL SOLN 100 MG/ML                          Immunosuppressive Agents                      30
 CYCLOSPORINE SOL MODIFIED            CYCLOSPORINE MODIFIED ORAL SOLN 100 MG/ML                      Immunosuppressive Agents                      30      18
    CYPROHEPTAD TAB 4MG                       CYPROHEPTADINE HCL TAB 4 MG                             Derivatives, Miscellaneous                   30
         CYTUSS HC SYP       PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 5-2-2.5 MG/5ML                          Antitussives                 178     30
          D 1000    TAB                       CHOLECALCIFEROL TAB 1000 UNIT                                    Vitamin D                    30     30
          D 2000    TAB                       CHOLECALCIFEROL TAB 2000 UNIT                                    Vitamin D                    30     30
      D.O.S.    CAP 100MG                     DOCUSATE SODIUM CAP 100 MG                               Cathartics and Laxatives            100     30
      D.O.S.    CAP 250MG                     DOCUSATE SODIUM CAP 250 MG                               Cathartics and Laxatives            100     30
          D-1000    TAB                       CHOLECALCIFEROL TAB 1000 UNIT                                    Vitamin D                    30     30
 D-2000 MAX TAB STRENGTH                      CHOLECALCIFEROL TAB 2000 UNIT                                    Vitamin D                    30     30
          D-400    TAB                         CHOLECALCIFEROL TAB 400 UNIT                                    Vitamin D                    30     30
       DACARBAZINE POW                              DACARBAZINE POWDER                                   Pharmaceutical Aids                       30
    DANAZOL CAP 100MG                               DANAZOL CAP 100 MG                                        Androgens                            30                                                   Prior Authorization Req'd
    DANAZOL CAP 200MG                               DANAZOL CAP 200 MG                                        Androgens                            30                                                   Prior Authorization Req'd
     DANAZOL CAP 50MG                                DANAZOL CAP 50 MG                                        Androgens                            30                                                   Prior Authorization Req'd
   DANTROLENE CAP 100MG                      DANTROLENE SODIUM CAP 100 MG                    DIRECT ACTING SKELETAL MUSCLE RELAXANTS               30                                                   Prior Authorization Req'd
   DANTROLENE CAP 25MG                        DANTROLENE SODIUM CAP 25 MG                    DIRECT ACTING SKELETAL MUSCLE RELAXANTS               30                                                   Prior Authorization Req'd
   DANTROLENE CAP 50MG                        DANTROLENE SODIUM CAP 50 MG                    DIRECT ACTING SKELETAL MUSCLE RELAXANTS               30                                                   Prior Authorization Req'd
    DARAPRIM TAB 25MG                           PYRIMETHAMINE TAB 25 MG                                      Antimalarials                         30
  DAYTRANA DIS 10MG/9HR                   METHYLPHENIDATE TD PATCH 10 MG/9HR                   Anorexigenics & Resp & Cereb Stim, Misc      30     30      20                                           Prior Authorization Req'd
  DAYTRANA DIS 15MG/9HR                   METHYLPHENIDATE TD PATCH 15 MG/9HR                   Anorexigenics & Resp & Cereb Stim, Misc      30     30      20                                           Prior Authorization Req'd
  DAYTRANA DIS 20MG/9HR                   METHYLPHENIDATE TD PATCH 20 MG/9HR                   Anorexigenics & Resp & Cereb Stim, Misc      30     30      20                                           Prior Authorization Req'd
  DAYTRANA DIS 30MG/9HR                   METHYLPHENIDATE TD PATCH 30 MG/9HR                   Anorexigenics & Resp & Cereb Stim, Misc      30     30      20                                           Prior Authorization Req'd
     DAZIDOX TAB 10MG                           OXYCODONE HCL TAB 10 MG                                    Opiate Agonists                 120     30
     DAZIDOX TAB 20MG                           OXYCODONE HCL TAB 20 MG                                    Opiate Agonists                 120     30
   DE-CHLOR HC SYP LIQUID    PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 10-2-2.5 MG/5ML                         Antitussives                 178     30
   DE-CHLOR HD SYP LIQUID    PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 10-4-2.5 MG/5ML                         Antitussives                 178     30
       DE-CHLOR MR SYP         PHENYLEPH-PYRILAMINE W/ HYDROCODONE SYRUP 5-5-5 MG/5ML                         Antitussives                 178     30
   DECON-DM SYP 30-2-10            PSEUDOEPHED-BROMPHEN-DM SYRUP 30-2-10 MG/5ML                               Antitussives                 178     30
  DECONGESTANT TAB 30MG                      PSEUDOEPHEDRINE HCL TAB 30 MG                       alpha- and beta-Adrenergic Agonists       120     30
  DECONGESTANT TAB 60MG                      PSEUDOEPHEDRINE HCL TAB 60 MG                       alpha- and beta-Adrenergic Agonists        60     30
     DEL-BETA LOT 0.05%                BETAMETHASONE DIPROPIONATE LOTION 0.05%                        Anti-inflammatory Agents                     30                                                   Prior Authorization Req'd
    DELTA D3 TAB 400UNIT                       CHOLECALCIFEROL TAB 400 UNIT                                    Vitamin D                   30      30
   DEMAREST CRE DRICORT                    HYDROCORTISONE ACETATE CREAM 1%                            Anti-inflammatory Agents             30      30
     DENTA 5000 CRE PLUS                       SODIUM FLUORIDE CREAM 1.1%                         Miscellaneous Therapeutic Agents                 30      18
  DENTA 5000 CRE PLUS 2PK                      SODIUM FLUORIDE CREAM 1.1%                         Miscellaneous Therapeutic Agents                 30      18
     DENTAGEL GEL 1.1%                      SODIUM FLUORIDE GEL 1.1% (0.5% F)                     Miscellaneous Therapeutic Agents                 30      18
    DENTALL 1100 CRE PLUS                      SODIUM FLUORIDE CREAM 1.1%                         Miscellaneous Therapeutic Agents                 30      18
  DEPO-PROVERA INJ 400/ML          MEDROXYPROGESTERONE ACETATE IM SUSP 400 MG/ML                               Progestins                          30                                                   Prior Authorization Req'd
        DERMADAILY LOT                             *EMOLLIENT - LOTION**                             Basic Lotions and Liniments                   30                                                   Prior Authorization Req'd
        DERMALUBE LOT                              *EMOLLIENT - LOTION**                             Basic Lotions and Liniments                   30                                                   Prior Authorization Req'd
  DERMALUBE LOT W/PUMP                             *EMOLLIENT - LOTION**                             Basic Lotions and Liniments                   30                                                   Prior Authorization Req'd
      DERMAVANTAGE LOT                             *EMOLLIENT - LOTION**                             Basic Lotions and Liniments                   30                                                   Prior Authorization Req'd
      DERMTEX HC CRE 1%                    HYDROCORTISONE ACETATE CREAM 1%                            Anti-inflammatory Agents             30      30
    DERMTEX HC LOT 0.5%                        HYDROCORTISONE LOTION 0.5%                             Anti-inflammatory Agents                     30
     DERMTEX HC SPR 0.5%                        HYDROCORTISONE SOLN 0.5%                              Anti-inflammatory Agents             120     30
       DESENEX CRE 1%                             CLOTRIMAZOLE CREAM 1%                                          Azoles                     30     30
 DESMOPRESSIN INJ 4MCG/ML                  DESMOPRESSIN ACETATE INJ 4 MCG/ML                                    Pituitary                          30                                                   Prior Authorization Req'd
                                                                                                                                      Max Qty
                                                                                                                                        Limit   Max Max Age
                                                                                                                                      (Liquids Days    Limit    Step      Step Therapy   Specialty
     Drug/Product Name                              Generic Name                                      Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
   DESMOPRESSIN TAB 0.1MG                    DESMOPRESSIN ACETATE TAB 0.1 MG                                Pituitary                           30                                                   Prior Authorization Req'd
   DESMOPRESSIN TAB 0.2MG                    DESMOPRESSIN ACETATE TAB 0.2 MG                                Pituitary                           30                                                   Prior Authorization Req'd
      DESONIDE CRE 0.05%                           DESONIDE CREAM 0.05%                           Anti-inflammatory Agents                      30                                                   Prior Authorization Req'd
      DESONIDE OIN 0.05%                            DESONIDE OINT 0.05%                           Anti-inflammatory Agents                      30                                                   Prior Authorization Req'd
    DESOXIMETAS CRE 0.05%                       DESOXIMETASONE CREAM 0.05%                        Anti-inflammatory Agents                      30                                                   Prior Authorization Req'd
    DESOXIMETAS CRE 0.25%                       DESOXIMETASONE CREAM 0.25%                        Anti-inflammatory Agents                      30                                                   Prior Authorization Req'd
    DESOXIMETAS GEL 0.05%                        DESOXIMETASONE GEL 0.05%                         Anti-inflammatory Agents                      30                                                   Prior Authorization Req'd
    DESOXIMETAS OIN 0.25%                        DESOXIMETASONE OINT 0.25%                        Anti-inflammatory Agents                      30                                                   Prior Authorization Req'd
 DEXAMETH PHO INJ 10MG/ML            DEXAMETHASONE SODIUM PHOSPHATE INJ 10 MG/ML                           Adrenals                             30
  DEXAMETH PHO INJ 4MG/ML            DEXAMETHASONE SODIUM PHOSPHATE INJ 4 MG/ML                            Adrenals                             30
  DEXAMETH PHO SOL 0.1% OP         DEXAMETHASONE SODIUM PHOSPHATE OPHTH SOLN 0.1%                       Corticosteroids                         30
DEXAMETH SOD POW PHOSPHAT              DEXAMETHASONE SODIUM PHOSPHATE POWDER                        Pharmaceutical Aids                         30
 DEXAMETHASON CON 1MG/ML                       DEXAMETHASONE CONC 1 MG/ML                                  Adrenals                             30
  DEXAMETHASON ELX 0.5/5ML                   DEXAMETHASONE ELIXIR 0.5 MG/5ML                               Adrenals                             30
      DEXAMETHASON POW                            DEXAMETHASONE POWDER                              Pharmaceutical Aids                         30
DEXAMETHASON POW ACETATE                      DEXAMETHASONE ACETATE POWDER                          Pharmaceutical Aids                         30
DEXAMETHASON POW MICRONIZ                         DEXAMETHASONE POWDER                              Pharmaceutical Aids                         30
   DEXAMETHASON POW USP                           DEXAMETHASONE POWDER                              Pharmaceutical Aids                         30
 DEXAMETHASON SOL 0.5/5ML                    DEXAMETHASONE SOLN 0.5 MG/5ML                                 Adrenals                             30
  DEXAMETHASON TAB 0.5MG                         DEXAMETHASONE TAB 0.5 MG                                  Adrenals                             30
  DEXAMETHASON TAB 0.75MG                       DEXAMETHASONE TAB 0.75 MG                                  Adrenals                             30
  DEXAMETHASON TAB 1.5MG                         DEXAMETHASONE TAB 1.5 MG                                  Adrenals                             30
   DEXAMETHASON TAB 1MG                           DEXAMETHASONE TAB 1 MG                                   Adrenals                             30
   DEXAMETHASON TAB 2MG                           DEXAMETHASONE TAB 2 MG                                   Adrenals                             30
   DEXAMETHASON TAB 4MG                           DEXAMETHASONE TAB 4 MG                                   Adrenals                             30
   DEXAMETHASON TAB 6MG                           DEXAMETHASONE TAB 6 MG                                   Adrenals                             30
     DEXASOL SOL 0.1% OP           DEXAMETHASONE SODIUM PHOSPHATE OPHTH SOLN 0.1%                       Corticosteroids                         30
   DEXASPORIN SUS 0.1% OP         NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH SUSP 0.1%                      Corticosteroids                         30
   DEXFERRUM INJ 50MG/ML               IRON DEXTRAN INJ 50 MG/ML (ELEMENTAL IRON)                     Iron Preparations                         30                                                   Prior Authorization Req'd
    DEXMETHYLPH TAB 10MG                    DEXMETHYLPHENIDATE HCL TAB 10 MG              Anorexigenics & Resp & Cereb Stim, Misc        60     30      20
   DEXMETHYLPH TAB 2.5MG                    DEXMETHYLPHENIDATE HCL TAB 2.5 MG             Anorexigenics & Resp & Cereb Stim, Misc        60     30      20
    DEXMETHYLPH TAB 5MG                      DEXMETHYLPHENIDATE HCL TAB 5 MG              Anorexigenics & Resp & Cereb Stim, Misc        60     30      20
 DEXTROAMPHET CAP 10MG CR            DEXTROAMPHETAMINE SULFATE CAP SR 24HR 10 MG                        Amphetamines                    120     30      20
 DEXTROAMPHET CAP 10MG ER            DEXTROAMPHETAMINE SULFATE CAP SR 24HR 10 MG                        Amphetamines                    120     30      20
 DEXTROAMPHET CAP 15MG CR            DEXTROAMPHETAMINE SULFATE CAP SR 24HR 15 MG                        Amphetamines                    120     30      20
 DEXTROAMPHET CAP 15MG ER            DEXTROAMPHETAMINE SULFATE CAP SR 24HR 15 MG                        Amphetamines                    120     30      20
  DEXTROAMPHET CAP 5MG CR             DEXTROAMPHETAMINE SULFATE CAP SR 24HR 5 MG                        Amphetamines                    120     30      20
  DEXTROAMPHET CAP 5MG ER             DEXTROAMPHETAMINE SULFATE CAP SR 24HR 5 MG                        Amphetamines                    120     30      20
   DEXTROAMPHET TAB 10MG                  DEXTROAMPHETAMINE SULFATE TAB 10 MG                           Amphetamines                     90     30      20
    DEXTROAMPHET TAB 5MG                  DEXTROAMPHETAMINE SULFATE TAB 5 MG                            Amphetamines                     90     30      20
     DEXTROSTAT TAB 5MG                   DEXTROAMPHETAMINE SULFATE TAB 5 MG                            Amphetamines                     90     30      20
        DEX-TUSS DM LIQ           DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-300 MG/5ML                       Antitussives                  180     30
     DIABETA TAB 1.25MG                            GLYBURIDE TAB 1.25 MG                                 Sulfonylureas                          30
      DIABETA TAB 2.5MG                             GLYBURIDE TAB 2.5 MG                                 Sulfonylureas                          30
       DIABETA TAB 5MG                               GLYBURIDE TAB 5 MG                                  Sulfonylureas                          30
   DIABETIC TUS LIQ CHILDREN      DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                       Antitussives                  180     30
       DIABETIC TUS LIQ DM        DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                       Antitussives                  180     30
    DIABETIC TUS LIQ MAX ST       DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/5ML                       Antitussives                  180     30
        DIABETIDERM LOT                            *EMOLLIENT - LOTION**                         Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
   DIABTC TUSSN SYP 100/5ML                    GUAIFENESIN SYRUP 100 MG/5ML                              Expectorants                           30
        DIACETAZONE CAP        ACETAMINOPHEN-ISOMETHEPTENE-DICHLORAL CAP 325-65-100 MG       Antimigraine Agents, Miscellaneous         6       30
      DIAMODE TAB 2MG                             LOPERAMIDE HCL TAB 2 MG                           Antidiarrhea Agents                 31      30
     DIARRHEA SUS RELIEF                 BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                     Antidiarrhea Agents                1800     30
     DIAZEPAM GEL 10MG                  DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG                      Benzodiazepines                  2       30
     DIAZEPAM GEL 2.5MG                DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG                      Benzodiazepines                  2       30
     DIAZEPAM GEL 20MG                  DIAZEPAM RECTAL GEL DELIVERY SYSTEM 20 MG                      Benzodiazepines                  2       30
     DIBENZYLINE CAP 10MG                    PHENOXYBENZAMINE HCL CAP 10 MG               Sympatholytic (Adrenergic Block) Agents               30
   DICLOFENAC SOL 0.1% OP                   DICLOFENAC SODIUM OPHTH SOLN 0.1%              Nonsteroidal Anti-inflammatory Agents         5      30
  DICLOFENAC TAB 100MG ER                 DICLOFENAC SODIUM TAB SR 24HR 100 MG           Other Nonsteroidal Anti-inflammtory Agents             30
  DICLOFENAC TAB 100MG SR                 DICLOFENAC SODIUM TAB SR 24HR 100 MG           Other Nonsteroidal Anti-inflammtory Agents             30
  DICLOFENAC TAB 100MG XR                 DICLOFENAC SODIUM TAB SR 24HR 100 MG           Other Nonsteroidal Anti-inflammtory Agents             30
   DICLOFENAC TAB 25MG DR             DICLOFENAC SODIUM TAB DELAYED RELEASE 25 MG        Other Nonsteroidal Anti-inflammtory Agents             30
   DICLOFENAC TAB 25MG EC             DICLOFENAC SODIUM TAB DELAYED RELEASE 25 MG        Other Nonsteroidal Anti-inflammtory Agents             30
   DICLOFENAC TAB 50MG DR             DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG        Other Nonsteroidal Anti-inflammtory Agents             30
   DICLOFENAC TAB 50MG EC             DICLOFENAC SODIUM TAB DELAYED RELEASE 50 MG        Other Nonsteroidal Anti-inflammtory Agents             30
                                                                                                                                        Max Qty
                                                                                                                                          Limit   Max Max Age
                                                                                                                                        (Liquids Days    Limit    Step      Step Therapy   Specialty
   Drug/Product Name                            Generic Name                                         Therapy Class                       in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
DICLOFENAC TAB 75MG DR            DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG          Other Nonsteroidal Anti-inflammtory Agents                 30
DICLOFENAC TAB 75MG EC            DICLOFENAC SODIUM TAB DELAYED RELEASE 75 MG          Other Nonsteroidal Anti-inflammtory Agents                 30
  DICLOXACILL CAP 250MG                   DICLOXACILLIN SODIUM CAP 250 MG                    Penicillinase-resistant Penicillins                  14
  DICLOXACILL CAP 500MG                   DICLOXACILLIN SODIUM CAP 500 MG                    Penicillinase-resistant Penicillins                  14
  DICYCLOMINE CAP 10MG                        DICYCLOMINE HCL CAP 10 MG                      Antimuscarinics/Antispasmodics               60      30
  DICYCLOMINE TAB 20MG                        DICYCLOMINE HCL TAB 20 MG                      Antimuscarinics/Antispasmodics               60      30
 DIDANOSINE CAP 125MG               DIDANOSINE DELAYED RELEASE CAPSULE 125 MG         Nucleoside & Nucleotide Rev Transcriptase Inhib             30
 DIDANOSINE CAP 200MG               DIDANOSINE DELAYED RELEASE CAPSULE 200 MG         Nucleoside & Nucleotide Rev Transcriptase Inhib             30
 DIDANOSINE CAP 250MG               DIDANOSINE DELAYED RELEASE CAPSULE 250 MG         Nucleoside & Nucleotide Rev Transcriptase Inhib             30
 DIDANOSINE CAP 400MG               DIDANOSINE DELAYED RELEASE CAPSULE 400 MG         Nucleoside & Nucleotide Rev Transcriptase Inhib             30
  DIFLORASONE CRE 0.05%                 DIFLORASONE DIACETATE CREAM 0.05%                       Anti-inflammatory Agents                          30                                                   Prior Authorization Req'd
  DIFLORASONE OIN 0.05%                  DIFLORASONE DIACETATE OINT 0.05%                       Anti-inflammatory Agents                          30                                                   Prior Authorization Req'd
  DIFLUNISAL TAB 500MG                           DIFLUNISAL TAB 500 MG                 Other Nonsteroidal Anti-inflammtory Agents                 30
DIGOXIN SOL 50MCG/ML                        DIGOXIN ORAL SOLN 0.05 MG/ML                            Cardiotonic Agents                            30
  DIGOXIN TAB 0.125MG                            DIGOXIN TAB 0.125 MG                               Cardiotonic Agents                            30
  DIGOXIN TAB 0.25MG                              DIGOXIN TAB 0.25 MG                               Cardiotonic Agents                            30
DIHYDROERGOT INJ 1MG/ML              DIHYDROERGOTAMINE MESYLATE INJ 1 MG/ML              Sympatholytic (Adrenergic Block) Agents                  30                                                   Prior Authorization Req'd
   DILANTIN CAP 100MG                 PHENYTOIN SODIUM EXTENDED CAP 100 MG                              Hydantoins                                30
   DILANTIN CAP 30MG                   PHENYTOIN SODIUM EXTENDED CAP 30 MG                              Hydantoins                                30
DILANTIN-125 SUS 125/5ML                     PHENYTOIN SUSP 125 MG/5ML                                  Hydantoins                                30      18
  DILATRATE SR CAP 40MG                  ISOSORBIDE DINITRATE CAP CR 40 MG                         Nitrates and Nitrites                          30
   DILT-CD CAP 120MG              DILTIAZEM HCL COATED BEADS CAP SR 24HR 120 MG           Calcium-Channel Blocking Agents, Misc                   30
   DILT-CD CAP 180MG              DILTIAZEM HCL COATED BEADS CAP SR 24HR 180 MG           Calcium-Channel Blocking Agents, Misc                   30
   DILT-CD CAP 240MG              DILTIAZEM HCL COATED BEADS CAP SR 24HR 240 MG           Calcium-Channel Blocking Agents, Misc                   30
   DILT-CD CAP 300MG              DILTIAZEM HCL COATED BEADS CAP SR 24HR 300 MG           Calcium-Channel Blocking Agents, Misc                   30
DILTIAZEM CAP 120MG CD            DILTIAZEM HCL COATED BEADS CAP SR 24HR 120 MG           Calcium-Channel Blocking Agents, Misc                   30
DILTIAZEM CAP 120MG ER                    DILTIAZEM HCL CAP SR 12HR 120 MG                Calcium-Channel Blocking Agents, Misc                   30
DILTIAZEM CAP 120MG SR            DILTIAZEM HCL COATED BEADS CAP SR 24HR 120 MG           Calcium-Channel Blocking Agents, Misc                   30
DILTIAZEM CAP 120MG/24      DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 120 MG       Calcium-Channel Blocking Agents, Misc                   30
DILTIAZEM CAP 180MG CD            DILTIAZEM HCL COATED BEADS CAP SR 24HR 180 MG           Calcium-Channel Blocking Agents, Misc                   30
DILTIAZEM CAP 180MG ER                    DILTIAZEM HCL CAP SR 24HR 180 MG                Calcium-Channel Blocking Agents, Misc                   30
DILTIAZEM CAP 180MG/24      DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 180 MG       Calcium-Channel Blocking Agents, Misc                   30
DILTIAZEM CAP 240MG CD            DILTIAZEM HCL COATED BEADS CAP SR 24HR 240 MG           Calcium-Channel Blocking Agents, Misc                   30
DILTIAZEM CAP 240MG ER                    DILTIAZEM HCL CAP SR 24HR 240 MG                Calcium-Channel Blocking Agents, Misc                   30
DILTIAZEM CAP 240MG XR                    DILTIAZEM HCL CAP SR 24HR 240 MG                Calcium-Channel Blocking Agents, Misc                   30
DILTIAZEM CAP 240MG/24      DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 240 MG       Calcium-Channel Blocking Agents, Misc                   30
DILTIAZEM CAP 300MG CD            DILTIAZEM HCL COATED BEADS CAP SR 24HR 300 MG           Calcium-Channel Blocking Agents, Misc                   30
DILTIAZEM CAP 300MG ER            DILTIAZEM HCL COATED BEADS CAP SR 24HR 300 MG           Calcium-Channel Blocking Agents, Misc                   30
DILTIAZEM CAP 300MG/24      DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 300 MG       Calcium-Channel Blocking Agents, Misc                   30
DILTIAZEM CAP 360MG/24      DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 360 MG       Calcium-Channel Blocking Agents, Misc                   30
DILTIAZEM CAP 420MG/24      DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 420 MG       Calcium-Channel Blocking Agents, Misc                   30
 DILTIAZEM CAP 60MG ER                     DILTIAZEM HCL CAP SR 12HR 60 MG                Calcium-Channel Blocking Agents, Misc                   30
 DILTIAZEM CAP 90MG ER                     DILTIAZEM HCL CAP SR 12HR 90 MG                Calcium-Channel Blocking Agents, Misc                   30
  DILTIAZEM TAB 120MG                          DILTIAZEM HCL TAB 120 MG                   Calcium-Channel Blocking Agents, Misc                   30
   DILTIAZEM TAB 30MG                          DILTIAZEM HCL TAB 30 MG                    Calcium-Channel Blocking Agents, Misc                   30
   DILTIAZEM TAB 60MG                          DILTIAZEM HCL TAB 60 MG                    Calcium-Channel Blocking Agents, Misc                   30
   DILTIAZEM TAB 90MG                          DILTIAZEM HCL TAB 90 MG                    Calcium-Channel Blocking Agents, Misc                   30
   DILT-XR CAP 120MG                      DILTIAZEM HCL CAP SR 24HR 120 MG                Calcium-Channel Blocking Agents, Misc                   30
   DILT-XR CAP 180MG                      DILTIAZEM HCL CAP SR 24HR 180 MG                Calcium-Channel Blocking Agents, Misc                   30
   DILT-XR CAP 240MG                      DILTIAZEM HCL CAP SR 24HR 240 MG                Calcium-Channel Blocking Agents, Misc                   30
 DILTZAC CAP 120MG/24       DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 120 MG       Calcium-Channel Blocking Agents, Misc                   30
 DILTZAC CAP 180MG/24       DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 180 MG       Calcium-Channel Blocking Agents, Misc                   30
 DILTZAC CAP 240MG/24       DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 240 MG       Calcium-Channel Blocking Agents, Misc                   30
 DILTZAC CAP 300MG/24       DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 300 MG       Calcium-Channel Blocking Agents, Misc                   30
 DILTZAC CAP 360MG/24       DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 360 MG       Calcium-Channel Blocking Agents, Misc                   30
  DIMETAPP ND TAB 10MG             LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG              Second Generation Antihistamines                      30
  DIOCTO     LIQ 150/15ML              DOCUSATE SODIUM LIQUID 150 MG/15ML                         Cathartics and Laxatives               480      30
 DIOCTO     LIQ 50MG/5ML               DOCUSATE SODIUM LIQUID 150 MG/15ML                         Cathartics and Laxatives               480      30
  DIOCTO     SYP 60/15ML                DOCUSATE SODIUM SYRUP 60 MG/15ML                          Cathartics and Laxatives               480      30
  DIOCTYL SYP 60/15ML                   DOCUSATE SODIUM SYRUP 60 MG/15ML                          Cathartics and Laxatives               480      30
  DIOCTYL S.S CAP 100MG                     DOCUSATE SODIUM CAP 100 MG                            Cathartics and Laxatives               100      30
  DIOTAME CHW 262MG                   BISMUTH SUBSALICYLATE CHEW TAB 262 MG                         Antidiarrhea Agents                  120      30
 DIOTAME SUS 524/30ML                BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                         Antidiarrhea Agents                  1800     30
   DIPHEDRYL TAB 25MG                     DIPHENHYDRAMINE HCL TAB 25 MG                          Ethanolamine Derivatives                         30
  DIPHEN/ATROP LIQ 2.5/5         DIPHENOXYLATE W/ ATROPINE LIQ 2.5-0.025 MG/5ML                     Antidiarrhea Agents                   120     30      18
                                                                                                                                    Max Qty
                                                                                                                                      Limit   Max Max Age
                                                                                                                                    (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                              Generic Name                                      Therapy Class                   in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
  DIPHEN/ATROP TAB 2.5MG             DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG                     Antidiarrhea Agents               240     30
   DIPHENATOL TAB 2.5MG              DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG                     Antidiarrhea Agents               240     30
    DIPHENDRYL CAP 25MG                    DIPHENHYDRAMINE HCL CAP 25 MG                         Ethanolamine Derivatives                     30
    DIPHENDRYL TAB 25MG                    DIPHENHYDRAMINE HCL TAB 25 MG                         Ethanolamine Derivatives                     30
    DIPHENHIST CAP 25MG                    DIPHENHYDRAMINE HCL CAP 25 MG                         Ethanolamine Derivatives                     30
  DIPHENHIST LIQ 12.5/5ML             DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                     Ethanolamine Derivatives                     30
    DIPHENHIST TAB 25MG                    DIPHENHYDRAMINE HCL TAB 25 MG                         Ethanolamine Derivatives                     30
  DIPHENHYDRAM CAP 25MG                    DIPHENHYDRAMINE HCL CAP 25 MG                         Ethanolamine Derivatives                     30
  DIPHENHYDRAM CAP 50MG                    DIPHENHYDRAMINE HCL CAP 50 MG                         Ethanolamine Derivatives                     30
DIPHENHYDRAM ELX 12.5/5ML              DIPHENHYDRAMINE HCL ELIXIR 12.5 MG/5ML                    Ethanolamine Derivatives                     30
DIPHENHYDRAM LIQ 12.5/5ML             DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                     Ethanolamine Derivatives                     30
  DIPHENHYDRAM TAB 25MG                    DIPHENHYDRAMINE HCL TAB 25 MG                         Ethanolamine Derivatives                     30
  DIPHENHYDRAM TAB 50MG                    DIPHENHYDRAMINE HCL TAB 50 MG                         Ethanolamine Derivatives                     30
   DIPIVEFRIN SOL 0.1% OP                   DIPIVEFRIN HCL OPHTH SOLN 0.1%                                Mydriatics                          30
   DIPYRIDAMOLE TAB 25MG                        DIPYRIDAMOLE TAB 25 MG                       Vasodilating Agents, Miscellaneous               30
   DIPYRIDAMOLE TAB 50MG                        DIPYRIDAMOLE TAB 50 MG                       Vasodilating Agents, Miscellaneous               30
   DIPYRIDAMOLE TAB 75MG                        DIPYRIDAMOLE TAB 75 MG                       Vasodilating Agents, Miscellaneous               30
  DISOPYRAMIDE CAP 100MG                 DISOPYRAMIDE PHOSPHATE CAP 100 MG                        Class Ia Antiarrhythmics                    30
  DISOPYRAMIDE CAP 150MG                 DISOPYRAMIDE PHOSPHATE CAP 150 MG                        Class Ia Antiarrhythmics                    30
DISOPYRAMIDE CAP 150MG ER            DISOPYRAMIDE PHOSPHATE CAP SR 12HR 150 MG                    Class Ia Antiarrhythmics                    30
   DM/GG      SYP 10-100/5      DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                         Antitussives                 180     30
  DM/GUAI LIQ 10-300MG          DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-300 MG/5ML                        Antitussives                 180     30
       DM/PSE/BPM SYP             PSEUDOEPHED-BROMPHEN-DM SYRUP 50-3-30 MG/5ML                           Antitussives                 178     30
         DML      LOT                            *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                   30                                                   Prior Authorization Req'd
       DOCOSAVIT CAP          *PRENATAL W/FE FUM-FE POLY -FA-OMEGA 3 CAP 15-15-1 MG***           Multivitamin Preparations                    30      40
   DOC-Q-LACE CAP 100MG                      DOCUSATE SODIUM CAP 100 MG                           Cathartics and Laxatives            100     30
  DOC-Q-LACE LIQ 150/15ML               DOCUSATE SODIUM LIQUID 150 MG/15ML                        Cathartics and Laxatives            480     30
  DOC-Q-LACE SYP 60/15ML                 DOCUSATE SODIUM SYRUP 60 MG/15ML                         Cathartics and Laxatives            480     30
  DOC-Q-LAX TAB 8.6-50MG             SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                     Cathartics and Laxatives            100     30
    DOCU     LIQ 150/15ML               DOCUSATE SODIUM LIQUID 150 MG/15ML                        Cathartics and Laxatives            480     30
   DOCU SOFT CAP 100MG                       DOCUSATE SODIUM CAP 100 MG                           Cathartics and Laxatives            100     30
   DOCUPRENE TAB 100MG                       DOCUSATE SODIUM TAB 100 MG                           Cathartics and Laxatives            100     30
  DOCUSATE SOD CAP 100MG                     DOCUSATE SODIUM CAP 100 MG                           Cathartics and Laxatives            100     30
  DOCUSATE SOD CAP 250MG                     DOCUSATE SODIUM CAP 250 MG                           Cathartics and Laxatives            100     30
DOCUSATE SOD LIQ 150/15ML               DOCUSATE SODIUM LIQUID 150 MG/15ML                        Cathartics and Laxatives            480     30
DOCUSATE SOD LIQ 50MG/5ML               DOCUSATE SODIUM LIQUID 150 MG/15ML                        Cathartics and Laxatives            480     30
DOCUSATE SOD SYP 20MG/5ML                DOCUSATE SODIUM SYRUP 60 MG/15ML                         Cathartics and Laxatives            480     30
 DOCUSATE SOD SYP 60/15ML                DOCUSATE SODIUM SYRUP 60 MG/15ML                         Cathartics and Laxatives            480     30
  DOCUSATE SOD TAB 100MG                     DOCUSATE SODIUM TAB 100 MG                           Cathartics and Laxatives            100     30
  DOCUSATE SOD TAB SENNA             SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                     Cathartics and Laxatives            100     30
    DOCUSIL CAP 100MG                        DOCUSATE SODIUM CAP 100 MG                           Cathartics and Laxatives            100     30
   DOCUSOFT S CAP 100MG                      DOCUSATE SODIUM CAP 100 MG                           Cathartics and Laxatives            100     30
   DOCUSOFT-S CAP 100MG                      DOCUSATE SODIUM CAP 100 MG                           Cathartics and Laxatives            100     30
      DOK     CAP 100MG                      DOCUSATE SODIUM CAP 100 MG                           Cathartics and Laxatives            100     30
      DOK     CAP 250MG                      DOCUSATE SODIUM CAP 250 MG                           Cathartics and Laxatives            100     30
      DOK     TAB 100MG                      DOCUSATE SODIUM TAB 100 MG                           Cathartics and Laxatives            100     30
 DOK PLUS TAB NEW FORM               SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                     Cathartics and Laxatives            100     30
   DOLACET CAP 5-500MG               HYDROCODONE-ACETAMINOPHEN CAP 5-500 MG                            Opiate Agonists                150     30
  DOLAGESIC CAP 500-5MG              HYDROCODONE-ACETAMINOPHEN CAP 5-500 MG                            Opiate Agonists                150     30
       DOLGIC PLUS TAB          BUTALBITAL-ACETAMINOPHEN-CAFFEINE TAB 50-750-40 MG            Analgesics and Antipyretics, Misc        20     30
 DOLOREX FORT CAP 5-500MG            HYDROCODONE-ACETAMINOPHEN CAP 5-500 MG                            Opiate Agonists                150     30
 DOMETUSS DM LIQ 200-20/5       DEXTROMETHORPHAN-GUAIFENESIN LIQUID 20-200 MG/5ML                        Antitussives                 180     30
    DONEPEZIL TAB 10MG                   DONEPEZIL HYDROCHLORIDE TAB 10 MG               Parasympathomimetic (Cholinergic) Agents             30                                                   Prior Authorization Req'd
     DONEPEZIL TAB 5MG                    DONEPEZIL HYDROCHLORIDE TAB 5 MG               Parasympathomimetic (Cholinergic) Agents             30                                                   Prior Authorization Req'd
       DONNAPHEN TAB              BELLADONNA ALKALOIDS-PHENOBARBITAL TAB 16.2 MG              Antimuscarinics/Antispasmodics          20      30
     DORMIN     CAP 25MG                   DIPHENHYDRAMINE HCL CAP 25 MG                         Ethanolamine Derivatives                     30
DORZOL/TIMOL SOL 2-0.5%OP    DORZOLAMIDE HCL-TIMOLOL MALEATE OPHTH SOLN 22.3-6.8 MG/ML       CARBONIC ANYDRASE INHIBITORS                     30
  DORZOLAMIDE SOL 2% OP                    DORZOLAMIDE HCL OPHTH SOLN 2%                     CARBONIC ANYDRASE INHIBITORS                     30
       DOUBLE ANTIB OIN                    *BACITRACIN-POLYMYXIN B OINT***                              Antibacterials                        30
     DOXAZOSIN TAB 1MG                       DOXAZOSIN MESYLATE TAB 1 MG                     Alpha-Adrenergic Blocking Agents                 30
     DOXAZOSIN TAB 2MG                       DOXAZOSIN MESYLATE TAB 2 MG                     Alpha-Adrenergic Blocking Agents                 30
     DOXAZOSIN TAB 4MG                       DOXAZOSIN MESYLATE TAB 4 MG                     Alpha-Adrenergic Blocking Agents                 30
     DOXAZOSIN TAB 8MG                       DOXAZOSIN MESYLATE TAB 8 MG                     Alpha-Adrenergic Blocking Agents                 30
   DOXY-CAPS CAP 100MG                     DOXYCYCLINE HYCLATE CAP 100 MG                               Tetracyclines                         30
  DOXYCYCL HYC CAP 100MG                   DOXYCYCLINE HYCLATE CAP 100 MG                               Tetracyclines                         30
                                                                                                                                          Max Qty
                                                                                                                                            Limit   Max Max Age
                                                                                                                                          (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                               Generic Name                                          Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
   DOXYCYCL HYC CAP 50MG                       DOXYCYCLINE HYCLATE CAP 50 MG                                 Tetracyclines                          30
  DOXYCYCL HYC TAB 100MG                      DOXYCYCLINE HYCLATE TAB 100 MG                                 Tetracyclines                          30
DOXYCYCLINE SUS 25MG/5ML             DOXYCYCLINE MONOHYDRATE FOR SUSP 25 MG/5ML                              Tetracyclines                          14      18
  DRITHO-CREME CRE HP 1%                             ANTHRALIN CREAM 1%                       Skin and Mucous Membrane Agents, Misc                 30
    DRITHO-SCALP CRE 0.5%                           ANTHRALIN CREAM 0.5%                      Skin and Mucous Membrane Agents, Misc                 30
  DRITUSS DM ELX 200-20/5         DEXTROMETHORPHAN-GUAIFENESIN ELIXIR 20-200 MG/5ML                          Antitussives                   178     30
        DRITUSS HD ELX        PSEUDOEPHEDRINE W/ HYDROCODONE-GG ELIXIR 30-2.5-100 MG/5ML                     Antitussives                   178     30
        DROTUSS-CP LIQ          PHENYLEPH-CHLORPHEN W/ HYDROCODONE LIQD 5-2-5 MG/5ML                         Antitussives                           30
 DRY SKIN CAR LOT ORIGINAL                          *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
DRY SKIN CAR LOT UNSCENTD                           *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
      DSS      CAP 100MG                        DOCUSATE SODIUM CAP 100 MG                             Cathartics and Laxatives             100     30
      DSS      CAP 250MG                        DOCUSATE SODIUM CAP 250 MG                             Cathartics and Laxatives             100     30
   DT BODY LOTI LOT EX STR                          *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
        DT FACE CARE LOT                            *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
       DT FOOT MASS LOT                             *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
 DT HAND ELBO LOT & KNEE                            *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
        DT HEEL CARE LOT                            *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
  DULCOLAX SS CAP 100MG                         DOCUSATE SODIUM CAP 100 MG                             Cathartics and Laxatives             100     30
        DUOSPORE OIN                          *BACITRACIN-POLYMYXIN B OINT***                               Antibacterials                          30
    DURADEX TAB FORTE            DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 45-1200 MG                         Antitussives                   31      30
        DURADRIN CAP           ACETAMINOPHEN-ISOMETHEPTENE-DICHLORAL CAP 325-65-100 MG           Antimigraine Agents, Miscellaneous         6       30
DURAMORPH INJ 0.5MG/ML                       MORPHINE SULFATE INJ PF 0.5 MG/ML                             Opiate Agonists                          30                                                   Prior Authorization Req'd
 DURAMORPH INJ 1MG/ML                         MORPHINE SULFATE INJ PF 1 MG/ML                              Opiate Agonists                          30                                                   Prior Authorization Req'd
   DYNACIRC CR TAB 10MG                         ISRADIPINE TAB SR 24HR 10 MG                              Dihydropyridines                          30
    DYNACIRC CR TAB 5MG                          ISRADIPINE TAB SR 24HR 5 MG                              Dihydropyridines                          30
     DYSPEL     TAB 200MG                           IBUPROFEN TAB 200 MG                     Other Nonsteroidal Anti-inflammtory Agents             30
   DYTUSS      SYP 12.5/5ML              DIPHENHYDRAMINE HCL SYRUP 12.5 MG/5ML                        Ethanolamine Derivatives                      30
    E.E.S. 200 SUS 200/5ML           ERYTHROMYCIN ETHYLSUCCINATE SUSP 200 MG/5ML                            Erythromycins                           14      18
    E.E.S. 400 SUS 400/5ML           ERYTHROMYCIN ETHYLSUCCINATE SUSP 400 MG/5ML                            Erythromycins                           14      18
     E.E.S. 400 TAB 400MG                ERYTHROMYCIN ETHYLSUCCINATE TAB 400 MG                             Erythromycins                           14
  E.E.S. GRAN SUS 200/5ML          ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 200 MG/5ML                          Erythromycins                           30      18
     E.S.P.    SUS 200-600        ERYTHROMYCIN-SULFISOXAZOLE FOR SUSP 200-600 MG/5ML                        Erythromycins                  6720     30      18
     EAR DROPS SOL OTIC                  BENZOCAINE-ANTIPYRINE OTIC SOLN 1.4-5.4%                         Local Anesthetics                         30
         EASIVENT MIS                *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***                               Devices                      2      30
  EASIVENT MIS MASK LG               *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***                               Devices                      2      30
  EASIVENT MIS MASK SM               *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***                               Devices                      2      30
 EASIVENT MIS MASK MED               *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***                               Devices                      2      30
    EASY-LAX CAP 100MG                          DOCUSATE SODIUM CAP 100 MG                             Cathartics and Laxatives             100     30
      EASY-LAX TAB PLUS                 SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                       Cathartics and Laxatives             100     30
  ECK ACETAMIN TAB 325MG                         ACETAMINOPHEN TAB 325 MG                          Analgesics and Antipyretics, Misc        250     30
   ECK ASPIRIN TAB 325MG                              ASPIRIN TAB 325 MG                                      Salicylates                    31     30
  ECK CHILD SUS NON-ASA                       ACETAMINOPHEN SUSP 160 MG/5ML                        Analgesics and Antipyretics, Misc        240     30
  ECK CHLD ASA CHW 81MG                            ASPIRIN CHEW TAB 81 MG                                     Salicylates                    31     30
    ECK DIPH-AL CAP 25MG                      DIPHENHYDRAMINE HCL CAP 25 MG                           Ethanolamine Derivatives                      30
   ECK DIPHEDRY CAP 25MG                      DIPHENHYDRAMINE HCL CAP 25 MG                           Ethanolamine Derivatives                      30
 ECK DIPHEDRY CHW 12.5MG                  DIPHENHYDRAMINE HCL CHEW TAB 12.5 MG                        Ethanolamine Derivatives                      30
 ECK DIPHEDRY LIQ 12.5/5ML               DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                       Ethanolamine Derivatives                      30
    ECK HYDROCOR OIN 1%                       HYDROCORTISONE ACETATE OINT 1%                          Anti-inflammatory Agents              30      30
   ECK IBUPROF TAB 200MG                            IBUPROFEN TAB 200 MG                     Other Nonsteroidal Anti-inflammtory Agents             30
  ECK IBUPROFE TAB 100MG                            IBUPROFEN TAB 100 MG                     Other Nonsteroidal Anti-inflammtory Agents             30
ECK NICOTINE DIS 14MG/24H                   NICOTINE TD PATCH 24HR 14 MG/24HR                      Autonomic Drugs, Miscellaneous                   30
ECK NICOTINE DIS 21MG/24H                   NICOTINE TD PATCH 24HR 21 MG/24HR                      Autonomic Drugs, Miscellaneous                   30
ECK NICOTINE DIS 7MG/24HR                    NICOTINE TD PATCH 24HR 7 MG/24HR                      Autonomic Drugs, Miscellaneous                   30
   ECK NICOTINE GUM 2MG                        NICOTINE POLACRILEX GUM 2 MG                        Autonomic Drugs, Miscellaneous                   30
   ECK NICOTINE GUM 4MG                        NICOTINE POLACRILEX GUM 4 MG                        Autonomic Drugs, Miscellaneous                   30
  ECK NON-ASA CHW 80MG                        ACETAMINOPHEN CHEW TAB 80 MG                         Analgesics and Antipyretics, Misc         60     30
     ECK PERMETHR LIQ 1%                         PERMETHRIN CREME RINSE 1%                           Scabicides and Pediculicides           120     30
       ECK POLYMYXI OIN                       *BACITRACIN-POLYMYXIN B OINT***                               Antibacterials                          30
  ECK TRIPLE OIN ANTIBIOT          NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%                          Antibacterials                  15      30
 ECK TUSSIN CAP SEV CONG               PSEUDOEPHEDRINE-GUAIFENESIN CAP 30-200 MG                             Expectorants                           30
       ECK TUSSIN SYP PE           PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 30-100 MG/5ML                           Expectorants                           30
      ECONAZOLE CRE 1%                          ECONAZOLE NITRATE CREAM 1%                                      Azoles                              30                                                   Prior Authorization Req'd
 ECOTRIN LOW TAB 81MG EC                     ASPIRIN TAB DELAYED RELEASE 81 MG                                Salicylates                   31      30
   ED BACLOFEN TAB 10MG                              BACLOFEN TAB 10 MG                    GABA DERIVATIVE SKELETAL MUSCLE RELAXANTS                30                                                   Prior Authorization Req'd
  ED K+10 TAB 10MEQ CR                       POTASSIUM CHLORIDE TAB CR 10 MEQ                         Replacement Preparations                      30
                                                                                                                                                Max Qty
                                                                                                                                                  Limit   Max Max Age
                                                                                                                                                (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                                 Generic Name                                           Therapy Class                       in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
  ED-APAP LIQ 80MG/2.5                        ACETAMINOPHEN LIQUID 160 MG/5ML                        Analgesics and Antipyretics, Misc            240     30
      EDEX       KIT 10MCG                        ALPROSTADIL FOR INJ KIT 10 MCG                    Vasodilating Agents, Miscellaneous                    30                                                   Prior Authorization Req'd
      EDEX       KIT 20MCG                        ALPROSTADIL FOR INJ KIT 20 MCG                    Vasodilating Agents, Miscellaneous                    30                                                   Prior Authorization Req'd
      EDEX       KIT 40MCG                        ALPROSTADIL FOR INJ KIT 40 MCG                    Vasodilating Agents, Miscellaneous                    30                                                   Prior Authorization Req'd
        EDGE OB CHW               *PRENATAL VIT W/ FE POLYSAC CMPLX-FA CHEW TAB 29-1 MG***              Multivitamin Preparations                         30      40
    ED-TLC      SYP 5-2-1.67   PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 5-2-1.67 MG/5ML                          Antitussives                     178     30
        ED-TUSS HC SYP         PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 10-4-2.5 MG/5ML                          Antitussives                     178     30
          EEMT       TAB         ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 1.25-2.5 MG                        Estrogens                               30
         EEMT HS TAB            ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 0.625-1.25 MG                       Estrogens                               30
 EES/SULFISOX SUS 200-600           ERYTHROMYCIN-SULFISOXAZOLE FOR SUSP 200-600 MG/5ML                         Erythromycins                     6720     30      18
   ELEXA       MIS STIMULAT                         CONDOMS LATEX LUBRICATED                                   Contraceptives                             30
   ELEXA NATURL MIS FEEL                            CONDOMS LATEX LUBRICATED                                   Contraceptives                             30
 ELEXA ULTRA MIS SENSITIV                           CONDOMS LATEX LUBRICATED                                   Contraceptives                             30
    ELIPHOS TAB 667MG                  CALCIUM ACETATE (PHOSPHATE BINDER) TAB 667 MG                    Replacement Preparations                          30
    ELITE OB CAP W/DHA            *PRENATAL VIT W/ FE FUM-FA-OMEGA 3 CAP 28-1.25-200 MG***              Multivitamin Preparations                         30      40
         ELITE-OB TAB                *PRENATAL VIT W/ IRON CARBONYL-FA TAB 50-1.25 MG***                Multivitamin Preparations                         30      40
  ELIXSURE IB SUS 100/5ML                          IBUPROFEN SUSP 100 MG/5ML                   Other Nonsteroidal Anti-inflammtory Agents                 30      18
      ELLA       TAB 30MG                          ULIPRISTAL ACETATE TAB 30 MG                                Contraceptives                             30
          ELTA       LOT                               *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                       30                                                   Prior Authorization Req'd
    EMCYT        CAP 140MG               ESTRAMUSTINE PHOSPHATE SODIUM CAP 140 MG                          Antineoplastic Agents                          30
       EMOLLIA-LOT LOT                                 *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                       30                                                   Prior Authorization Req'd
   EMTRIVA CAP 200MG                                EMTRICITABINE CAPS 200 MG                 Nucleoside & Nucleotide Rev Transcriptase Inhib             30
 EMTRIVA SOL 10MG/ML                              EMTRICITABINE SOLN 10 MG/ML                 Nucleoside & Nucleotide Rev Transcriptase Inhib             30
    ENALAPRIL TAB 10MG                            ENALAPRIL MALEATE TAB 10 MG                   Angiotensin-Converting Enzyme Inhibitors                  30
   ENALAPRIL TAB 2.5MG                            ENALAPRIL MALEATE TAB 2.5 MG                  Angiotensin-Converting Enzyme Inhibitors                  30
    ENALAPRIL TAB 20MG                            ENALAPRIL MALEATE TAB 20 MG                   Angiotensin-Converting Enzyme Inhibitors                  30
     ENALAPRIL TAB 5MG                             ENALAPRIL MALEATE TAB 5 MG                   Angiotensin-Converting Enzyme Inhibitors                  30
       ENDACOF-DM SYP                 PSEUDOEPHED-BROMPHEN-DM SYRUP 60-4-30 MG/5ML                               Antitussives                     178     30
       ENDACOF-XP SYP                  HYDROCODONE-GUAIFENESIN SYRUP 2.5-200 MG/5ML                              Antitussives                     178     30
  ENDOCET TAB 5-325MG                    OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG                              Opiate Agonists                     120     30
        ENDODAN TAB                        OXYCODONE W/ ASPIRIN TAB FULL STRENGTH                             Opiate Agonists                     120     30
ENDUR-ACIN TAB 250MG SR                                 NIACIN TAB CR 250 MG                                 Vitamin B Complex                     62     30
ENDUR-ACIN TAB 500MG SR                                 NIACIN TAB CR 500 MG                                 Vitamin B Complex                     62     30
ENOXAPARIN INJ 100MG/ML                        ENOXAPARIN SODIUM INJ 100 MG/ML                                    Heparins                                 7
  ENOXAPARIN INJ 120/0.8                     ENOXAPARIN SODIUM INJ 120 MG/0.8ML                                   Heparins                                 7
ENOXAPARIN INJ 150MG/ML                        ENOXAPARIN SODIUM INJ 150 MG/ML                                    Heparins                                 7
 ENOXAPARIN INJ 30/0.3ML                      ENOXAPARIN SODIUM INJ 30 MG/0.3ML                                   Heparins                                 7
 ENOXAPARIN INJ 40/0.4ML                      ENOXAPARIN SODIUM INJ 40 MG/0.4ML                                   Heparins                                 7
 ENOXAPARIN INJ 60/0.6ML                      ENOXAPARIN SODIUM INJ 60 MG/0.6ML                                   Heparins                                 7
 ENOXAPARIN INJ 80/0.8ML                      ENOXAPARIN SODIUM INJ 80 MG/0.8ML                                   Heparins                                 7
       ENPRESSE-28 TAB         LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG                    Contraceptives                             30
 ENTEX PSE TAB 50-525MG              PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 50-525 MG                          Expectorants                       31     30
  ENULOSE SOL 10GM/15                 LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML                       Ammonia Detoxicants                    947     30
         EPIDRIN CAP            ACETAMINOPHEN-ISOMETHEPTENE-DICHLORAL CAP 325-65-100 MG             Antimigraine Agents, Miscellaneous             6      30
  EPIFLUR CHW 0.25MG F             SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF)             Miscellaneous Therapeutic Agents                     30
  EPIFLUR CHW 0.5MG F               SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)              Miscellaneous Therapeutic Agents                     30
    EPIFLUR CHW 1MG F                SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)               Miscellaneous Therapeutic Agents                     30
   EPIKLOR POW 20MEQ                      POTASSIUM CHLORIDE POWDER PACKET 20 MEQ                       Replacement Preparations                          30
          EPILYT     LOT                               *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                       30                                                   Prior Authorization Req'd
   EPINEPHRINE INJ 0.3MG                  EPINEPHRINE INJ DEVICE 0.3 MG/0.3ML (1:1000)             alpha- and beta-Adrenergic Agonists                    30
     EPIPEN       INJ 0.3MG               EPINEPHRINE INJ DEVICE 0.3 MG/0.3ML (1:1000)             alpha- and beta-Adrenergic Agonists                    30
   EPIPEN 2-PAK INJ 0.3MG                 EPINEPHRINE INJ DEVICE 0.3 MG/0.3ML (1:1000)             alpha- and beta-Adrenergic Agonists                    30
    EPIPEN-JR INJ 0.15MG                 EPINEPHRINE INJ DEVICE 0.15 MG/0.3ML (1:2000)             alpha- and beta-Adrenergic Agonists                    30
     EPIPEN-JR INJ 2-PAK                 EPINEPHRINE INJ DEVICE 0.15 MG/0.3ML (1:2000)             alpha- and beta-Adrenergic Agonists                    30
    EPITOL       TAB 200MG                          CARBAMAZEPINE TAB 200 MG                          Anticonvulsants, Miscellaneous                      30
   EPIVIR      SOL 10MG/ML                      LAMIVUDINE ORAL SOLN 10 MG/ML                 Nucleoside & Nucleotide Rev Transcriptase Inhib             30
     EPIVIR     TAB 150MG                             LAMIVUDINE TAB 150 MG                   Nucleoside & Nucleotide Rev Transcriptase Inhib             30
     EPIVIR     TAB 300MG                             LAMIVUDINE TAB 300 MG                   Nucleoside & Nucleotide Rev Transcriptase Inhib             30
  EPIVIR HBV SOL 5MG/ML                          LAMIVUDINE ORAL SOLN 5 MG/ML                 Nucleoside & Nucleotide Rev Transcriptase Inhib             30
   EPIVIR HBV TAB 100MG                               LAMIVUDINE TAB 100 MG                   Nucleoside & Nucleotide Rev Transcriptase Inhib             30
        EPZICOM TAB                      ABACAVIR SULFATE-LAMIVUDINE TAB 600-300 MG           Nucleoside & Nucleotide Rev Transcriptase Inhib             30
   EQ ALLERGY CAP 25MG                          DIPHENHYDRAMINE HCL CAP 25 MG                            Ethanolamine Derivatives                         30
 EQ ANTACID SUS ANTI-GAS         ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML                 Antacids and Adsorbents                  480     30
  EQ ANTACID SUS MAX ST          ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML                 Antacids and Adsorbents                  480     30
  EQ ARTHRITIS TAB 650MG                         ACETAMINOPHEN TAB CR 650 MG                         Analgesics and Antipyretics, Misc            120     30
                                                                                                                                     Max Qty
                                                                                                                                       Limit   Max Max Age
                                                                                                                                     (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                              Generic Name                                      Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug      Coverage Status
     EQ ASPIRIN TAB 325MG                            ASPIRIN TAB 325 MG                                  Salicylates                    31     30
      EQ ASPIRIN TAB 81MG                            ASPIRIN TAB 81 MG                                   Salicylates                    31     30
    EQ BUFF ASA TAB 325MG        ASPIRIN BUFFERED (CA CARB-MG CARB-MG OX) TAB 325 MG                     Salicylates                    31     30
    EQ CHILD ASA CHW 81MG                         ASPIRIN CHEW TAB 81 MG                                 Salicylates                    31     30
   EQ IBUPROFEN CAP 200MG                          IBUPROFEN CAP 200 MG                 Other Nonsteroidal Anti-inflammtory Agents     100     30
 EQ IBUPROFEN DRO INFANTS                       IBUPROFEN SUSP 40 MG/ML                 Other Nonsteroidal Anti-inflammtory Agents             30      18
   EQ IBUPROFEN TAB 200MG                          IBUPROFEN TAB 200 MG                 Other Nonsteroidal Anti-inflammtory Agents             30
 EQ NICOTINE DIS 14MG/24H                  NICOTINE TD PATCH 24HR 14 MG/24HR                 Autonomic Drugs, Miscellaneous                    30
 EQ NICOTINE DIS 21MG/24H                  NICOTINE TD PATCH 24HR 21 MG/24HR                 Autonomic Drugs, Miscellaneous                    30
 EQ NICOTINE DIS 7MG/24HR                   NICOTINE TD PATCH 24HR 7 MG/24HR                 Autonomic Drugs, Miscellaneous                    30
EQ NICOTINE GUM 2MG MINT                      NICOTINE POLACRILEX GUM 2 MG                   Autonomic Drugs, Miscellaneous                    30
  EQ NICOTINE GUM 2MG REF                     NICOTINE POLACRILEX GUM 2 MG                   Autonomic Drugs, Miscellaneous                    30
 EQ NICOTINE GUM 2MG STRT                     NICOTINE POLACRILEX GUM 2 MG                   Autonomic Drugs, Miscellaneous                    30
EQ NICOTINE GUM 2MGFRUIT                      NICOTINE POLACRILEX GUM 2 MG                   Autonomic Drugs, Miscellaneous                    30
EQ NICOTINE GUM 4MG MINT                      NICOTINE POLACRILEX GUM 4 MG                   Autonomic Drugs, Miscellaneous                    30
  EQ NICOTINE GUM 4MG REF                     NICOTINE POLACRILEX GUM 4 MG                   Autonomic Drugs, Miscellaneous                    30
 EQ NICOTINE GUM 4MG STRT                     NICOTINE POLACRILEX GUM 4 MG                   Autonomic Drugs, Miscellaneous                    30
    EQ NON-DRY CAP SINUS              PSEUDOEPHEDRINE-GUAIFENESIN CAP 30-200 MG                         Expectorants                           30
  EQ STOMACH CHW 262MG                  BISMUTH SUBSALICYLATE CHEW TAB 262 MG                       Antidiarrhea Agents                120     30
    EQ SUPHEDRIN TAB 30MG                    PSEUDOEPHEDRINE HCL TAB 30 MG                 alpha- and beta-Adrenergic Agonists         120     30
        EQ TUSSIN SYP DM         DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                       Antitussives                   180     30
   EQL ACETAMIN TAB 650MG                     ACETAMINOPHEN TAB CR 650 MG                    Analgesics and Antipyretics, Misc         120     30
   EQL ALL DAY TAB ALLERGY                       CETIRIZINE HCL TAB 10 MG                   Second Generation Antihistamines                   30
     EQL ALLERGY CAP 25MG                    DIPHENHYDRAMINE HCL CAP 25 MG                       Ethanolamine Derivatives                      30
     EQL ALLERGY TAB 25MG                    DIPHENHYDRAMINE HCL TAB 25 MG                       Ethanolamine Derivatives                      30
  EQL ANTACID SUS ANTI-GAS    ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML            Antacids and Adsorbents               480     30
   EQL ANTACID SUS MAX ST     ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML            Antacids and Adsorbents               480     30
   EQL ARTHRITS TAB 650MG                     ACETAMINOPHEN TAB CR 650 MG                    Analgesics and Antipyretics, Misc         120     30
    EQL ASPIRIN TAB 325MG                            ASPIRIN TAB 325 MG                                  Salicylates                    31     30
   EQL ASPIRIN TAB 81MG EC                  ASPIRIN TAB DELAYED RELEASE 81 MG                            Salicylates                    31     30
       EQL ATHLETES CRE 1%                       CLOTRIMAZOLE CREAM 1%                                     Azoles                       30     30
   EQL BUFF ASA TAB 325MG        ASPIRIN BUFFERED (CA CARB-MG CARB-MG OX) TAB 325 MG                     Salicylates                    31     30
   EQL CHLD ASA CHW 81MG                          ASPIRIN CHEW TAB 81 MG                                 Salicylates                    31     30
   EQL HEARTBRN TAB RELIEF                       RANITIDINE HCL TAB 75 MG                        Histamine H2-Antagonists               60     30
  EQL INFANT DRO 80/0.8ML                   ACETAMINOPHEN SUSP 80 MG/0.8ML                   Analgesics and Antipyretics, Misc          30     30
     EQL LICE LIQ TRTMENT              PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.33-4%                Scabicides and Pediculicides           120     30
 EQL NICOTINE DIS 14MG/24H                 NICOTINE TD PATCH 24HR 14 MG/24HR                 Autonomic Drugs, Miscellaneous                    30
 EQL NICOTINE DIS 21MG/24H                 NICOTINE TD PATCH 24HR 21 MG/24HR                 Autonomic Drugs, Miscellaneous                    30
 EQL NICOTINE DIS 7MG/24HR                  NICOTINE TD PATCH 24HR 7 MG/24HR                 Autonomic Drugs, Miscellaneous                    30
 EQL NICOTINE GUM 2MG REF                     NICOTINE POLACRILEX GUM 2 MG                   Autonomic Drugs, Miscellaneous                    30
EQL NICOTINE GUM 2MG STRT                     NICOTINE POLACRILEX GUM 2 MG                   Autonomic Drugs, Miscellaneous                    30
 EQL NICOTINE GUM 4MG REF                     NICOTINE POLACRILEX GUM 4 MG                   Autonomic Drugs, Miscellaneous                    30
EQL NICOTINE GUM 4MG STRT                     NICOTINE POLACRILEX GUM 4 MG                   Autonomic Drugs, Miscellaneous                    30
 EQL NON-DRYI CAP 30-200MG            PSEUDOEPHEDRINE-GUAIFENESIN CAP 30-200 MG                         Expectorants                           30
  EQL STOMACH CHW 262MG                 BISMUTH SUBSALICYLATE CHEW TAB 262 MG                       Antidiarrhea Agents                120     30
   EQL TUSSIN SYP 100/5ML                     GUAIFENESIN SYRUP 100 MG/5ML                              Expectorants                           30
       EQL TUSSIN SYP DM         DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                       Antitussives                   180     30
ERGOCALCIFER CAP 50000UNT                     ERGOCALCIFEROL CAP 50000 UNIT                              Vitamin D                             30
      ERGOMAR SUB 2MG                       ERGOTAMINE TARTRATE SL TAB 2 MG              Sympatholytic (Adrenergic Block) Agents        6      30
   ERGOTAM/CAFF TAB 1/100                ERGOTAMINE W/ CAFFEINE TAB 1-100 MG                Antimigraine Agents, Miscellaneous          6      30
      ERRIN     TAB 0.35MG                     NORETHINDRONE TAB 0.35 MG                              Contraceptives                           30
     ERYPED     DRO 100/2.5      ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 100 MG/2.5ML                     Erythromycins                           30      18
   ERYPED 200 SUS 200/5ML         ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 200 MG/5ML                      Erythromycins                           30      18
   ERYPED 400 SUS 400/5ML         ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 400 MG/5ML                      Erythromycins                           30      18
   ERY-TAB TAB 250MG EC                ERYTHROMYCIN TAB DELAYED RELEASE 250 MG                         Erythromycins                           14
   ERY-TAB TAB 333MG EC                ERYTHROMYCIN TAB DELAYED RELEASE 333 MG                         Erythromycins                           14
   ERY-TAB TAB 500MG EC                ERYTHROMYCIN TAB DELAYED RELEASE 500 MG                         Erythromycins                           14
    ERYTHROCIN TAB 250MG                   ERYTHROMYCIN STEARATE TAB 250 MG                            Erythromycins                           30
    ERYTHROCIN TAB 500MG                   ERYTHROMYCIN STEARATE TAB 500 MG                            Erythromycins                           30
 ERYTHROM ETH SUS 200/5ML           ERYTHROMYCIN ETHYLSUCCINATE SUSP 200 MG/5ML                        Erythromycins                           14      18
 ERYTHROM ETH SUS 400/5ML           ERYTHROMYCIN ETHYLSUCCINATE SUSP 400 MG/5ML                        Erythromycins                           14      18
  ERYTHROM ETH TAB 400MG               ERYTHROMYCIN ETHYLSUCCINATE TAB 400 MG                          Erythromycins                           14
   ERYTHROM ST TAB 250MG                   ERYTHROMYCIN STEARATE TAB 250 MG                            Erythromycins                           30
   ERYTHROM ST TAB 500MG                   ERYTHROMYCIN STEARATE TAB 500 MG                            Erythromycins                           30
ERYTHROMYCIN CAP 250MG EC       ERYTHROMYCIN W/ DELAYED RELEASE PARTICLES CAP 250 MG                   Erythromycins                           30
                                                                                                                                        Max Qty
                                                                                                                                          Limit   Max Max Age
                                                                                                                                        (Liquids Days    Limit    Step         Step Therapy      Specialty
    Drug/Product Name                               Generic Name                                        Therapy Class                    in mLs) Supply (Years) Required?      Requirement         Drug         Coverage Status
    ERYTHROMYCIN OIN OP                    ERYTHROMYCIN OPHTH OINT 5 MG/GM                               Antibacterials                           30
ERYTHROMYCIN TAB 250MG BS                       ERYTHROMYCIN TAB 250 MG                                  Erythromycins                            14
ERYTHROMYCIN TAB 333MG EC              ERYTHROMYCIN TAB DELAYED RELEASE 333 MG                           Erythromycins                            14
ERYTHROMYCIN TAB 500MG BS                       ERYTHROMYCIN TAB 500 MG                                  Erythromycins                            14
          ESSIAN    TAB       ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 1.25-2.5 MG                    Estrogens                              30
         ESSIAN H.S. TAB     ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 0.625-1.25 MG                   Estrogens                              30
   EST ESTROGEN TAB MTEST     ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 1.25-2.5 MG                    Estrogens                              30
 EST ESTROGEN TAB MTEST DS    ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 1.25-2.5 MG                    Estrogens                              30
 EST ESTROGEN TAB MTEST HS   ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 0.625-1.25 MG                   Estrogens                              30
   ESTRADERM DIS 0.05MG                ESTRADIOL TD PATCH BIWEEKLY 0.05 MG/24HR                            Estrogens                              30
    ESTRADERM DIS 0.1MG                 ESTRADIOL TD PATCH BIWEEKLY 0.1 MG/24HR                            Estrogens                              30
   ESTRADIOL DIS 0.025MG                ESTRADIOL TD PATCH WEEKLY 0.025 MG/24HR                            Estrogens                              30
  ESTRADIOL DIS 0.0375MG       ESTRADIOL TD PATCH WEEKLY 0.0375 MG/24HR (37.5 MCG/24HR)                    Estrogens                              30
    ESTRADIOL DIS 0.05MG                 ESTRADIOL TD PATCH WEEKLY 0.05 MG/24HR                            Estrogens                              30
    ESTRADIOL DIS 0.06MG                 ESTRADIOL TD PATCH WEEKLY 0.06 MG/24HR                            Estrogens                              30
   ESTRADIOL DIS 0.075MG                ESTRADIOL TD PATCH WEEKLY 0.075 MG/24HR                            Estrogens                              30
     ESTRADIOL DIS 0.1MG                 ESTRADIOL TD PATCH WEEKLY 0.1 MG/24HR                             Estrogens                              30
    ESTRADIOL TAB 0.5MG                            ESTRADIOL TAB 0.5 MG                                    Estrogens                              30
     ESTRADIOL TAB 1MG                              ESTRADIOL TAB 1 MG                                     Estrogens                              30
     ESTRADIOL TAB 2MG                              ESTRADIOL TAB 2 MG                                     Estrogens                              30
        ESTRATEST HS TAB     ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 0.625-1.25 MG                   Estrogens                              30
  ESTROPIPATE TAB 0.75MG                         ESTROPIPATE TAB 0.75 MG                                   Estrogens                              30
   ESTROPIPATE TAB 1.5MG                         ESTROPIPATE TAB 1.5 MG                                    Estrogens                              30
    ESTROPIPATE TAB 3MG                           ESTROPIPATE TAB 3 MG                                     Estrogens                              30
  ETHAMBUTOL TAB 100MG                         ETHAMBUTOL HCL TAB 100 MG                            Antituberculosis Agents                       30
  ETHAMBUTOL TAB 400MG                         ETHAMBUTOL HCL TAB 400 MG                            Antituberculosis Agents                       30
  ETHEDENT CHW 0.25MG           SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF)          Miscellaneous Therapeutic Agents                   30
   ETHEDENT CHW 0.5MG            SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)           Miscellaneous Therapeutic Agents                   30
     ETHEDENT CHW 1MG             SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)            Miscellaneous Therapeutic Agents                   30
   ETHEDENT CRE DENTAL                        SODIUM FLUORIDE CREAM 1.1%                       Miscellaneous Therapeutic Agents                   30      18
      ETHEDENT GEL 1.1%                     SODIUM FLUORIDE GEL 1.1% (0.5% F)                  Miscellaneous Therapeutic Agents                   30      18
  ETHOSUXIMIDE CAP 250MG                        ETHOSUXIMIDE CAP 250 MG                                   Succinimides                            30
 ETHOSUXIMIDE SOL 250/5ML                    ETHOSUXIMIDE SOLN 250 MG/5ML                                 Succinimides                            30      18




                                                                                                                                                                             USE FORMULARY
  ETODOLAC   CAP 200MG                          ETODOLAC CAP 200 MG                        Other Nonsteroidal Anti-inflammtory Agents             30                Y       GENERIC NSAIDS 1ST




                                                                                                                                                                             USE FORMULARY
  ETODOLAC   CAP 300MG                          ETODOLAC CAP 300 MG                        Other Nonsteroidal Anti-inflammtory Agents             30                Y       GENERIC NSAIDS 1ST




                                                                                                                                                                             USE FORMULARY
  ETODOLAC   TAB 400MG                          ETODOLAC TAB 400 MG                        Other Nonsteroidal Anti-inflammtory Agents             30                Y       GENERIC NSAIDS 1ST




                                                                                                                                                                             USE FORMULARY
  ETODOLAC TAB 500MG                          ETODOLAC TAB 500 MG                          Other Nonsteroidal Anti-inflammtory Agents             30                Y       GENERIC NSAIDS 1ST
       EUCERIN LOT                            *EMOLLIENT - LOTION**                                Basic Lotions and Liniments                    30                                                         Prior Authorization Req'd
     EUCERIN PLUS LOT                         *EMOLLIENT - LOTION**                                Basic Lotions and Liniments                    30                                                         Prior Authorization Req'd
    EVISTA     TAB 60MG                     RALOXIFENE HCL TAB 60 MG                              Estrogen Agonist-Antagonists                    30                                                         Prior Authorization Req'd
   EX STR PAIN TAB RELIEF                  ACETAMINOPHEN TAB 500 MG                             Analgesics and Antipyretics, Misc         250     30
 EX STR PAIN TAB RELIEVER                  ACETAMINOPHEN TAB 500 MG                             Analgesics and Antipyretics, Misc         250     30
  EXECLEAR SYP 3.5-100             HYDROCODONE-GUAIFENESIN SYRUP 3.5-100 MG/5ML                            Antitussives                   178     30
       EXECOF-XP SYP                HYDROCODONE-GUAIFENESIN SYRUP 3-90 MG/5ML                              Antitussives                   178     30
 EXEFEN      TAB 80-780MG        PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 80-780 MG                        Expectorants                     31     30
                                                                                                                                          Max Qty
                                                                                                                                            Limit   Max Max Age
                                                                                                                                          (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                                 Generic Name                                         Therapy Class                   in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
   EXEFEN-DM TAB 55-1000          DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 55-1000 MG                          Antitussives                 31      30
  EXEFEN-IR TAB 60-400MG                  PSEUDOEPHEDRINE-GUAIFENESIN TAB 60-400 MG                           Expectorants                          30
       EXELDERM CRE 1%                           SULCONAZOLE NITRATE CREAM 1%                                     Azoles                            30                                                   Prior Authorization Req'd
       EXELDERM SOL 1%                         SULCONAZOLE NITRATE SOLUTION 1%                                    Azoles                            30                                                   Prior Authorization Req'd
      EXELON     CAP 1.5MG                      RIVASTIGMINE TARTRATE CAP 1.5 MG               Parasympathomimetic (Cholinergic) Agents             30                                                   Prior Authorization Req'd
    EXELON      SOL 2MG/ML                    RIVASTIGMINE TARTRATE SOLN 2 MG/ML               Parasympathomimetic (Cholinergic) Agents             30      18                                           Prior Authorization Req'd
  EXTRA ACTION SYP COUGH           DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                            Antitussives                 180     30
 EXTRA SENSIT MIS SPERMICI                          CONDOMS LATEX LUBRICATED                                 Contraceptives                         30
     FANSIDAR TAB 500/25                  SULFADOXINE & PYRIMETHAMINE TAB 500-25 MG                           Antimalarials                         30
   FANTASY MIS LUBRICAT                             CONDOMS LATEX LUBRICATED                                 Contraceptives                         30
        FANTASY LUBR MIS                            CONDOMS LATEX LUBRICATED                                 Contraceptives                         30
  FANTASY LUBR MIS COLORS                           CONDOMS LATEX LUBRICATED                                 Contraceptives                         30
FANTASY LUBR MIS SPERMICI                           CONDOMS LATEX LUBRICATED                                 Contraceptives                         30
          FARBITAL TAB                   BUTALBITAL-ASPIRIN-CAFFEINE TAB 50-325-40 MG            Nonsteroidal Anti-inflammatory Agents              30
     FARESTON TAB 60MG                  TOREMIFENE CITRATE TAB 60 MG (BASE EQUIVALENT)                   Antineoplastic Agents                      30
   FE TABS TAB 325MG EC              FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)                   Iron Preparations                        30
   FELBATOL SUS 600/5ML                             FELBAMATE SUSP 600 MG/5ML                       Anticonvulsants, Miscellaneous                  30
    FELBATOL TAB 400MG                                 FELBAMATE TAB 400 MG                         Anticonvulsants, Miscellaneous                  30
    FELBATOL TAB 600MG                                 FELBAMATE TAB 600 MG                         Anticonvulsants, Miscellaneous                  30
  FELODIPINE TAB 10MG ER                           FELODIPINE TAB SR 24HR 10 MG                             Dihydropyridines                        30
  FELODIPINE TAB 2.5MG ER                         FELODIPINE TAB SR 24HR 2.5 MG                             Dihydropyridines                        30
   FELODIPINE TAB 5MG ER                            FELODIPINE TAB SR 24HR 5 MG                             Dihydropyridines                        30
     FEMARA      TAB 2.5MG                              LETROZOLE TAB 2.5 MG                             Antineoplastic Agents                      30
     FEMHRT      TAB 0.5-2.5   NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 0.5 MG-2.5 MCG                       Estrogens                           30
 FENESIN DM TAB 15-400MG                DEXTROMETHORPHAN-GUAIFENESIN TAB 15-400 MG                             Antitussives                 31      30
   FENOFIBRATE TAB 160MG                              FENOFIBRATE TAB 160 MG                             Fibric Acid Derivatives                    30
    FENOFIBRATE TAB 54MG                               FENOFIBRATE TAB 54 MG                             Fibric Acid Derivatives                    30
  FENTANYL DIS 100MCG/H                       FENTANYL TD PATCH 72HR 100 MCG/HR                             Opiate Agonists                 10      30                                                   Prior Authorization Req'd
 FENTANYL DIS 12MCG/HR                         FENTANYL TD PATCH 72HR 12 MCG/HR                             Opiate Agonists                 10      30                                                   Prior Authorization Req'd
 FENTANYL DIS 25MCG/HR                         FENTANYL TD PATCH 72HR 25 MCG/HR                             Opiate Agonists                 10      30                                                   Prior Authorization Req'd
 FENTANYL DIS 50MCG/HR                         FENTANYL TD PATCH 72HR 50 MCG/HR                             Opiate Agonists                 10      30                                                   Prior Authorization Req'd
 FENTANYL DIS 75MCG/HR                         FENTANYL TD PATCH 72HR 75 MCG/HR                             Opiate Agonists                 10      30                                                   Prior Authorization Req'd
          FEOGEN    CAP                             *IRON COMBINATION CAP***                               Iron Preparations                        30
 FER-GEN-SOL DRO 15/0.6ML      FERROUS SULFATE SOLN 75 MG/0.6ML (15 MG/0.6ML ELEMENTAL FE)                 Iron Preparations                        30
  FER-IRON DRO 15MG/ML            FERROUS SULFATE SOLN 75 MG/ML (15 MG/ML ELEMENTAL FE)                    Iron Preparations                        30
         FERRAGEN CAP                               *IRON COMBINATION CAP***                               Iron Preparations                        30
     FERREX 150 CAP FORTE           IRON POLYSACCH COMPLEX-VIT B12-FA CAP 150-0.025-1 MG                   Iron Preparations                        30
    FERRO-BOB TAB 325MG                FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)                     Iron Preparations                        30
   FERROGELS FO CAP FORTE         FE FUMARATE-VIT C-VIT B12-FA CAP 460 (151 FE)-60-0.01-1 MG               Iron Preparations                        30
       FERROUS SULF DRO        FERROUS SULFATE SOLN 75 MG/0.6ML (15 MG/0.6ML ELEMENTAL FE)                 Iron Preparations                        30
FERROUS SULF DRO 15/0.6ML      FERROUS SULFATE SOLN 75 MG/0.6ML (15 MG/0.6ML ELEMENTAL FE)                 Iron Preparations                        30
FERROUS SULF DRO 15MG/ML          FERROUS SULFATE SOLN 75 MG/ML (15 MG/ML ELEMENTAL FE)                    Iron Preparations                        30
 FERROUS SULF ELX 220/5ML       FERROUS SULFATE ELIXIR 220 MG/5ML (44 MG/5ML ELEMENTAL FE)                 Iron Preparations                        30
FERROUS SULF TAB 324MG EC            FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)                   Iron Preparations                        30
  FERROUS SULF TAB 325MG               FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)                     Iron Preparations                        30
FERROUS SULF TAB 325MG EC            FERROUS SULFATE TAB EC 325 MG (65 MG FE EQUIVALENT)                   Iron Preparations                        30
FERROUS SULF TAB 325MG FC              FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)                     Iron Preparations                        30
     FERROUS SULF TAB 5GR              FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)                     Iron Preparations                        30
   FERROUSUL TAB 325MG                 FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)                     Iron Preparations                        30
     FIFTY50 PREP PAD PADS                               *ALCOHOL SWABS***                                       Devices                            30
   FIRST AID CRE ANTIBIOT                NEOMYCIN-POLYMYXIN W/ PRAMOXINE CREAM 1%                            Antibacterials                 15      30
     FLAGYL ER TAB 750MG                       METRONIDAZOLE TAB SR 24HR 750 MG                      Antiprotozoals, Miscellaneous                  30
    FLECAINIDE TAB 100MG                          FLECAINIDE ACETATE TAB 100 MG                         Class Ic Antiarrhythmics                    30
    FLECAINIDE TAB 150MG                          FLECAINIDE ACETATE TAB 150 MG                         Class Ic Antiarrhythmics                    30
     FLECAINIDE TAB 50MG                           FLECAINIDE ACETATE TAB 50 MG                         Class Ic Antiarrhythmics                    30
      FLEXBUMIN INJ 25%                               ALBUMIN HUMAN INJ 25%                                Blood Derivatives                        30                                                   Prior Authorization Req'd
  FLOVENT DISK AER 100MCG            FLUTICASONE PROPIONATE AER POW BA 100 MCG/BLISTER                           Adrenals                   60      30
  FLOVENT DISK AER 250MCG            FLUTICASONE PROPIONATE AER POW BA 250 MCG/BLISTER                           Adrenals                   60      30
   FLOVENT DISK AER 50MCG             FLUTICASONE PROPIONATE AER POW BA 50 MCG/BLISTER                           Adrenals                   60      30
  FLOVENT HFA AER 110MCG          FLUTICASONE PROPIONATE HFA INHAL AEROSOL 110 MCG/ACT                           Adrenals                   12      30
  FLOVENT HFA AER 220MCG          FLUTICASONE PROPIONATE HFA INHAL AEROSOL 220 MCG/ACT                           Adrenals                   12      30
   FLOVENT HFA AER 44MCG           FLUTICASONE PROPIONATE HFA INHAL AEROSOL 44 MCG/ACT                           Adrenals                   12      30
     FLUARIX INJ PF 06-07             INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                        Vaccines                           30
     FLUARIX INJ PF 07-08             INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                        Vaccines                           30
     FLUARIX INJ PF 08-09             INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                        Vaccines                           30
                                                                                                                                         Max Qty
                                                                                                                                           Limit   Max Max Age
                                                                                                                                         (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                                Generic Name                                        Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
     FLUARIX INJ PF 09-10            INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                      Vaccines                             30
     FLUARIX INJ PF 10-11            INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                      Vaccines                             30
FLUCONAZOLE SUS 10MG/ML                         FLUCONAZOLE FOR SUSP 10 MG/ML                                  Azoles                              30
FLUCONAZOLE SUS 40MG/ML                         FLUCONAZOLE FOR SUSP 40 MG/ML                                  Azoles                              30
  FLUCONAZOLE TAB 100MG                             FLUCONAZOLE TAB 100 MG                                     Azoles                      60      30
  FLUCONAZOLE TAB 150MG                             FLUCONAZOLE TAB 150 MG                                     Azoles                      60      30
  FLUCONAZOLE TAB 200MG                             FLUCONAZOLE TAB 200 MG                                     Azoles                      60      30
   FLUCONAZOLE TAB 50MG                              FLUCONAZOLE TAB 50 MG                                     Azoles                      60      30
   FLUDROCORT TAB 0.1MG                      FLUDROCORTISONE ACETATE TAB 0.1 MG                               Adrenals                             30
    FLULAVAL INJ 2008-09                        INFLUENZA VIRUS VACCINE SPLIT INJ                             Vaccines                             30
    FLULAVAL INJ 2009-10                        INFLUENZA VIRUS VACCINE SPLIT INJ                             Vaccines                             30
    FLULAVAL INJ 2010-11                        INFLUENZA VIRUS VACCINE SPLIT INJ                             Vaccines                             30
      FLULAVAL INJ SPLIT                        INFLUENZA VIRUS VACCINE SPLIT INJ                             Vaccines                             30
  FLUMIST NASA LIQ 2006-07             INFLUENZA VIRUS VACCINE LIVE INTRANASAL LIQUID                         Vaccines                             30
  FLUMIST NASA LIQ 2007-08             INFLUENZA VIRUS VACCINE LIVE INTRANASAL LIQUID                         Vaccines                             30
  FLUMIST NASA LIQ 2008-09             INFLUENZA VIRUS VACCINE LIVE INTRANASAL LIQUID                         Vaccines                             30
  FLUMIST NASA LIQ 2009-10             INFLUENZA VIRUS VACCINE LIVE INTRANASAL LIQUID                         Vaccines                             30
  FLUMIST NASA LIQ 2010-11             INFLUENZA VIRUS VACCINE LIVE INTRANASAL LIQUID                         Vaccines                             30
   FLUOCIN ACET CRE 0.01%                   FLUOCINOLONE ACETONIDE CREAM 0.01%                       Anti-inflammatory Agents                      30                                                   Prior Authorization Req'd
  FLUOCIN ACET CRE 0.025%                  FLUOCINOLONE ACETONIDE CREAM 0.025%                       Anti-inflammatory Agents                      30                                                   Prior Authorization Req'd
  FLUOCIN ACET OIN 0.025%                   FLUOCINOLONE ACETONIDE OINT 0.025%                       Anti-inflammatory Agents                      30                                                   Prior Authorization Req'd
   FLUOCIN ACET SOL 0.01%                    FLUOCINOLONE ACETONIDE SOLN 0.01%                       Anti-inflammatory Agents                      30                                                   Prior Authorization Req'd
   FLUOCINONIDE CRE 0.05%                          FLUOCINONIDE CREAM 0.05%                          Anti-inflammatory Agents              30      30
 FLUOCINONIDE CRE -E 0.05%               FLUOCINONIDE EMULSIFIED BASE CREAM 0.05%                    Anti-inflammatory Agents                      30
   FLUOCINONIDE GEL 0.05%                            FLUOCINONIDE GEL 0.05%                          Anti-inflammatory Agents                      30                                                   Prior Authorization Req'd
  FLUOCINONIDE OIN 0.05%                            FLUOCINONIDE OINT 0.05%                          Anti-inflammatory Agents              30      30
   FLUOCINONIDE SOL 0.05%                           FLUOCINONIDE SOLN 0.05%                          Anti-inflammatory Agents              60      30
        FLUORABON DRO         SODIUM FLUORIDE SOLN 0.25 MG/0.6ML (FROM 0.55 MG/0.6ML NAF)        Miscellaneous Therapeutic Agents                  30
 FLUOR-A-DAY DRO 0.125MG        SODIUM FLUORIDE SOLN 0.125 MG/DROP F (0.275 MG/DROP NAF)         Miscellaneous Therapeutic Agents                  30
 FLUORIDE CHW 0.25MG F           SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF)           Miscellaneous Therapeutic Agents                  30
  FLUORIDE CHW 0.5MG F             SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)           Miscellaneous Therapeutic Agents                  30
    FLUORIDE CHW 1MG F              SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)            Miscellaneous Therapeutic Agents                  30
      FLUORIDEX GEL 1.1%                       SODIUM FLUORIDE GEL 1.1% (0.5% F)                 Miscellaneous Therapeutic Agents                  30      18
 FLUORIDEX GEL WHITENIN                        SODIUM FLUORIDE GEL 1.1% (0.5% F)                 Miscellaneous Therapeutic Agents                  30      18
    FLUORIGARD SOL 0.05%                          SODIUM FLUORIDE RINSE 0.05%                    Miscellaneous Therapeutic Agents                  30      18
 FLUORITAB CHW 0.25MG F          SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF)           Miscellaneous Therapeutic Agents                  30
  FLUORITAB CHW 0.5MG F            SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)           Miscellaneous Therapeutic Agents                  30
   FLUORITAB CHW 1MG F              SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)            Miscellaneous Therapeutic Agents                  30
   FLUORITAB CHW 2.2MG              SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)            Miscellaneous Therapeutic Agents                  30
  FLUORITAB DRO 0.125MG         SODIUM FLUORIDE SOLN 0.125 MG/DROP F (0.275 MG/DROP NAF)         Miscellaneous Therapeutic Agents                  30
FLUOROMETHOL SUS 0.1% OP                      FLUOROMETHOLONE OPHTH SUSP 0.1%                              Corticosteroids                         30
   FLUOR-OP SUS 0.1% OP                       FLUOROMETHOLONE OPHTH SUSP 0.1%                              Corticosteroids                         30
      FLUOROPLEX CRE 1%                             FLUOROURACIL CREAM 1%                    Skin and Mucous Membrane Agents, Misc                 30
     FLUOROURACIL CRE 5%                            FLUOROURACIL CREAM 5%                    Skin and Mucous Membrane Agents, Misc                 30
    FLUOROURACIL DRO 2%                               FLUOROURACIL SOLN 2%                   Skin and Mucous Membrane Agents, Misc                 30
    FLUOROURACIL DRO 5%                               FLUOROURACIL SOLN 5%                   Skin and Mucous Membrane Agents, Misc                 30
     FLUOROURACIL SOL 2%                              FLUOROURACIL SOLN 2%                   Skin and Mucous Membrane Agents, Misc                 30
     FLUOROURACIL SOL 5%                              FLUOROURACIL SOLN 5%                   Skin and Mucous Membrane Agents, Misc                 30
FLURA-DROPS DRO 0.125MG         SODIUM FLUORIDE SOLN 0.125 MG/DROP F (0.275 MG/DROP NAF)         Miscellaneous Therapeutic Agents                  30
FLURA-DROPS DRO 0.25MG F      SODIUM FLUORIDE SOLN 0.25 MG/DROP F (FROM 0.55 MG/DROP NAF)        Miscellaneous Therapeutic Agents                  30
  FLURBIPROFEN TAB 100MG                            FLURBIPROFEN TAB 100 MG                 Other Nonsteroidal Anti-inflammtory Agents             30
   FLURBIPROFEN TAB 50MG                             FLURBIPROFEN TAB 50 MG                 Other Nonsteroidal Anti-inflammtory Agents             30
   FLUTAMIDE CAP 125MG                                FLUTAMIDE CAP 125 MG                             Antineoplastic Agents                       30
  FLUTICASONE SPR 50MCG                FLUTICASONE PROPIONATE NASAL SUSP 50 MCG/ACT                        Corticosteroids                         30                                                   Prior Authorization Req'd
     FLUVIRIN INJ 2006-07         INFLUENZA VIRUS VACCINE TYPES A & B SURFACE ANTIGEN INJ                     Vaccines                             30
     FLUVIRIN INJ 2007-08         INFLUENZA VIRUS VACCINE TYPES A & B SURFACE ANTIGEN INJ                     Vaccines                             30
     FLUVIRIN INJ 2008-09         INFLUENZA VIRUS VACCINE TYPES A & B SURFACE ANTIGEN INJ                     Vaccines                             30
     FLUVIRIN INJ 2009-10         INFLUENZA VIRUS VACCINE TYPES A & B SURFACE ANTIGEN INJ                     Vaccines                             30
     FLUVIRIN INJ 2010-11         INFLUENZA VIRUS VACCINE TYPES A & B SURFACE ANTIGEN INJ                     Vaccines                             30
    FLUZONE INJ PF 06-07             INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                      Vaccines                             30
    FLUZONE INJ PF 07-08             INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                      Vaccines                             30
    FLUZONE INJ PF 08-09             INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                      Vaccines                             30
    FLUZONE INJ PF 09-10             INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                      Vaccines                             30
    FLUZONE INJ PF 10-11             INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                      Vaccines                             30
  FLUZONE PED/ INJ PF 06-07          INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                      Vaccines                             30
                                                                                                                                         Max Qty
                                                                                                                                           Limit   Max Max Age
                                                                                                                                         (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                                Generic Name                                          Therapy Class                  in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
  FLUZONE PED/ INJ PF 07-08         INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                         Vaccines                           30
  FLUZONE PED/ INJ PF 08-09         INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                         Vaccines                           30
  FLUZONE PED/ INJ PF 09-10         INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                         Vaccines                           30
  FLUZONE PED/ INJ PF 10-11         INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ                         Vaccines                           30
   FLUZONE SPLT INJ 2006-07                  INFLUENZA VIRUS VACCINE SPLIT INJ                                  Vaccines                           30
   FLUZONE SPLT INJ 2007-08                  INFLUENZA VIRUS VACCINE SPLIT INJ                                  Vaccines                           30
   FLUZONE SPLT INJ 2008-09                  INFLUENZA VIRUS VACCINE SPLIT INJ                                  Vaccines                           30
   FLUZONE SPLT INJ 2009-10                  INFLUENZA VIRUS VACCINE SPLIT INJ                                  Vaccines                           30
   FLUZONE SPLT INJ 2010-11                  INFLUENZA VIRUS VACCINE SPLIT INJ                                  Vaccines                           30
  FML FORTE SUS 0.25% OP                   FLUOROMETHOLONE OPHTH SUSP 0.25%                                 Corticosteroids                        30
        FOLBECAL TAB             *PRENATAL W/ CALCIUM CARBONATE-B6-B12-FA TAB 1 MG***                 Multivitamin Preparations                    30      40
     FOLCAPS CARE CAP ONE     *PRENATAL W/FE CBNYL-FE ASP GLYC-FA-DSS-OMEGA CAP 20-7-1 MG*            Multivitamin Preparations                    30      40
   FOLIC ACID TAB 1000MCG                           FOLIC ACID TAB 1 MG                                   Vitamin B Complex                30      30
      FOLIC ACID TAB 1MG                            FOLIC ACID TAB 1 MG                                   Vitamin B Complex                30      30
   FOLTABS TAB PRENATAL       *PRENATAL W/O A W/ FE CARBONYL-FE GLUC-DSS-FA TAB 27-1MG***             Multivitamin Preparations                    30      40
    FORMULA 405 LOT BODY                          *EMOLLIENT - LOTION**                               Basic Lotions and Liniments                  30                                                   Prior Authorization Req'd
FORMULA 405 LOT MOISTURI                          *EMOLLIENT - LOTION**                               Basic Lotions and Liniments                  30                                                   Prior Authorization Req'd
    FORTICAL SPR 200/ACT               CALCITONIN (SALMON) NASAL SOLN 200 UNIT/ACT                            Parathyroid                          30                                                   Prior Authorization Req'd
   FRAGMIN INJ 10000/ML                    DALTEPARIN SODIUM INJ 10000 UNIT/ML                                  Heparins                           30                                                   Prior Authorization Req'd
   FRAGMIN INJ 12500UNT                   DALTEPARIN SODIUM INJ 12500 UNIT/0.5ML                                Heparins                           30                                                   Prior Authorization Req'd
   FRAGMIN INJ 15000UNT                   DALTEPARIN SODIUM INJ 15000 UNIT/0.6ML                                Heparins                           30                                                   Prior Authorization Req'd
   FRAGMIN INJ 18000UNT                  DALTEPARIN SODIUM INJ 18000 UNIT/0.72ML                                Heparins                           30                                                   Prior Authorization Req'd
    FRAGMIN INJ 2500/0.2                  DALTEPARIN SODIUM INJ 2500 UNIT/0.2ML                                 Heparins                           30                                                   Prior Authorization Req'd
   FRAGMIN INJ 25000/ML                    DALTEPARIN SODIUM INJ 25000 UNIT/ML                                  Heparins                           30                                                   Prior Authorization Req'd
    FRAGMIN INJ 5000/0.2                  DALTEPARIN SODIUM INJ 5000 UNIT/0.2ML                                 Heparins                           30                                                   Prior Authorization Req'd
    FRAGMIN INJ 7500/0.3                  DALTEPARIN SODIUM INJ 7500 UNIT/0.3ML                                 Heparins                           30                                                   Prior Authorization Req'd
   FRAGMIN INJ 95000UNT                   DALTEPARIN SODIUM INJ 95000 UNIT/9.5ML                                Heparins                           30                                                   Prior Authorization Req'd
 FRUIT OF THE LOT EARTH/AV                        *EMOLLIENT - LOTION**                               Basic Lotions and Liniments                  30                                                   Prior Authorization Req'd
    FUNGICURE SPR INTENS                          CLOTRIMAZOLE SOLN 1%                                           Azoles                            30                                                   Prior Authorization Req'd
FURADANTIN SUS 25MG/5ML                      NITROFURANTOIN SUSP 25 MG/5ML                              Urinary Anti-infectives                    30      18
 FUROSEMIDE SOL 10MG/ML                      FUROSEMIDE ORAL SOLN 10 MG/ML                                   Loop Diuretics                        30      18
FUROSEMIDE SOL 40MG/4ML                      FUROSEMIDE ORAL SOLN 10 MG/ML                                   Loop Diuretics                        30      18
  FUROSEMIDE SOL 8MG/ML                       FUROSEMIDE ORAL SOLN 8 MG/ML                                   Loop Diuretics                        30      18
    FUROSEMIDE TAB 20MG                           FUROSEMIDE TAB 20 MG                                       Loop Diuretics                        30
    FUROSEMIDE TAB 40MG                           FUROSEMIDE TAB 40 MG                                       Loop Diuretics                        30
    FUROSEMIDE TAB 80MG                           FUROSEMIDE TAB 80 MG                                       Loop Diuretics                        30
   GABAPENTIN CAP 100MG                           GABAPENTIN CAP 100 MG                             Anticonvulsants, Miscellaneous         180     30
   GABAPENTIN CAP 300MG                           GABAPENTIN CAP 300 MG                             Anticonvulsants, Miscellaneous         180     30
   GABAPENTIN CAP 400MG                           GABAPENTIN CAP 400 MG                             Anticonvulsants, Miscellaneous         270     30
  GABAPENTIN SOL 250/5ML                    GABAPENTIN ORAL SOLN 250 MG/5ML                         Anticonvulsants, Miscellaneous                 30      18                                           Prior Authorization Req'd
   GABAPENTIN TAB 100MG                           GABAPENTIN TAB 100 MG                             Anticonvulsants, Miscellaneous         180     30
   GABAPENTIN TAB 300MG                           GABAPENTIN TAB 300 MG                             Anticonvulsants, Miscellaneous         180     30
   GABAPENTIN TAB 400MG                           GABAPENTIN TAB 400 MG                             Anticonvulsants, Miscellaneous         270     30
   GABAPENTIN TAB 600MG                           GABAPENTIN TAB 600 MG                             Anticonvulsants, Miscellaneous         180     30
   GABAPENTIN TAB 800MG                           GABAPENTIN TAB 800 MG                             Anticonvulsants, Miscellaneous         180     30
    GABARONE TAB 100MG                            GABAPENTIN TAB 100 MG                             Anticonvulsants, Miscellaneous         180     30
    GABARONE TAB 300MG                            GABAPENTIN TAB 300 MG                             Anticonvulsants, Miscellaneous         180     30
    GABARONE TAB 400MG                            GABAPENTIN TAB 400 MG                             Anticonvulsants, Miscellaneous         270     30
      GABITRIL TAB 12MG                          TIAGABINE HCL TAB 12 MG                            Anticonvulsants, Miscellaneous                 30
      GABITRIL TAB 16MG                          TIAGABINE HCL TAB 16 MG                            Anticonvulsants, Miscellaneous                 30
      GABITRIL TAB 2MG                            TIAGABINE HCL TAB 2 MG                            Anticonvulsants, Miscellaneous                 30
      GABITRIL TAB 4MG                            TIAGABINE HCL TAB 4 MG                            Anticonvulsants, Miscellaneous                 30
   GABLOFEN INJ 2000MCG          BACLOFEN INTRATHECAL INJ 40000 MCG/20ML (2000 MCG/ML)       GABA DERIVATIVE SKELETAL MUSCLE RELAXANTS             30                                                   Prior Authorization Req'd
    GABLOFEN INJ 500MCG           BACLOFEN INTRATHECAL INJ 10000 MCG/20ML (500 MCG/ML)       GABA DERIVATIVE SKELETAL MUSCLE RELAXANTS             30                                                   Prior Authorization Req'd
 GABLOFEN INJ 50MCG/ML                     BACLOFEN INTRATHECAL INJ 50 MCG/ML                GABA DERIVATIVE SKELETAL MUSCLE RELAXANTS             30                                                   Prior Authorization Req'd
   GANCICLOVIR CAP 250MG                         GANCICLOVIR CAP 250 MG                              Nucleosides and Nucleotides                   30
   GANCICLOVIR CAP 500MG                         GANCICLOVIR CAP 500 MG                              Nucleosides and Nucleotides                   30
 GANI-TUSS DM LIQ 100-10/5        DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                           Antitussives                 180     30
  GANI-TUSS NR LIQ 100-10/5              GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML                               Antitussives                         30
  GANTRIS PED SUS 500/5ML                 SULFISOXAZOLE ACETYL SUSP 500 MG/5ML                               Sulfonamides                          14      18
        GAVILYTE-C SOL           PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 240 GM                Cathartics and Laxatives           4000     30
        GAVILYTE-G SOL           PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM                Cathartics and Laxatives           4000     30
        G-BID DM TAB             DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 60-1200 MG                          Antitussives                 31      30
     GEMCITABINE INJ 1 GM                      GEMCITABINE HCL FOR INJ 1 GM                              Antineoplastic Agents                     30                                                   Prior Authorization Req'd
   GEMCITABINE INJ 200MG                      GEMCITABINE HCL FOR INJ 200 MG                             Antineoplastic Agents                     30                                                   Prior Authorization Req'd
                                                                                                                                        Max Qty
                                                                                                                                          Limit   Max Max Age
                                                                                                                                        (Liquids Days    Limit    Step      Step Therapy   Specialty
   Drug/Product Name                                Generic Name                                        Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
 GEMFIBROZIL TAB 600MG                            GEMFIBROZIL TAB 600 MG                             Fibric Acid Derivatives                      30
   GENAHIST CAP 25MG                          DIPHENHYDRAMINE HCL CAP 25 MG                        Ethanolamine Derivatives                       30
 GENAHIST LIQ 12.5/5ML                   DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                    Ethanolamine Derivatives                       30
   GENAHIST TAB 25MG                          DIPHENHYDRAMINE HCL TAB 25 MG                        Ethanolamine Derivatives                       30
GENAPAP CHW 80MG GRP                          ACETAMINOPHEN CHEW TAB 80 MG                      Analgesics and Antipyretics, Misc          60     30
 GENAPAP DRO 80/0.8ML                         ACETAMINOPHEN SOLN 100 MG/ML                      Analgesics and Antipyretics, Misc          30     30
  GENAPAP TAB 325MG                             ACETAMINOPHEN TAB 325 MG                        Analgesics and Antipyretics, Misc         250     30
  GENAPAP TAB 500MG                             ACETAMINOPHEN TAB 500 MG                        Analgesics and Antipyretics, Misc         250     30
 GENAPAP TAB 500MG ES                           ACETAMINOPHEN TAB 500 MG                        Analgesics and Antipyretics, Misc         250     30
  GENAPHED TAB 30MG                           PSEUDOEPHEDRINE HCL TAB 30 MG                   alpha- and beta-Adrenergic Agonists         120     30
  GENASOFT CAP 100MG                           DOCUSATE SODIUM CAP 100 MG                           Cathartics and Laxatives              100     30
GENATUSS DM SYP 100-10/5        DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                           Antitussives                   180     30
     GENEBROM DM SYP               PSEUDOEPHED-BROMPHEN-DM SYRUP 30-2-10 MG/5ML                            Antitussives                   178     30
   GENEBS      TAB 325MG                        ACETAMINOPHEN TAB 325 MG                        Analgesics and Antipyretics, Misc         250     30
   GENEBS      TAB 500MG                        ACETAMINOPHEN TAB 500 MG                        Analgesics and Antipyretics, Misc         250     30
   GENEDOTUSS LIQ -DM           DEXTROMETHORPHAN-GUAIFENESIN LIQUID 20-200 MG/5ML                          Antitussives                   180     30
 GENERLAC SOL 10GM/15              LACTULOSE (ENCEPHALOPATHY) SOLUTION 10 GM/15ML                    Ammonia Detoxicants                  947     30
  GENGRAF CAP 100MG                         CYCLOSPORINE MODIFIED CAP 100 MG                      Immunosuppressive Agents                        30
   GENGRAF CAP 25MG                          CYCLOSPORINE MODIFIED CAP 25 MG                      Immunosuppressive Agents                        30
GENGRAF SOL 100MG/ML                   CYCLOSPORINE MODIFIED ORAL SOLN 100 MG/ML                  Immunosuppressive Agents                        30      18
  GENOPTIC SOL 0.3% OP                     GENTAMICIN SULFATE OPHTH SOLN 0.3%                            Antibacterials                           30
   GENPRIL TAB 200MG                               IBUPROFEN TAB 200 MG                    Other Nonsteroidal Anti-inflammtory Agents             30
  GENTAK       SOL 0.3% OP                 GENTAMICIN SULFATE OPHTH SOLN 0.3%                            Antibacterials                           30
   GENTAMICIN CRE 0.1%                        GENTAMICIN SULFATE CREAM 0.1%                              Antibacterials                           30
   GENTAMICIN OIN 0.1%                         GENTAMICIN SULFATE OINT 0.1%                              Antibacterials                   15      30
 GENTAMICIN SOL 0.3% OP                    GENTAMICIN SULFATE OPHTH SOLN 0.3%                            Antibacterials                           30
 GENTASOL SOL 0.3% OP                      GENTAMICIN SULFATE OPHTH SOLN 0.3%                            Antibacterials                           30
 GENTEX ADE TAB 28-1MG        *PRENATAL VIT W/ FE BISGLYCINATE CHELATE-FA TAB 28-1 MG***           Multivitamin Preparations                      30      40
      GEONE (G-1) CAP            BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-325-40 MG             Analgesics and Antipyretics, Misc         20      30
   GERI-DRYL CAP 25MG                         DIPHENHYDRAMINE HCL CAP 25 MG                        Ethanolamine Derivatives                       30
   GERI-DRYL TAB 25MG                         DIPHENHYDRAMINE HCL TAB 25 MG                        Ethanolamine Derivatives                       30
      GERI-LANTA SUS         ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML               Antacids and Adsorbents                480     30
      GERI-MOX SUS           ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML               Antacids and Adsorbents                480     30
      GERI-SOFT LOT                                *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
 GERI-TUSSIN SYP 100/5ML                       GUAIFENESIN SYRUP 100 MG/5ML                               Expectorants                            30
    GERI-TUSSIN SYP DM          DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                           Antitussives                   180     30
G-FEN DM TAB 20-400MG                DEXTROMETHORPHAN-GUAIFENESIN TAB 20-400 MG                            Antitussives                    31     30
   GFN 1200/ TAB PSE 50          PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 50-1200 MG                       Expectorants                     31     30
 GFN/PSE TAB 1200/120           PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-1200 MG                       Expectorants                     31     30
     GFN1000/DM60 TAB          DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 60-1000 MG                         Antitussives                    31     30
     GFN1200/DM60 TAB          DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 60-1200 MG                         Antitussives                    31     30
     GFN595/PSE48 TAB             PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 48-595 MG                       Expectorants                     31     30
     GFN800/DM30 TAB            DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 30-800 MG                         Antitussives                    31     30
  GG 200 NR TAB 200MG                             GUAIFENESIN TAB 200 MG                                  Expectorants                    180     30
GG/CODEINE SOL 100-10/5                  GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML                            Antitussives                           30
GG/CODEINE SYP 100-10/5                  GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML                            Antitussives                           30
  GG/DM       SYP 100-10/5      DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                           Antitussives                   180     30
       GG/DM       TAB         DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 60-1000 MG                         Antitussives                    31     30
  GG/DM        TAB 1200-20     DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 20-1200 MG                         Antitussives                    31     30
GG/DM CR TAB 600-30MG           DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 30-600 MG                         Antitussives                    31     30
 GG/DM NR LIQ 100-10/5          DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                          Antitussives                   180     30
GG/DM SR TAB 600-30MG           DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 30-600 MG                         Antitussives                    31     30
  GG/PSE      SYP 30-100/5        PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 30-100 MG/5ML                         Expectorants                            30
 GG/PSE      TAB 80/800MG         PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 80-800 MG                       Expectorants                    31      30
GG/PSE CR CAP 300-60MG               PSEUDOEPHEDRINE-GUAIFENESIN CAP CR 60-300 MG                         Expectorants                    31      30
  GG/PSE CR TAB 600-120          PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-600 MG                       Expectorants                    31      30
GG/PSE CR TAB 600-60MG            PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 60-600 MG                       Expectorants                    31      30
  GG/PSE ER TAB 600-120          PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-600 MG                       Expectorants                    31      30
  GIANVI     TAB 3-0.02MG             DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG                       Contraceptives                           30
   GILDESS FE TAB 1.5/30     NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG                  Contraceptives                           30
    GILDESS FE TAB 1/20       NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG                   Contraceptives                           30
   GLIMEPIRIDE TAB 1MG                              GLIMEPIRIDE TAB 1 MG                                  Sulfonylureas                           30
   GLIMEPIRIDE TAB 2MG                              GLIMEPIRIDE TAB 2 MG                                  Sulfonylureas                           30
   GLIMEPIRIDE TAB 4MG                              GLIMEPIRIDE TAB 4 MG                                  Sulfonylureas                           30
    GLIPIZIDE TAB 10MG                               GLIPIZIDE TAB 10 MG                                  Sulfonylureas                           30
                                                                                                                                  Max Qty
                                                                                                                                    Limit   Max Max Age
                                                                                                                                  (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                               Generic Name                                      Therapy Class                in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
     GLIPIZIDE TAB 5MG                                 GLIPIZIDE TAB 5 MG                               Sulfonylureas                       30
    GLIPIZIDE ER TAB 10MG                        GLIPIZIDE TAB SR 24HR 10 MG                            Sulfonylureas                       30
   GLIPIZIDE ER TAB 2.5MG                        GLIPIZIDE TAB SR 24HR 2.5 MG                           Sulfonylureas                       30
     GLIPIZIDE ER TAB 5MG                         GLIPIZIDE TAB SR 24HR 5 MG                            Sulfonylureas                       30
    GLIPIZIDE XL TAB 10MG                        GLIPIZIDE TAB SR 24HR 10 MG                            Sulfonylureas                       30
    GLIPIZIDE XL TAB 2.5MG                       GLIPIZIDE TAB SR 24HR 2.5 MG                           Sulfonylureas                       30
     GLIPIZIDE XL TAB 5MG                         GLIPIZIDE TAB SR 24HR 5 MG                            Sulfonylureas                       30
    GLUCAGON KIT 1MG                         GLUCAGON (RDNA) FOR INJ KIT 1 MG                      Glycogenolytic Agents                    30
  GLUCOTROL XL TAB 2.5MG                         GLIPIZIDE TAB SR 24HR 2.5 MG                           Sulfonylureas                       30
GLYB/METFORM TAB 1.25-250                  GLYBURIDE-METFORMIN TAB 1.25-250 MG                          Sulfonylureas                       30
 GLYB/METFORM TAB 2.5-500                  GLYBURIDE-METFORMIN TAB 2.5-500 MG                           Sulfonylureas                       30
GLYB/METFORM TAB 5-500MG                    GLYBURIDE-METFORMIN TAB 5-500 MG                            Sulfonylureas                       30
  GLYBURID MCR TAB 1.5MG                     GLYBURIDE MICRONIZED TAB 1.5 MG                            Sulfonylureas                       30
   GLYBURID MCR TAB 3MG                       GLYBURIDE MICRONIZED TAB 3 MG                             Sulfonylureas                       30
   GLYBURID MCR TAB 6MG                       GLYBURIDE MICRONIZED TAB 6 MG                             Sulfonylureas                       30
   GLYBURIDE TAB 1.25MG                             GLYBURIDE TAB 1.25 MG                               Sulfonylureas                       30
   GLYBURIDE TAB 2.5MG                               GLYBURIDE TAB 2.5 MG                               Sulfonylureas                       30
    GLYBURIDE TAB 5MG                                 GLYBURIDE TAB 5 MG                                Sulfonylureas                       30
  GLYCOLAX POW 3350 NF                    POLYETHYLENE GLYCOL 3350 ORAL POWDER                    Cathartics and Laxatives                  30      12
    GLYCRON TAB 1.5MG                        GLYBURIDE MICRONIZED TAB 1.5 MG                            Sulfonylureas                       30
     GLYCRON TAB 3MG                          GLYBURIDE MICRONIZED TAB 3 MG                             Sulfonylureas                       30
     GLYCRON TAB 6MG                          GLYBURIDE MICRONIZED TAB 6 MG                             Sulfonylureas                       30
  GNP ALCOHOL PAD SWABS                              *ALCOHOL SWABS***                                     Devices                          30
  GNP ALL DAY TAB ALLERGY                          CETIRIZINE HCL TAB 10 MG                  Second Generation Antihistamines               30
   GNP ALLERGY CAP 25MG                       DIPHENHYDRAMINE HCL CAP 25 MG                      Ethanolamine Derivatives                   30
   GNP ALLERGY TAB 25MG                       DIPHENHYDRAMINE HCL TAB 25 MG                      Ethanolamine Derivatives                   30
 GNP ANTACID SUS ANTI-GAS      ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML            Antacids and Adsorbents           480     30
  GNP ANTACID SUS CHERRY       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML            Antacids and Adsorbents           480     30
   GNP ASPIRIN CHW 81MG                            ASPIRIN CHEW TAB 81 MG                                 Salicylates                31     30
   GNP ASPIRIN TAB 325MG                              ASPIRIN TAB 325 MG                                  Salicylates                31     30
    GNP ATHLETES CRE 1%                            CLOTRIMAZOLE CREAM 1%                                    Azoles                   30     30
GNP DERMALUB LOT W/PUMP                             *EMOLLIENT - LOTION**                       Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
    GNP HYDROCOR CRE 1%                          HYDROCORTISONE CREAM 1%                         Anti-inflammatory Agents                   30
 GNP HYDROCOR CRE 1% PLUS                        HYDROCORTISONE CREAM 1%                         Anti-inflammatory Agents                   30
   GNP IRON TAB 325MG               FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)                   Iron Preparations                     30
  GNP K-PEC SUS 262/15ML                 BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                     Antidiarrhea Agents            1800     30
        GNP LICE KIT         PYRETH-PIPERONYL BUTOX SHAM-PERMETH AERO-NIT REMOVER GEL KIT       Scabicides and Pediculicides                30
  GNP MASANTI SUS MAX ST       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML            Antacids and Adsorbents           480     30
  GNP MASANTI SUS REG ST       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML            Antacids and Adsorbents           480     30
 GNP NIACIN TAB 250MG TR                             NIACIN TAB CR 250 MG                            Vitamin B Complex               62     30
GNP NICOTINE GUM 2MG MINT                      NICOTINE POLACRILEX GUM 2 MG                   Autonomic Drugs, Miscellaneous                30
GNP NICOTINE GUM 2MG ORIG                      NICOTINE POLACRILEX GUM 2 MG                   Autonomic Drugs, Miscellaneous                30
GNP NICOTINE GUM 4MG MINT                      NICOTINE POLACRILEX GUM 4 MG                   Autonomic Drugs, Miscellaneous                30
GNP NICOTINE GUM 4MG ORIG                      NICOTINE POLACRILEX GUM 4 MG                   Autonomic Drugs, Miscellaneous                30
 GNP PEDIATRI SOL ELECTROL                    *ORAL ELECTROLYTE SOLUTION***                      Replacement Preparations                   30      18
    GNP PERMETHR LIQ 1%                         PERMETHRIN CREME RINSE 1%                       Scabicides and Pediculicides       120      30
 GNP PINK BIS SUS 524/15ML               BISMUTH SUBSALICYLATE SUSP 525 MG/15ML                     Antidiarrhea Agents            1800     30
  GNP POTASSIU TAB 99MG                             POTASSIUM TAB 99 MG                          Replacement Preparations                   30
GNP SUPHEDRN LIQ 15MG/5ML                   PSEUDOEPHEDRINE HCL LIQ 15 MG/5ML               alpha- and beta-Adrenergic Agonists     480     30
     GNP TUSSIN LIQ DM            DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                      Antitussives               180     30
 GNP TUSSIN LIQ DM COUGH          DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                      Antitussives               180     30
  GNP TUSSIN LIQ DM MAX           DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/5ML                      Antitussives               180     30
  GNP TUSSIN SYP 100/5ML                       GUAIFENESIN SYRUP 100 MG/5ML                              Expectorants                       30
   GNP VIT B-6 TAB 100MG                         PYRIDOXINE HCL TAB 100 MG                           Vitamin B Complex                      30
    GNP VIT B-6 TAB 50MG                          PYRIDOXINE HCL TAB 50 MG                           Vitamin B Complex                      30
  GNP VIT D TAB 1000UNIT                       CHOLECALCIFEROL TAB 1000 UNIT                              Vitamin D                 30      30
 GOLD BOND LOT MEDICATD                             *EMOLLIENT - LOTION**                       Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
 GOLD BOND LOT PROTECTN                             *EMOLLIENT - LOTION**                       Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
 GOLD BOND LOT RESTORIN                             *EMOLLIENT - LOTION**                       Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
 GOLD BOND LOT SOOTHING                             *EMOLLIENT - LOTION**                       Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
 GOLD BOND LOT ULTIMATE                             *EMOLLIENT - LOTION**                       Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
 GOLD SOD THI INJ 50MG/ML                 GOLD SODIUM THIOMALATE INJ 50 MG/ML                         Gold Compounds                        30                                                   Prior Authorization Req'd
      GORDOMATIC LOT                                *EMOLLIENT - LOTION**                       Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
      G-PHED      CAP SR             PSEUDOEPHEDRINE-GUAIFENESIN CAP CR 120-250 MG                       Expectorants               31      30
  G-PHED-PD CAP 60-300SR             PSEUDOEPHEDRINE-GUAIFENESIN CAP CR 60-300 MG                        Expectorants               31      30
                                                                                                                     Max Qty
                                                                                                                       Limit   Max Max Age
                                                                                                                     (Liquids Days    Limit    Step      Step Therapy   Specialty
   Drug/Product Name                              Generic Name                              Therapy Class             in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
   GRA/NEO/POLY SOL OP               NEOMYCIN-POLYMYXIN B-GRAMICIDIN OPHTH SOLN                Antibacterials                  30
  GRIFULVIN V TAB 500MG                   GRISEOFULVIN MICROSIZE TAB 500 MG            Antifungals, Miscellaneous              30
GRISEOFULVIN SUS 125/5ML               GRISEOFULVIN MICROSIZE SUSP 125 MG/5ML          Antifungals, Miscellaneous              30
GRISEOFULVIN TAB 250 ULTR              GRISEOFULVIN ULTRAMICROSIZE TAB 250 MG          Antifungals, Miscellaneous              30
   GRIS-PEG TAB 125MG                  GRISEOFULVIN ULTRAMICROSIZE TAB 125 MG          Antifungals, Miscellaneous              30
   GRIS-PEG TAB 250MG                  GRISEOFULVIN ULTRAMICROSIZE TAB 250 MG          Antifungals, Miscellaneous              30
       GRX VIT E LOT                             *EMOLLIENT - LOTION**                 Basic Lotions and Liniments             30                                                   Prior Authorization Req'd
 GUAI/DM TAB 800-30MG           DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 30-800 MG              Antitussives            31     30
GUAIASORB DM LIQ 100-10/5       DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML               Antitussives           180     30
    GUAIATUSSIN SYP AC                 GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML                   Antitussives           180     30
GUAICON DM SYP 100-10/5         DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                Antitussives           180     30
GUAICON DMS SYP 100-10/5        DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                Antitussives           180     30
GUAIFEN DM TAB 600-30MG         DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 30-600 MG              Antitussives            31     30
 GUAIFEN PSE TAB 600-120         PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-600 MG            Expectorants             31     30
 GUAIFEN/PSE SYP 30-100/5         PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 30-100 MG/5ML              Expectorants                    30
 GUAIFEN/PSE TAB 600-120         PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-600 MG            Expectorants            31      30
    GUAIFENESIN LIQ AC                 GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML                   Antitussives                   30
 GUAIFENESIN LIQ AC EXPCT              GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML                   Antitussives                   30
    GUAIFENESIN LIQ DM          DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML               Antitussives           180     30
 GUAIFENESIN LIQ DM MAX         DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/5ML               Antitussives           180     30
  GUAIFENESIN LIQ DM NR         DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML               Antitussives           180     30
    GUAIFENESIN LIQ NR                 GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML                   Antitussives                   30
 GUAIFENESIN SYP 100/5ML                    GUAIFENESIN SYRUP 100 MG/5ML                       Expectorants                    30
    GUAIFENESIN SYP AC                 GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML                   Antitussives                   30
    GUAIFENESIN SYP DM          DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                Antitussives           180     30
  GUAIFENESIN TAB /DM ER       DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 60-1200 MG              Antitussives            31     30
  GUAIFENESIN TAB /DM SR       DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 60-1200 MG              Antitussives            31     30
  GUAIFENESIN TAB 200MG                         GUAIFENESIN TAB 200 MG                         Expectorants            180     30
    GUAIFENESIN TAB DM         DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 60-1000 MG              Antitussives            31     30
  GUAIFENESIN/ TAB PSE SA        PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-600 MG            Expectorants             31     30
  GUAIFENEX TAB PSE 120          PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-600 MG            Expectorants             31     30
   GUAIFENEX TAB PSE 60           PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 60-600 MG            Expectorants             31     30
   GUAIFENEX TAB PSE 85           PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 85-795 MG            Expectorants             31     30
GUAIFENEX DM TAB 30-600CR       DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 30-600 MG              Antitussives            31     30
GUAIFENEX GP TAB 120/1200       PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-1200 MG            Expectorants             31     30
GUAIFENEX PS TAB 80-800MG         PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 80-800 MG            Expectorants             31     30
   GUANFACINE TAB 1MG                          GUANFACINE HCL TAB 1 MG                   Central Alpha-Agonists                30
   GUANFACINE TAB 2MG                          GUANFACINE HCL TAB 2 MG                   Central Alpha-Agonists                30
       GUIA-D    TAB           DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 60-1000 MG              Antitussives            31     30
 GUIAT CLR DM SYP 100-10/5      DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                Antitussives           180     30
  GUIATUSS SYP 100/5ML                      GUAIFENESIN SYRUP 100 MG/5ML                       Expectorants                    30
 GUIATUSS AC SYP 100-10/5              GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML                   Antitussives           180     30
GUIATUSS DM SYP 100-10/5        DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                Antitussives           180     30
    GYNECORT 10 CRE 1%                    HYDROCORTISONE ACETATE CREAM 1%               Anti-inflammatory Agents        30     30
   GYNODIOL TAB 0.5MG                             ESTRADIOL TAB 0.5 MG                           Estrogens                     30
    GYNODIOL TAB 1MG                               ESTRADIOL TAB 1 MG                            Estrogens                     30
    GYNODIOL TAB 2MG                               ESTRADIOL TAB 2 MG                            Estrogens                     30
  HALFPRIN TAB 81MG EC                    ASPIRIN TAB DELAYED RELEASE 81 MG                      Salicylates           31      30
  HALOBETASOL CRE 0.05%                 HALOBETASOL PROPIONATE CREAM 0.05%              Anti-inflammatory Agents               30                                                   Prior Authorization Req'd
  HALOBETASOL OIN 0.05%                  HALOBETASOL PROPIONATE OINT 0.05%              Anti-inflammatory Agents               30                                                   Prior Authorization Req'd
     HALOG     CRE 0.1%                        HALCINONIDE CREAM 0.1%                   Anti-inflammatory Agents               30                                                   Prior Authorization Req'd
     HALOG     OIN 0.1%                         HALCINONIDE OINT 0.1%                   Anti-inflammatory Agents               30                                                   Prior Authorization Req'd
     HALOG     SOL 0.1%                         HALCINONIDE SOLN 0.1%                   Anti-inflammatory Agents               30                                                   Prior Authorization Req'd
      HC TUSSIVE SYP         PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 5-2-2.5 MG/5ML            Antitussives           178     30
HC TUSSIVE-D SOL 60-5/5ML        PSEUDOEPHEDRINE W/ HYDROCODONE SOLN 60-5 MG/5ML                Antitussives           178     30
   HC VALERATE CRE 0.2%                 HYDROCORTISONE VALERATE CREAM 0.2%              Anti-inflammatory Agents               30                                                   Prior Authorization Req'd
   HC VALERATE OIN 0.2%                  HYDROCORTISONE VALERATE OINT 0.2%              Anti-inflammatory Agents               30                                                   Prior Authorization Req'd
   HC/ACET ACID SOL OTIC             HYDROCORTISONE W/ ACETIC ACID OTIC SOLN 1-2%             Corticosteroids                  30
   HC/GUAI SYP 3.5-300              HYDROCODONE-GUAIFENESIN SYRUP 3.5-300 MG/5ML                Antitussives           178     30
   HC-1% HEMORR OIN 1%                     HYDROCORTISONE ACETATE OINT 1%               Anti-inflammatory Agents        30     30
HCOD/PE/CPM LIQ 5-5-2MG       PHENYLEPH-CHLORPHEN W/ HYDROCODONE LIQD 5-2-5 MG/5ML              Antitussives                   30
HCTZ/TRIAMT CAP 25-50MG            TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 50-25 MG      Potassium-sparing Diuretics             30
 HCTZ/TRIAMT TAB 25-37.5          TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG     Potassium-sparing Diuretics             30
HCTZ/TRIAMT TAB 50-75MG            TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG      Potassium-sparing Diuretics             30
   HEALTHY SKIN LOT FACE                         *EMOLLIENT - LOTION**                 Basic Lotions and Liniments             30                                                   Prior Authorization Req'd
                                                                                                                             Max Qty
                                                                                                                               Limit   Max Max Age
                                                                                                                             (Liquids Days    Limit    Step      Step Therapy   Specialty
     Drug/Product Name                                Generic Name                                  Therapy Class             in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
      HEALTUSSIN SYP DM            DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                    Antitussives            180     30
  HEARTBURN TAB REL 75MG                           RANITIDINE HCL TAB 75 MG                     Histamine H2-Antagonists        60     30
    HEATHER TAB 0.35MG                           NORETHINDRONE TAB 0.35 MG                            Contraceptives                   30
       HEMATOGEN CAP                              *IRON COMBINATION CAP***                          Iron Preparations                  30
   HEMATOGEN CAP FORTE            FE FUMARATE-VIT C-VIT B12-FA CAP 460 (151 FE)-60-0.01-1 MG        Iron Preparations                  30
      HEMATOGEN FA CAP                FE FUMARATE-VIT C-VIT B12-FA CAP 200-250-0.01-1 MG            Iron Preparations                  30
   HEP SOD/NACL INJ 100/ML    HEPARIN SODIUM (PORCINE) 100 UNIT/ML IN SODIUM CHLORIDE 0.9%               Heparins                      30
  HEP SOD/NACL INJ 1000UNIT    HEPARIN SODIUM (PORCINE) 2 UNIT/ML IN SODIUM CHLORIDE 0.9%                Heparins                      30
  HEP SOD/NACL INJ 12500UNT   HEPARIN SODIUM (PORCINE) 50 UNIT/ML IN SODIUM CHLORIDE 0.45%               Heparins                      30
  HEP SOD/NACL INJ 25000UNT   HEPARIN SODIUM (PORCINE) 50 UNIT/ML IN SODIUM CHLORIDE 0.45%               Heparins                      30
  HEP SOD/NACL INJ 2UNIT/ML    HEPARIN SODIUM (PORCINE) 2 UNIT/ML IN SODIUM CHLORIDE 0.9%                Heparins                      30
     HEXALEN CAP 50MG                               ALTRETAMINE CAP 50 MG                         Antineoplastic Agents                30
    HIGH POTENCY TAB VIT D                      CHOLECALCIFEROL TAB 1000 UNIT                           Vitamin D              30      30
  HIGH SENSATI MIS SPERMICI                       CONDOMS LATEX LUBRICATED                            Contraceptives                   30
        HISTINEX HC SYP       PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 5-2-2.5 MG/5ML                  Antitussives            178     30
   HT-TUSS DM ELX 200-20/5         DEXTROMETHORPHAN-GUAIFENESIN ELIXIR 20-200 MG/5ML                   Antitussives            178     30
    HUMALOG INJ 100/ML                      INSULIN LISPRO (HUMAN) INJ 100 UNIT/ML                        Insulins                     30
  HUMALOG KWIK INJ 100/ML                   INSULIN LISPRO (HUMAN) INJ 100 UNIT/ML                        Insulins                     30
    HUMALOG MIX INJ 50/50       INSULIN LISPRO PROT & LISPRO (HUMAN) INJ 100 UNIT/ML (50-50)              Insulins                     30
 HUMALOG MIX INJ 50/50KWP       INSULIN LISPRO PROT & LISPRO (HUMAN) INJ 100 UNIT/ML (50-50)              Insulins                     30
 HUMALOG MIX INJ 75/25KWP       INSULIN LISPRO PROT & LISPRO (HUMAN) INJ 100 UNIT/ML (75-25)              Insulins                     30
   HUMALOG MIX SUS 75/25        INSULIN LISPRO PROT & LISPRO (HUMAN) INJ 100 UNIT/ML (75-25)              Insulins                     30
   HUMALOG PEN INJ 100/ML                   INSULIN LISPRO (HUMAN) INJ 100 UNIT/ML                        Insulins                     30
    HUMALOG PEN INJ 50/50       INSULIN LISPRO PROT & LISPRO (HUMAN) INJ 100 UNIT/ML (50-50)              Insulins                     30
    HUMALOG PEN INJ 75/25       INSULIN LISPRO PROT & LISPRO (HUMAN) INJ 100 UNIT/ML (75-25)              Insulins                     30
     HUMULIN INJ 50/50          INSULIN ISOPHANE & REGULAR (HUMAN) INJ 100 UNIT/ML (50-50)                Insulins                     30
     HUMULIN INJ 70/30          INSULIN ISOPHANE & REGULAR (HUMAN) INJ 100 UNIT/ML (70-30)                Insulins                     30
     HUMULIN N INJ U-100                  INSULIN ISOPHANE (HUMAN) INJ 100 UNIT/ML                        Insulins                     30
    HUMULIN N PN INJ U-100                INSULIN ISOPHANE (HUMAN) INJ 100 UNIT/ML                        Insulins                     30
    HUMULIN PEN INJ 70/30       INSULIN ISOPHANE & REGULAR (HUMAN) INJ 100 UNIT/ML (70-30)                Insulins                     30
     HUMULIN R INJ U-100                   INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML                        Insulins                     30
     HUMULIN R INJ U-500                   INSULIN REGULAR (HUMAN) INJ 500 UNIT/ML                        Insulins                     30
     HYCET     SOL 7.5-325          HYDROCODONE-ACETAMINOPHEN SOLN 7.5-325 MG/15ML                   Opiate Agonists           480     30
   HYDRALAZINE TAB 100MG                         HYDRALAZINE HCL TAB 100 MG                         Direct Vasodilators                30
    HYDRALAZINE TAB 10MG                          HYDRALAZINE HCL TAB 10 MG                         Direct Vasodilators                30
    HYDRALAZINE TAB 25MG                          HYDRALAZINE HCL TAB 25 MG                         Direct Vasodilators                30
    HYDRALAZINE TAB 50MG                          HYDRALAZINE HCL TAB 50 MG                         Direct Vasodilators                30
        HYDRISINOL LOT                               *EMOLLIENT - LOTION**                     Basic Lotions and Liniments             30                                                   Prior Authorization Req'd
   HYDROCET CAP 500-5MG                  HYDROCODONE-ACETAMINOPHEN CAP 5-500 MG                      Opiate Agonists           150     30
  HYDROCHLOROT CAP 12.5MG                     HYDROCHLOROTHIAZIDE CAP 12.5 MG                       Thiazide Diuretics                 30
  HYDROCHLOROT TAB 12.5MG                     HYDROCHLOROTHIAZIDE TAB 12.5 MG                       Thiazide Diuretics                 30
   HYDROCHLOROT TAB 25MG                       HYDROCHLOROTHIAZIDE TAB 25 MG                        Thiazide Diuretics                 30
   HYDROCHLOROT TAB 50MG                       HYDROCHLOROTHIAZIDE TAB 50 MG                        Thiazide Diuretics                 30
 HYDROCO/APAP SOL 10-325MG          HYDROCODONE-ACETAMINOPHEN SOLN 10-325 MG/15ML                    Opiate Agonists           480     30
 HYDROCO/APAP TAB 10-300MG              HYDROCODONE-ACETAMINOPHEN TAB 10-300 MG                      Opiate Agonists           150     30
 HYDROCO/APAP TAB 10-325MG              HYDROCODONE-ACETAMINOPHEN TAB 10-325 MG                      Opiate Agonists           150     30
 HYDROCO/APAP TAB 10-500MG              HYDROCODONE-ACETAMINOPHEN TAB 10-500 MG                      Opiate Agonists           150     30
 HYDROCO/APAP TAB 10-650MG              HYDROCODONE-ACETAMINOPHEN TAB 10-650 MG                      Opiate Agonists           150     30
 HYDROCO/APAP TAB 10-660MG              HYDROCODONE-ACETAMINOPHEN TAB 10-660 MG                      Opiate Agonists           150     30
 HYDROCO/APAP TAB 10-750MG              HYDROCODONE-ACETAMINOPHEN TAB 10-750 MG                      Opiate Agonists           150     30
  HYDROCO/APAP TAB 2.5-500              HYDROCODONE-ACETAMINOPHEN TAB 2.5-500 MG                     Opiate Agonists           150     30
 HYDROCO/APAP TAB 5-300MG                HYDROCODONE-ACETAMINOPHEN TAB 5-300 MG                      Opiate Agonists           150     30
 HYDROCO/APAP TAB 5-325MG                HYDROCODONE-ACETAMINOPHEN TAB 5-325 MG                      Opiate Agonists           150     30
 HYDROCO/APAP TAB 5-500MG                HYDROCODONE-ACETAMINOPHEN TAB 5-500 MG                      Opiate Agonists           150     30
  HYDROCO/APAP TAB 7.5-300              HYDROCODONE-ACETAMINOPHEN TAB 7.5-300 MG                     Opiate Agonists           150     30
  HYDROCO/APAP TAB 7.5-325              HYDROCODONE-ACETAMINOPHEN TAB 7.5-325 MG                     Opiate Agonists           150     30
  HYDROCO/APAP TAB 7.5-500              HYDROCODONE-ACETAMINOPHEN TAB 7.5-500 MG                     Opiate Agonists           150     30
  HYDROCO/APAP TAB 7.5-650              HYDROCODONE-ACETAMINOPHEN TAB 7.5-650 MG                     Opiate Agonists           150     30
  HYDROCO/APAP TAB 7.5-750              HYDROCODONE-ACETAMINOPHEN TAB 7.5-750 MG                     Opiate Agonists           150     30
  HYDROCOD/GG SYP 3.5-100             HYDROCODONE-GUAIFENESIN SYRUP 3.5-100 MG/5ML                     Antitussives            178     30
  HYDROCOD/GG SYP 5-100/5              HYDROCODONE-GUAIFENESIN SYRUP 5-100 MG/5ML                      Antitussives            178     30
  HYDROCOD/HOM SYP 5-1.5/5           HYDROCODONE W/ HOMATROPINE SYRUP 5-1.5 MG/5ML                     Antitussives            178     30
  HYDROCODONE SYP PE/CPM      PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 5-2-2.5 MG/5ML                  Antitussives            178     30
   HYDROCODONE/ SOL APAP            HYDROCODONE-ACETAMINOPHEN SOLN 7.5-500 MG/15ML                   Opiate Agonists           480     30
HYDROCODONE/ TAB HOMATROP                HYDROCODONE W/ HOMATROPINE TAB 5-1.5 MG                       Antitussives             31     30
                                                                                                                                       Max Qty
                                                                                                                                         Limit   Max Max Age
                                                                                                                                       (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                               Generic Name                                       Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
     HYDROCORT CRE 0.5%                        HYDROCORTISONE CREAM 0.5%                           Anti-inflammatory Agents                      30
       HYDROCORT CRE 1%                         HYDROCORTISONE CREAM 1%                            Anti-inflammatory Agents                      30
  HYDROCORT CRE 1% PLUS                         HYDROCORTISONE CREAM 1%                            Anti-inflammatory Agents                      30
 HYDROCORT CRE 1%MAX ST                         HYDROCORTISONE CREAM 1%                            Anti-inflammatory Agents                      30
 HYDROCORT CRE 1%PLS 12                         HYDROCORTISONE CREAM 1%                            Anti-inflammatory Agents                      30
     HYDROCORT CRE 2.5%                        HYDROCORTISONE CREAM 2.5%                           Anti-inflammatory Agents                      30
       HYDROCORT LOT 1%                        HYDROCORTISONE LOTION 1%                            Anti-inflammatory Agents                      30
     HYDROCORT LOT 2.5%                       HYDROCORTISONE LOTION 2.5%                           Anti-inflammatory Agents                      30
     HYDROCORT OIN 0.5%                         HYDROCORTISONE OINT 0.5%                           Anti-inflammatory Agents                      30
       HYDROCORT OIN 1%                           HYDROCORTISONE OINT 1%                           Anti-inflammatory Agents                      30
     HYDROCORT OIN 2.5%                         HYDROCORTISONE OINT 2.5%                           Anti-inflammatory Agents                      30
    HYDROCORT TAB 10MG                          HYDROCORTISONE TAB 10 MG                                    Adrenals                             30
    HYDROCORT TAB 20MG                          HYDROCORTISONE TAB 20 MG                                    Adrenals                             30
     HYDROCORT TAB 5MG                          HYDROCORTISONE TAB 5 MG                                     Adrenals                             30
    HYDROCORT AC CRE 0.5%                 HYDROCORTISONE ACETATE CREAM 0.5%                        Anti-inflammatory Agents              30      30
     HYDROCORT AC CRE 1%                   HYDROCORTISONE ACETATE CREAM 1%                         Anti-inflammatory Agents              30      30
     HYDROCORT/AB OIN 1%                          HYDROCORTISONE OINT 1%                           Anti-inflammatory Agents                      30
     HYDROCREAM CRE 1%                          HYDROCORTISONE CREAM 1%                            Anti-inflammatory Agents                      30
 HYDROGESIC CAP 5-500MG                HYDROCODONE-ACETAMINOPHEN CAP 5-500 MG                            Opiate Agonists                 150     30
     HYDRO-LOTION LOT 1%                       HYDROCORTISONE LOTION 1%                            Anti-inflammatory Agents                      30
    HYDROMET SYP 5-1.5/5           HYDROCODONE W/ HOMATROPINE SYRUP 5-1.5 MG/5ML                           Antitussives                  178     30
    HYDRON CP SYP LIQUID       PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 10-2-5 MG/5ML                      Antitussives                  178     30
         HYDRO-PC II SYP       PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 7.5-2-2 MG/5ML                     Antitussives                  178     30
      HYDRO-PC II SYP PLUS    PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 7.5-2-3.5 MG/5ML                    Antitussives                  178     30
       HYDROSKIN CRE 1%                         HYDROCORTISONE CREAM 1%                            Anti-inflammatory Agents                      30
     HYDRO-TUSSIN ELX DM          DEXTROMETHORPHAN-GUAIFENESIN ELIXIR 20-200 MG/5ML                        Antitussives                  178     30
      HYDRO-TUSSIN SYP HG           HYDROCODONE-GUAIFENESIN SYRUP 3.5-100 MG/5ML                           Antitussives                  178     30
 HYDROXYCHLOR TAB 200MG                 HYDROXYCHLOROQUINE SULFATE TAB 200 MG                             Antimalarials                          30
  HYDROXYUREA CAP 500MG                          HYDROXYUREA CAP 500 MG                              Antineoplastic Agents                       30
HYDROXYZ HCL SOL 10MG/5ML                   HYDROXYZINE HCL SYRUP 10 MG/5ML                 Anxiolytics, Sedatives, & Hypnotics Misc             30      6
HYDROXYZ HCL SYP 10MG/5ML                   HYDROXYZINE HCL SYRUP 10 MG/5ML                 Anxiolytics, Sedatives, & Hypnotics Misc             30      6
    HYDROXYZ HCL TAB 10MG                       HYDROXYZINE HCL TAB 10 MG                   Anxiolytics, Sedatives, & Hypnotics Misc             30
    HYDROXYZ HCL TAB 25MG                       HYDROXYZINE HCL TAB 25 MG                   Anxiolytics, Sedatives, & Hypnotics Misc             30
    HYDROXYZ HCL TAB 50MG                       HYDROXYZINE HCL TAB 50 MG                   Anxiolytics, Sedatives, & Hypnotics Misc             30
  HYDROXYZ PAM CAP 25MG                      HYDROXYZINE PAMOATE CAP 25 MG                  Anxiolytics, Sedatives, & Hypnotics Misc             30
  HYDROXYZ PAM CAP 50MG                      HYDROXYZINE PAMOATE CAP 50 MG                  Anxiolytics, Sedatives, & Hypnotics Misc             30
   HYOMAX       TAB 0.125MG                 HYOSCYAMINE SULFATE TAB 0.125 MG                   Antimuscarinics/Antispasmodics            20      30
  HYOMAX-SL SUB 0.125MG                   HYOSCYAMINE SULFATE TAB SL 0.125 MG                  Antimuscarinics/Antispasmodics            20      30
 HYOSCYAMINE CAP 0.375 ER               HYOSCYAMINE SULFATE CAP SR 12HR 0.375 MG               Antimuscarinics/Antispasmodics            20      30
 HYOSCYAMINE CAP 0.375 TR               HYOSCYAMINE SULFATE CAP SR 12HR 0.375 MG               Antimuscarinics/Antispasmodics            20      30
HYOSCYAMINE DRO 0.125/ML                 HYOSCYAMINE SULFATE SOLN 0.125 MG/ML                  Antimuscarinics/Antispasmodics            30      30      18
  HYOSCYAMINE ELX 0.125/5               HYOSCYAMINE SULFATE ELIXIR 0.125 MG/5ML                Antimuscarinics/Antispasmodics            60      30      18
 HYOSCYAMINE SUB 0.125MG                  HYOSCYAMINE SULFATE TAB SL 0.125 MG                  Antimuscarinics/Antispasmodics            20      30
 HYOSCYAMINE TAB 0.125MG                    HYOSCYAMINE SULFATE TAB 0.125 MG                   Antimuscarinics/Antispasmodics            20      30
  HYOSYNE DRO 0.125/ML                   HYOSCYAMINE SULFATE SOLN 0.125 MG/ML                  Antimuscarinics/Antispasmodics            30      30      18
     HYOSYNE ELX 0.125/5                HYOSCYAMINE SULFATE ELIXIR 0.125 MG/5ML                Antimuscarinics/Antispasmodics            60      30      18
  HYPERRHO S/D INJ 300MCG            RHO D IMMUNE GLOBULIN (HUMAN) IM INJ 300 MCG                            Serums                              30                                                   Prior Authorization Req'd
   HYPERRHO S/D INJ 50MCG            RHO D IMMUNE GLOBULIN (HUMAN) IM INJ 50 MCG                             Serums                              30                                                   Prior Authorization Req'd
   HYPHEN-HD SYP 5-2-1.67     PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 5-2-1.67 MG/5ML                     Antitussives                  178     30
        HYTONE    CRE 1%                        HYDROCORTISONE CREAM 1%                            Anti-inflammatory Agents                      30
       IBU     TAB 400MG                           IBUPROFEN TAB 400 MG                   Other Nonsteroidal Anti-inflammtory Agents             30
       IBU     TAB 600MG                           IBUPROFEN TAB 600 MG                   Other Nonsteroidal Anti-inflammtory Agents             30
       IBU     TAB 800MG                           IBUPROFEN TAB 800 MG                   Other Nonsteroidal Anti-inflammtory Agents             30
      IBU-200 TAB 200MG                            IBUPROFEN TAB 200 MG                   Other Nonsteroidal Anti-inflammtory Agents             30
 IBU-DROPS DRO 40MG/ML                           IBUPROFEN SUSP 40 MG/ML                  Other Nonsteroidal Anti-inflammtory Agents             30      18
  IBU-DROPS DRO INFANTS                          IBUPROFEN SUSP 40 MG/ML                  Other Nonsteroidal Anti-inflammtory Agents             30      18
 IBUPROF CHLD SUS 100/5ML                      IBUPROFEN SUSP 100 MG/5ML                  Other Nonsteroidal Anti-inflammtory Agents             30      18
    IBUPROFEN CAP 200MG                            IBUPROFEN CAP 200 MG                   Other Nonsteroidal Anti-inflammtory Agents     100     30
   IBUPROFEN DRO 50/1.25                         IBUPROFEN SUSP 40 MG/ML                  Other Nonsteroidal Anti-inflammtory Agents             30      18
  IBUPROFEN DRO INFANTS                          IBUPROFEN SUSP 40 MG/ML                  Other Nonsteroidal Anti-inflammtory Agents             30      18
  IBUPROFEN SUS 100/5ML                        IBUPROFEN SUSP 100 MG/5ML                  Other Nonsteroidal Anti-inflammtory Agents             30      18
   IBUPROFEN SUS INFANTS                         IBUPROFEN SUSP 40 MG/ML                  Other Nonsteroidal Anti-inflammtory Agents             30      18
    IBUPROFEN TAB 200MG                            IBUPROFEN TAB 200 MG                   Other Nonsteroidal Anti-inflammtory Agents             30
    IBUPROFEN TAB 400MG                            IBUPROFEN TAB 400 MG                   Other Nonsteroidal Anti-inflammtory Agents             30
    IBUPROFEN TAB 600MG                            IBUPROFEN TAB 600 MG                   Other Nonsteroidal Anti-inflammtory Agents             30
                                                                                                                                                 Max Qty
                                                                                                                                                   Limit   Max Max Age
                                                                                                                                                 (Liquids Days    Limit    Step         Step Therapy      Specialty
    Drug/Product Name                                   Generic Name                                           Therapy Class                      in mLs) Supply (Years) Required?      Requirement         Drug         Coverage Status
     IBUPROFEN TAB 800MG                                IBUPROFEN TAB 800 MG                     Other Nonsteroidal Anti-inflammtory Agents                30
  IBUPROFEN 50 SUS INFANTS                           IBUPROFEN SUSP 40 MG/ML                     Other Nonsteroidal Anti-inflammtory Agents                30      18
   IBUPROFEN IB CHW 100MG                          IBUPROFEN CHEW TAB 100 MG                     Other Nonsteroidal Anti-inflammtory Agents                30
    IBUPROFEN IB TAB 200MG                              IBUPROFEN TAB 200 MG                     Other Nonsteroidal Anti-inflammtory Agents                30
   IBUPROFEN JR CHW 100MG                          IBUPROFEN CHEW TAB 100 MG                     Other Nonsteroidal Anti-inflammtory Agents                30
    IBUPROFEN JR TAB 100MG                              IBUPROFEN TAB 100 MG                     Other Nonsteroidal Anti-inflammtory Agents                30
       IBUTAB      TAB 200MG                            IBUPROFEN TAB 200 MG                     Other Nonsteroidal Anti-inflammtory Agents                30
      IFEREX 150 CAP FORTE          IRON POLYSACCH COMPLEX-VIT B12-FA CAP 150-0.025-1 MG                      Iron Preparations                            30
         ILOTYCIN OIN OP                     ERYTHROMYCIN OPHTH OINT 5 MG/GM                                     Antibacterials                            30
        IMIQUIMOD CRE 5%                                 IMIQUIMOD CREAM 5%                       Skin and Mucous Membrane Agents, Misc                    30                                                         Prior Authorization Req'd
      IMITREX KIT 4MG/0.5                 SUMATRIPTAN SUCCINATE INJ KIT 4 MG/0.5ML                       Selective Serotonin Agonists               2      30
    IMITREX SPR 20MG/ACT                     SUMATRIPTAN NASAL SPRAY 20 MG/ACT                           Selective Serotonin Agonists               6      30
     IMITREX SPR 5MG/ACT                      SUMATRIPTAN NASAL SPRAY 5 MG/ACT                           Selective Serotonin Agonists               6      30
    IMOGEN        LIQ 1MG/5ML              LOPERAMIDE HCL LIQ 1 MG/5ML (0.2 MG/ML)                           Antidiarrhea Agents                   180     30
        IMPERIM TAB 2MG                              LOPERAMIDE HCL TAB 2 MG                                 Antidiarrhea Agents                    31     30
            IMPRUV     LOT                              *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                       30                                                         Prior Authorization Req'd
          INATAL ADV TAB            *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***                  Multivitamin Preparations                        30
           INATAL GT TAB            *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***                  Multivitamin Preparations                        30
         INATAL ULTRA TAB           *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***                  Multivitamin Preparations                        30
   INDAPAMIDE TAB 1.25MG                              INDAPAMIDE TAB 1.25 MG                                Thiazide-like Diuretics                        30
     INDAPAMIDE TAB 2.5MG                              INDAPAMIDE TAB 2.5 MG                                Thiazide-like Diuretics                        30
       INDOCIN SUP 50MG                           INDOMETHACIN SUPPOS 50 MG                        Nonsteroidal Anti-inflammatory Agents                   30
  INDOCIN SUS 25MG/5ML                           INDOMETHACIN SUSP 25 MG/5ML                     Other Nonsteroidal Anti-inflammtory Agents                30      18
   INDOMETHACIN CAP 25MG                             INDOMETHACIN CAP 25 MG                      Other Nonsteroidal Anti-inflammtory Agents                30
   INDOMETHACIN CAP 50MG                             INDOMETHACIN CAP 50 MG                      Other Nonsteroidal Anti-inflammtory Agents                30
INDOMETHACIN CAP 75MG CR                           INDOMETHACIN CAP CR 75 MG                     Other Nonsteroidal Anti-inflammtory Agents                30
INDOMETHACIN CAP 75MG ER                           INDOMETHACIN CAP CR 75 MG                     Other Nonsteroidal Anti-inflammtory Agents                30
INDOMETHACIN CAP 75MG SA                           INDOMETHACIN CAP CR 75 MG                     Other Nonsteroidal Anti-inflammtory Agents                30
INDOMETHACIN CAP 75MG SR                           INDOMETHACIN CAP CR 75 MG                     Other Nonsteroidal Anti-inflammtory Agents                30
   INDOMETHACIN SUP 50MG                          INDOMETHACIN SUPPOS 50 MG                      Other Nonsteroidal Anti-inflammtory Agents                30
  INF SILAPAP DRO 80/0.8ML                      ACETAMINOPHEN SOLN 100 MG/ML                           Analgesics and Antipyretics, Misc           30      30
 INFANT APAP DRO 80/0.8ML                      ACETAMINOPHEN SUSP 80 MG/0.8ML                          Analgesics and Antipyretics, Misc           30      30
  INFANT APAP SUS 200/2ML                      ACETAMINOPHEN SUSP 80 MG/0.8ML                          Analgesics and Antipyretics, Misc           30      30
  INFANTAIRE DRO 80/0.8ML                       ACETAMINOPHEN SOLN 100 MG/ML                           Analgesics and Antipyretics, Misc           30      30
 INFANTS APAP DRO 80/0.8ML                      ACETAMINOPHEN SOLN 100 MG/ML                           Analgesics and Antipyretics, Misc           30      30
      INFED      INJ 50MG/ML             IRON DEXTRAN INJ 50 MG/ML (ELEMENTAL IRON)                           Iron Preparations                            30                                                         Prior Authorization Req'd
                                                                                                                                                                Limited to
 INFLUENZA A INJ 09 H1N1               INFLUENZA A (H1N1) MONOVALENT VACCINE SPLIT INJ                            Vaccines                          5      30     Adults
                                                                                                                                                                Limited to
 INFLUENZA A INJ PF09H1N1         INFLUENZA A (H1N1) MONOVAL VAC SPLIT PRESERVATIVE FREE INJ                      Vaccines                         0.5     30     Adults
                                                                                                                                                                Limited to
 INFLUENZA A SPR 09 H1N1         INFLUENZA A (H1N1) MONOVALENT VACCINE LIVE INTRANASAL LIQUID                      Vaccines                         1      30     Adults
  INNOHEP INJ 20000/ML                    TINZAPARIN SODIUM INJ 20000 ANTI-XA UNIT/ML                              Heparins                                30                                                         Prior Authorization Req'd
     INSTACORT SOL 1%                               HYDROCORTISONE SOLN 1%                                Anti-inflammatory Agents                 120     30
    INSTACORT 5 CRE 0.5%                          HYDROCORTISONE CREAM 0.5%                               Anti-inflammatory Agents                         30
   INTAL 112 AER 800MCG         CROMOLYN SODIUM INHAL AEROSOL SOLN 800 MCG/ACT (1 MG/VALVE)                 Mast-cell Stabilizers                          30
   INTAL 200 AER 800MCG         CROMOLYN SODIUM INHAL AEROSOL SOLN 800 MCG/ACT (1 MG/VALVE)                 Mast-cell Stabilizers                          30
   INTAL INH AER 800MCG         CROMOLYN SODIUM INHAL AEROSOL SOLN 800 MCG/ACT (1 MG/VALVE)                 Mast-cell Stabilizers                          30



                                                                                                                                                                                             USE
                                                                                                                                                                                     RESCRIPTOR/SUSTIVA
   INTELENCE TAB 100MG                              ETRAVIRINE TAB 100 MG                       Nonnucleoside Reverse Transcriptase Inhibitors             30                Y          /VIRAMUNE 1ST
INTENSE COUG LIQ RELIEVER           DEXTROMETHORPHAN-GUAIFENESIN LIQUID 20-300 MG/5ML                           Antitussives                       180     30
       INTENSE SENS MIS                           CONDOMS LATEX LUBRICATED                                     Contraceptives                              30
     INTRON-A INJ 10MU                     INTERFERON ALFA-2B FOR INJ 10000000 UNIT                        Antineoplastic Agents                           30                                             Specialty   Prior Authorization Req'd
 INTRON-A INJ 10MU PEN                  INTERFERON ALFA-2B INJ KIT 10000000 UNIT/0.2ML                     Antineoplastic Agents                           30                                             Specialty   Prior Authorization Req'd
     INTRON-A INJ 18MU                      INTERFERON ALFA-2B INJ 6000000 UNIT/ML                         Antineoplastic Agents                           30                                             Specialty   Prior Authorization Req'd
     INTRON-A INJ 25MU                     INTERFERON ALFA-2B INJ 10000000 UNIT/ML                         Antineoplastic Agents                           30                                             Specialty   Prior Authorization Req'd
  INTRON-A INJ 3MU PEN                   INTERFERON ALFA-2B INJ KIT 3000000 UNIT/0.2ML                     Antineoplastic Agents                           30                                             Specialty   Prior Authorization Req'd
     INTRON-A INJ 50MU                     INTERFERON ALFA-2B FOR INJ 50000000 UNIT                        Antineoplastic Agents                           30                                             Specialty   Prior Authorization Req'd
  INTRON-A INJ 5MU PEN                   INTERFERON ALFA-2B INJ KIT 5000000 UNIT/0.2ML                     Antineoplastic Agents                           30                                             Specialty   Prior Authorization Req'd
        INTROVALE TAB            LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG                  Contraceptives                      91      91
    INVIRASE CAP 200MG                         SAQUINAVIR MESYLATE CAP 200 MG                              HIV Protease Inhibitors                         30
    INVIRASE TAB 500MG                         SAQUINAVIR MESYLATE TAB 500 MG                             HIV Protease Inhibitors                          30
                                                                                                                                                Max Qty
                                                                                                                                                  Limit   Max Max Age
                                                                                                                                                (Liquids Days    Limit    Step      Step Therapy   Specialty
     Drug/Product Name                                     Generic Name                                         Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
      IOBID DM TAB 30-600CR            DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 30-600 MG                          Antitussives                    31     30
     IOPHEN C-NR LIQ 100-10/5                    GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML                            Antitussives                   180     30
      IOPHEN DM LIQ 100-10/5           DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                           Antitussives                   180     30
   IOPHEN DM-NR LIQ 100-10/5           DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                           Antitussives                   180     30
         IOSAL II TAB 60-600CR           PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 60-600 MG                         Expectorants                    31     30
         IOTEX PSE TAB 120-600          PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-600 MG                         Expectorants                    31     30
       IPRATROPIUM SOL INHAL                      IPRATROPIUM BROMIDE INHAL SOLN 0.02%                  Antimuscarinics/Antispasmodics                    30
  IPRATROPIUM/ SOL ALBUTER               IPRATROPIUM-ALBUTEROL NEBU SOLN 0.5-2.5(3) MG/3ML            Selective beta-2-Adrenergic Agonists        180     30
             I-PRIN     TAB 200MG                             IBUPROFEN TAB 200 MG                 Other Nonsteroidal Anti-inflammtory Agents             30
            IRESSA      TAB 250MG                               GEFITINIB TAB 250 MG                          Antineoplastic Agents                       30
      IRINOTECAN INJ 100/5ML                    IRINOTECAN HCL INJ 100 MG/5ML (20 MG/ML)                      Antineoplastic Agents                       30                                                   Prior Authorization Req'd
    IRINOTECAN INJ 20MG/ML                       IRINOTECAN HCL INJ 40 MG/2ML (20 MG/ML)                      Antineoplastic Agents                       30                                                   Prior Authorization Req'd
   IRINOTECAN INJ 40MG/2ML                       IRINOTECAN HCL INJ 40 MG/2ML (20 MG/ML)                      Antineoplastic Agents                       30                                                   Prior Authorization Req'd
    IRINOTECAN INJ 500MG/25                    IRINOTECAN HCL INJ 500 MG/25ML (20 MG/ML)                      Antineoplastic Agents                       30                                                   Prior Authorization Req'd
             IRON       TAB 325MG          FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)                      Iron Preparations                         30
  IRON DEXTRAN INJ 50MG/ML                    IRON DEXTRAN INJ 50 MG/ML (ELEMENTAL IRON)                        Iron Preparations                         30                                                   Prior Authorization Req'd
         ISENTRESS TAB 400MG                RALTEGRAVIR POTASSIUM TAB 400 MG (BASE EQUIV)                      Integrase Inhibitors                       30
     ISOCHRON TAB 40MG CR                             ISOSORBIDE DINITRATE TAB CR 40 MG                       Nitrates and Nitrites                       30
      ISODITRATE TAB 40MG ER                          ISOSORBIDE DINITRATE TAB CR 40 MG                       Nitrates and Nitrites                       30
  ISOMETH/APAP CAP DICHLOR          ACETAMINOPHEN-ISOMETHEPTENE-DICHLORAL CAP 325-65-100 MG            Antimigraine Agents, Miscellaneous          6      30
                 ISONARIF CAP                       ISONIAZID & RIFAMPIN CAP 150-300 MG                      Antituberculosis Agents                      30
    ISONIAZID SYP 50MG/5ML                                 ISONIAZID SYRUP 50 MG/5ML                         Antituberculosis Agents                      14      18
         ISONIAZID TAB 100MG                                   ISONIAZID TAB 100 MG                          Antituberculosis Agents                      30
         ISONIAZID TAB 300MG                                   ISONIAZID TAB 300 MG                          Antituberculosis Agents                      30
        ISOSORB DIN SUB 2.5MG                         ISOSORBIDE DINITRATE SL TAB 2.5 MG                      Nitrates and Nitrites                       30
          ISOSORB DIN SUB 5MG                          ISOSORBIDE DINITRATE SL TAB 5 MG                       Nitrates and Nitrites                       30
         ISOSORB DIN TAB 10MG                           ISOSORBIDE DINITRATE TAB 10 MG                        Nitrates and Nitrites                       30
         ISOSORB DIN TAB 20MG                           ISOSORBIDE DINITRATE TAB 20 MG                        Nitrates and Nitrites                       30
         ISOSORB DIN TAB 30MG                           ISOSORBIDE DINITRATE TAB 30 MG                        Nitrates and Nitrites                       30
     ISOSORB DIN TAB 40MG ER                          ISOSORBIDE DINITRATE TAB CR 40 MG                       Nitrates and Nitrites                       30
    ISOSORB DIN TAB 40MG SA                           ISOSORBIDE DINITRATE TAB CR 40 MG                       Nitrates and Nitrites                       30
           ISOSORB DIN TAB 5MG                           ISOSORBIDE DINITRATE TAB 5 MG                        Nitrates and Nitrites                       30
     ISOSORB MONO TAB 10MG                           ISOSORBIDE MONONITRATE TAB 10 MG                         Nitrates and Nitrites                       30
ISOSORB MONO TAB 120MG ER                    ISOSORBIDE MONONITRATE TAB SR 24HR 120 MG                        Nitrates and Nitrites                       30
     ISOSORB MONO TAB 20MG                           ISOSORBIDE MONONITRATE TAB 20 MG                         Nitrates and Nitrites                       30
 ISOSORB MONO TAB 30MG ER                      ISOSORBIDE MONONITRATE TAB SR 24HR 30 MG                       Nitrates and Nitrites                       30
 ISOSORB MONO TAB 60MG ER                      ISOSORBIDE MONONITRATE TAB SR 24HR 60 MG                       Nitrates and Nitrites                       30
            ISOVATE CRE 0.05%                       CLOBETASOL PROPIONATE CREAM 0.05%                       Anti-inflammatory Agents              30      30
          ISRADIPINE CAP 2.5MG                                 ISRADIPINE CAP 2.5 MG                            Dihydropyridines                          30
            ISRADIPINE CAP 5MG                                  ISRADIPINE CAP 5 MG                             Dihydropyridines                          30
          ISTALOL SOL 0.5% OP               TIMOLOL MALEATE OPHTH SOLN 0.5% (ONCE-DAILY)             BETA ADRENERGIC BLOCKING AGENTS                      30
                ITCH-X    LOT 1%                           HYDROCORTISONE LOTION 1%                         Anti-inflammatory Agents                      30
    ITRACONAZOLE CAP 100MG                                  ITRACONAZOLE CAP 100 MG                                    Azoles                             30                                                   Prior Authorization Req'd
 J&J SOOTHING LOT NATURALS                                    *EMOLLIENT - LOTION**                        Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
          JANTOVEN TAB 10MG                               WARFARIN SODIUM TAB 10 MG                           Coumarin Derivatives                        30
            JANTOVEN TAB 1MG                               WARFARIN SODIUM TAB 1 MG                           Coumarin Derivatives                        30
         JANTOVEN TAB 2.5MG                               WARFARIN SODIUM TAB 2.5 MG                          Coumarin Derivatives                        30
            JANTOVEN TAB 2MG                               WARFARIN SODIUM TAB 2 MG                           Coumarin Derivatives                        30
            JANTOVEN TAB 3MG                               WARFARIN SODIUM TAB 3 MG                           Coumarin Derivatives                        30
            JANTOVEN TAB 4MG                               WARFARIN SODIUM TAB 4 MG                           Coumarin Derivatives                        30
            JANTOVEN TAB 5MG                               WARFARIN SODIUM TAB 5 MG                           Coumarin Derivatives                        30
            JANTOVEN TAB 6MG                               WARFARIN SODIUM TAB 6 MG                           Coumarin Derivatives                        30
         JANTOVEN TAB 7.5MG                               WARFARIN SODIUM TAB 7.5 MG                          Coumarin Derivatives                        30
      JINTELI TAB 1MG-5MCG           NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TAB 1 MG-5 MCG                          Estrogens                            30
               JOCK ITCH CRE 1%                              CLOTRIMAZOLE CREAM 1%                                     Azoles                     30      30
       JOHNSON BODY LOT CARE                                  *EMOLLIENT - LOTION**                        Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
          JOHNSONS LOT BODY                                   *EMOLLIENT - LOTION**                        Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
     JOHNSONS LOT SOFTLOTI                                    *EMOLLIENT - LOTION**                        Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
                  JOLESSA TAB       LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG                  Contraceptives                  91      91
         JOLIVETTE TAB 0.35MG                             NORETHINDRONE TAB 0.35 MG                               Contraceptives                          30
     JR STR PAIN CHW RELIEVER                          ACETAMINOPHEN CHEW TAB 160 MG                    Analgesics and Antipyretics, Misc         60      30
       JR. ACETAMIN CHW 80MG                           ACETAMINOPHEN CHEW TAB 80 MG                     Analgesics and Antipyretics, Misc         60      30
                JUNEL 1.5/30 TAB     NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG                      Contraceptives                          30
                 JUNEL 1/20 TAB       NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG                       Contraceptives                          30
            JUNEL FE TAB 1.5/30     NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG                    Contraceptives                          30
                                                                                                                                           Max Qty
                                                                                                                                             Limit   Max Max Age
                                                                                                                                           (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                                 Generic Name                                         Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
      JUNEL FE TAB 1/20        NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG                       Contraceptives                         30
     JUST D     LIQ 400UNIT             CHOLECALCIFEROL ORAL LIQUID 400 UNIT/ML                                  Vitamin D                   50      30
          KALETRA SOL            LOPINAVIR-RITONAVIR SOLN 400-100 MG/5ML (80-20 MG/ML)                   HIV Protease Inhibitors                     30      18
  KALETRA TAB 100-25MG                     LOPINAVIR-RITONAVIR TAB 100-25 MG                             HIV Protease Inhibitors                     30
  KALETRA TAB 200-50MG                     LOPINAVIR-RITONAVIR TAB 200-50 MG                             HIV Protease Inhibitors                     30
  KAMELEON MIS TRI-COLR                        CONDOMS LATEX LUBRICATED                                       Contraceptives                         30
 KAMELEON LUB MIS COLORS                       CONDOMS LATEX LUBRICATED                                       Contraceptives                         30
    KAODENE AD TAB 2MG                          LOPERAMIDE HCL TAB 2 MG                                    Antidiarrhea Agents               31      30
 KAON-CL-10 TAB 10MEQ CR                   POTASSIUM CHLORIDE TAB CR 10 MEQ                            Replacement Preparations                      30
 KAOPECTATE SUS 262/15ML                BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                             Antidiarrhea Agents              1800     30
    KAOPECTATE SUS EX ST                BISMUTH SUBSALICYLATE SUSP 525 MG/15ML                             Antidiarrhea Agents              1800     30
        KAOPECTATE TAB                     BISMUTH SUBSALICYLATE TAB 262 MG                                Antidiarrhea Agents              120      30
   KAO-TIN SUS 262/15ML                 BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                             Antidiarrhea Agents              1800     30
 KAPECTOLIN SUS 262/15ML                BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                             Antidiarrhea Agents              1800     30
  KARIDIUM DRO 0.125MG         SODIUM FLUORIDE SOLN 0.125 MG/DROP F (0.275 MG/DROP NAF)           Miscellaneous Therapeutic Agents                   30
      KARIGEL GEL 0.5%                      SODIUM FLUORIDE GEL 1.1% (0.5% F)                     Miscellaneous Therapeutic Agents                   30      18
      KARIGEL-N GEL 1.1%                    SODIUM FLUORIDE GEL 1.1% (0.5% F)                     Miscellaneous Therapeutic Agents                   30      18
     KARIVA      TAB 28 DAY    DESOGEST-ETH ESTRAD & ETH ESTRAD TAB 0.15-0.02/0.01 MG(21/5)                   Contraceptives                         30
    KAY CIEL POW 20MEQ                 POTASSIUM CHLORIDE POWDER PACKET 20 MEQ                         Replacement Preparations                      30
     KEFLEX      CAP 750MG                        CEPHALEXIN CAP 750 MG                             First Generation Cephalosporins                  14
      KELNOR      TAB 1/35      ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG                      Contraceptives                         30
    KENALOG AER SPRAY                   TRIAMCINOLONE ACETONIDE AEROSOL SOLN                            Anti-inflammatory Agents                     30                                                   Prior Authorization Req'd
  KEN-TUSS SF SYP 10-100/5        DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                            Antitussives                  180     30
    KERI       LOT ORIGINAL                       *EMOLLIENT - LOTION**                                Basic Lotions and Liniments                   30                                                   Prior Authorization Req'd
    KERI      LOT OVRNIGHT                        *EMOLLIENT - LOTION**                                Basic Lotions and Liniments                   30                                                   Prior Authorization Req'd
KERI ADVANCE LOT MOISTURE                         *EMOLLIENT - LOTION**                                Basic Lotions and Liniments                   30                                                   Prior Authorization Req'd
 KERI NRSHING LOT SHEA BTR                        *EMOLLIENT - LOTION**                                Basic Lotions and Liniments                   30                                                   Prior Authorization Req'd
 KERI RENEWAL LOT FIRMING                         *EMOLLIENT - LOTION**                                Basic Lotions and Liniments                   30                                                   Prior Authorization Req'd
 KERI RENEWAL LOT MILK BDY                        *EMOLLIENT - LOTION**                                Basic Lotions and Liniments                   30                                                   Prior Authorization Req'd
 KERI RENEWAL LOT STRETCH                         *EMOLLIENT - LOTION**                                Basic Lotions and Liniments                   30                                                   Prior Authorization Req'd
      KERI SENSITI LOT SKIN                       *EMOLLIENT - LOTION**                                Basic Lotions and Liniments                   30                                                   Prior Authorization Req'd
   KERI SILKY LOT SMOOTH                          *EMOLLIENT - LOTION**                                Basic Lotions and Liniments                   30                                                   Prior Authorization Req'd
      KERICORT 10 CRE 1%                       HYDROCORTISONE CREAM 1%                                  Anti-inflammatory Agents                     30
    KETOCONAZOLE CRE 2%                          KETOCONAZOLE CREAM 2%                                             Azoles                            30                                                   Prior Authorization Req'd
 KETOCONAZOLE TAB 200MG                         KETOCONAZOLE TAB 200 MG                                            Azoles                            30
   KETOPROFEN CAP 50MG                            KETOPROFEN CAP 50 MG                        Other Nonsteroidal Anti-inflammtory Agents             30
   KETOPROFEN CAP 75MG                            KETOPROFEN CAP 75 MG                        Other Nonsteroidal Anti-inflammtory Agents             30
     KETOROLAC SOL 0.4%                KETOROLAC TROMETHAMINE OPHTH SOLN 0.4%                   Nonsteroidal Anti-inflammatory Agents        10      30
     KETOROLAC SOL 0.5%                KETOROLAC TROMETHAMINE OPHTH SOLN 0.5%                   Nonsteroidal Anti-inflammatory Agents        10      30
    KETOROLAC TAB 10MG                    KETOROLAC TROMETHAMINE TAB 10 MG                    Other Nonsteroidal Anti-inflammtory Agents     20      30
  KIDKARE DECO DRO 7.5/0.8              PSEUDOEPHEDRINE HCL SOLN 7.5 MG/0.8ML                    alpha- and beta-Adrenergic Agonists         15      30
  KIMONO        MIS LUBRICAT                   CONDOMS LATEX LUBRICATED                                       Contraceptives                         30
  KIMONO        MIS SENSATIO                   CONDOMS LATEX LUBRICATED                                       Contraceptives                         30
       KIMONO COLOR MIS                        CONDOMS LATEX LUBRICATED                                       Contraceptives                         30
   KIMONO MICRO MIS THIN                     CONDOMS LATEX NON-LUBRICATED                                     Contraceptives                         30
  KIMONO MICRO MIS THIN +                      CONDOMS LATEX LUBRICATED                                       Contraceptives                         30
KIMONO MICRO MIS THIN PLS                      CONDOMS LATEX LUBRICATED                                       Contraceptives                         30
 KIMONO PLUS MIS LUBRICAT                      CONDOMS LATEX LUBRICATED                                       Contraceptives                         30
 KIMONO PLUS MIS SPERMICI                      CONDOMS LATEX LUBRICATED                                       Contraceptives                         30
  KIMONO PS MIS LUBRICAT                       CONDOMS LATEX LUBRICATED                                       Contraceptives                         30
     KIMONO PS MIS PLUS                        CONDOMS LATEX LUBRICATED                                       Contraceptives                         30
   KIMONO SENSA MIS PLUS                       CONDOMS LATEX LUBRICATED                                       Contraceptives                         30
        KIMONO SPEC MIS                        CONDOMS LATEX LUBRICATED                                       Contraceptives                         30
   KLOR-CON POW 20MEQ                  POTASSIUM CHLORIDE POWDER PACKET 20 MEQ                         Replacement Preparations                      30
 KLOR-CON 10 TAB 10MEQ ER                  POTASSIUM CHLORIDE TAB CR 10 MEQ                            Replacement Preparations                      30
KLOR-CON M10 TAB 10MEQ ER      POTASSIUM CHLORIDE MICROENCAPSULATED CRYS CR TAB 10 MEQ                 Replacement Preparations                      30
       KLOR-CON M15 TAB        POTASSIUM CHLORIDE MICROENCAPSULATED CRYS CR TAB 15 MEQ                 Replacement Preparations                      30
KLOR-CON M20 TAB 20MEQ ER      POTASSIUM CHLORIDE MICROENCAPSULATED CRYS CR TAB 20 MEQ                 Replacement Preparations                      30
   KLOTRIX TAB 10MEQ CR                    POTASSIUM CHLORIDE TAB CR 10 MEQ                            Replacement Preparations                      30
     KODET-SE TAB 30MG                       PSEUDOEPHEDRINE HCL TAB 30 MG                       alpha- and beta-Adrenergic Agonists        120      30
      KOLA-PECTIN SUS DS                BISMUTH SUBSALICYLATE SUSP 525 MG/15ML                             Antidiarrhea Agents              1800     30
    K-PEC      SUS 262/15ML             BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                             Antidiarrhea Agents              1800     30
 KRO PED ELEC SOL BUBBLE G                   *ORAL ELECTROLYTE SOLUTION***                             Replacement Preparations                      30      18
    KRO PED ELEC SOL FRUIT                   *ORAL ELECTROLYTE SOLUTION***                             Replacement Preparations                      30      18
   KRO PED ELEC SOL GRAPE                    *ORAL ELECTROLYTE SOLUTION***                             Replacement Preparations                      30      18
                                                                                                                                  Max Qty
                                                                                                                                    Limit   Max Max Age
                                                                                                                                  (Liquids Days    Limit    Step         Step Therapy      Specialty
    Drug/Product Name                                Generic Name                                      Therapy Class               in mLs) Supply (Years) Required?      Requirement         Drug         Coverage Status
 KRO PED ELEC SOL UNFLAVOR                   *ORAL ELECTROLYTE SOLUTION***                        Replacement Preparations                  30      18
  KRONOFED-A CAP 8-120 CR         CHLORPHENIRAMINE & PSEUDOEPHEDRINE CAP CR 8-120 MG               Proplamine Derivatives           31      30
       KURIC    CRE 2%                          KETOCONAZOLE CREAM 2%                                       Azoles                          30                                                         Prior Authorization Req'd
   K-VESCENT POW 20MEQ                 POTASSIUM CHLORIDE POWDER PACKET 20 MEQ                    Replacement Preparations                  30
   KWELCOF SYP 5-100/5               HYDROCODONE-GUAIFENESIN SYRUP 5-100 MG/5ML                          Antitussives               178     30
   LABETALOL TAB 100MG                         LABETALOL HCL TAB 100 MG                        Beta-Adrenergic Blocking Agents              30
   LABETALOL TAB 200MG                         LABETALOL HCL TAB 200 MG                        Beta-Adrenergic Blocking Agents              30
   LABETALOL TAB 300MG                         LABETALOL HCL TAB 300 MG                        Beta-Adrenergic Blocking Agents              30
  LACTULOSE SOL 10GM/15                     LACTULOSE SOLUTION 10 GM/15ML                           Ammonia Detoxicants             947     30
  LACTULOSE SOL 20GM/30                     LACTULOSE SOLUTION 10 GM/15ML                           Ammonia Detoxicants             947     30
     LANACORT 10 CRE 1%                    HYDROCORTISONE ACETATE CREAM 1%                        Anti-inflammatory Agents           30     30
LANSOPRAZOLE TAB 15MG ODT     LANSOPRAZOLE TAB DELAYED RELEASE ORALLY DISINTEGRATING 15 MG         Proton-pump Inhibitors                   30      12
LANSOPRAZOLE TAB 30MG ODT     LANSOPRAZOLE TAB DELAYED RELEASE ORALLY DISINTEGRATING 30 MG         Proton-pump Inhibitors                   30      12




                                                                                                                                                                      USE INSULIN MIX OR
                                                                                                                                                                        INTERMEDIATE
   LANTUS    INJ 100/ML                     INSULIN GLARGINE INJ 100 UNIT/ML                              Insulins                          30                Y           INSULIN 1ST




                                                                                                                                                                      USE INSULIN MIX OR
                                                                                                                                                                        INTERMEDIATE
  LANTUS    INJ SOLOSTAR                    INSULIN GLARGINE INJ 100 UNIT/ML                              Insulins                          30                Y           INSULIN 1ST




                                                                                                                                                                      USE INSULIN MIX OR
                                                                                                                                                                        INTERMEDIATE
    LANTUS FOR INJ OPTICLIK                 INSULIN GLARGINE INJ 100 UNIT/ML                               Insulins                         30                Y           INSULIN 1ST
   LATANOPROST SOL 0.005%                   LATANOPROST OPHTH SOLN 0.005%                         PROSTAGLANDIN ANALOGS                     30
  LAX/STL SOFT TAB 8.6-50MG           SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                     Cathartics and Laxatives         100     30
     LAXA BASIC CAP 100MG                     DOCUSATE SODIUM CAP 100 MG                           Cathartics and Laxatives         100     30
     LAXA BASIC CAP 250MG                     DOCUSATE SODIUM CAP 250 MG                           Cathartics and Laxatives         100     30
          LEENA    TAB         NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG                Contraceptives                      30
       LESCOL    CAP 20MG                    FLUVASTATIN SODIUM CAP 20 MG                       HMG-CoA Reductase Inhibitors                30
       LESCOL    CAP 40MG                    FLUVASTATIN SODIUM CAP 40 MG                       HMG-CoA Reductase Inhibitors                30
         LESSINA-28 TAB          LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG                   Contraceptives                      30
     LEUCOVOR CA INJ 50MG                  LEUCOVORIN CALCIUM FOR INJ 50 MG                    Miscellaneous Therapeutic Agents             30                                                         Prior Authorization Req'd
    LEUCOVOR CA TAB 10MG                     LEUCOVORIN CALCIUM TAB 10 MG                      Miscellaneous Therapeutic Agents             30
    LEUCOVOR CA TAB 15MG                     LEUCOVORIN CALCIUM TAB 15 MG                      Miscellaneous Therapeutic Agents             30
    LEUCOVOR CA TAB 25MG                     LEUCOVORIN CALCIUM TAB 25 MG                      Miscellaneous Therapeutic Agents             30
     LEUCOVOR CA TAB 5MG                      LEUCOVORIN CALCIUM TAB 5 MG                      Miscellaneous Therapeutic Agents             30
    LEUCOVORIN INJ 200MG                  LEUCOVORIN CALCIUM FOR INJ 200 MG                    Miscellaneous Therapeutic Agents             30                                                         Prior Authorization Req'd
       LEUKERAN TAB 2MG                            CHLORAMBUCIL TAB 2 MG                             Antineoplastic Agents                  30
      LEVAMISOLE POW HCL                           LEVAMISOLE HCL POWDER                              Pharmaceutical Aids                   30
   LEVAQUIN SOL 25MG/ML                    LEVOFLOXACIN ORAL SOLN 25 MG/ML                                Quinolones                        14
     LEVAQUIN TAB 250MG                           LEVOFLOXACIN TAB 250 MG                                 Quinolones                        14
     LEVAQUIN TAB 500MG                           LEVOFLOXACIN TAB 500 MG                                 Quinolones                        14
     LEVAQUIN TAB 750MG                           LEVOFLOXACIN TAB 750 MG                                 Quinolones                        14
   LEVAQUIN TAB LEVA-PAK                          LEVOFLOXACIN TAB 750 MG                                 Quinolones                        14
LEVETIRACETA SOL 100MG/ML                LEVETIRACETAM ORAL SOLN 100 MG/ML                      Anticonvulsants, Miscellaneous              30
  LEVETIRACETA SOL 500/5ML               LEVETIRACETAM ORAL SOLN 100 MG/ML                      Anticonvulsants, Miscellaneous              30
  LEVETIRACETA TAB 1000MG                       LEVETIRACETAM TAB 1000 MG                       Anticonvulsants, Miscellaneous              30
    LEVETIRACETA TAB 250MG                       LEVETIRACETAM TAB 250 MG                       Anticonvulsants, Miscellaneous              30
    LEVETIRACETA TAB 500MG                       LEVETIRACETAM TAB 500 MG                       Anticonvulsants, Miscellaneous              30
    LEVETIRACETA TAB 750MG                       LEVETIRACETAM TAB 750 MG                       Anticonvulsants, Miscellaneous              30
 LEVOBUNOLOL SOL 0.25% OP                 LEVOBUNOLOL HCL OPHTH SOLN 0.25%                   BETA ADRENERGIC BLOCKING AGENTS                30
  LEVOBUNOLOL SOL 0.5% OP                  LEVOBUNOLOL HCL OPHTH SOLN 0.5%                   BETA ADRENERGIC BLOCKING AGENTS                30
LEVOCARNITIN SOL 1GM/10ML              LEVOCARNITINE ORAL SOLN 1 GM/10ML (10%)                  Other Misc Therapeutic Agents               30      18
   LEVOCARNITIN TAB 330MG                        LEVOCARNITINE TAB 330 MG                       Other Misc Therapeutic Agents               30
 LEVONORGESTR TAB 0.75MG                       LEVONORGESTREL TAB 0.75 MG                               Contraceptives                      30
     LEVORA-28 TAB 0.15/30      LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG                   Contraceptives                      30
   LEVOTHROID TAB 100MCG                  LEVOTHYROXINE SODIUM TAB 100 MCG                              Thyroid Agents                      30
                                                                                                                            Max Qty
                                                                                                                              Limit   Max Max Age
                                                                                                                            (Liquids Days    Limit    Step      Step Therapy   Specialty
   Drug/Product Name                                 Generic Name                                  Therapy Class             in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
 LEVOTHROID TAB 112MCG                      LEVOTHYROXINE SODIUM TAB 112 MCG                        Thyroid Agents                    30
 LEVOTHROID TAB 125MCG                      LEVOTHYROXINE SODIUM TAB 125 MCG                        Thyroid Agents                    30
 LEVOTHROID TAB 137MCG                      LEVOTHYROXINE SODIUM TAB 137 MCG                        Thyroid Agents                    30
 LEVOTHROID TAB 150MCG                      LEVOTHYROXINE SODIUM TAB 150 MCG                        Thyroid Agents                    30
 LEVOTHROID TAB 175MCG                      LEVOTHYROXINE SODIUM TAB 175 MCG                        Thyroid Agents                    30
 LEVOTHROID TAB 200MCG                      LEVOTHYROXINE SODIUM TAB 200 MCG                        Thyroid Agents                    30
  LEVOTHROID TAB 25MCG                       LEVOTHYROXINE SODIUM TAB 25 MCG                        Thyroid Agents                    30
 LEVOTHROID TAB 300MCG                      LEVOTHYROXINE SODIUM TAB 300 MCG                        Thyroid Agents                    30
  LEVOTHROID TAB 50MCG                       LEVOTHYROXINE SODIUM TAB 50 MCG                        Thyroid Agents                    30
  LEVOTHROID TAB 75MCG                       LEVOTHYROXINE SODIUM TAB 75 MCG                        Thyroid Agents                    30
  LEVOTHROID TAB 88MCG                       LEVOTHYROXINE SODIUM TAB 88 MCG                        Thyroid Agents                    30
LEVOTHYROXIN TAB 100MCG                     LEVOTHYROXINE SODIUM TAB 100 MCG                        Thyroid Agents                    30
LEVOTHYROXIN TAB 112MCG                     LEVOTHYROXINE SODIUM TAB 112 MCG                        Thyroid Agents                    30
LEVOTHYROXIN TAB 125MCG                     LEVOTHYROXINE SODIUM TAB 125 MCG                        Thyroid Agents                    30
LEVOTHYROXIN TAB 137MCG                     LEVOTHYROXINE SODIUM TAB 137 MCG                        Thyroid Agents                    30
LEVOTHYROXIN TAB 150MCG                     LEVOTHYROXINE SODIUM TAB 150 MCG                        Thyroid Agents                    30
LEVOTHYROXIN TAB 175MCG                     LEVOTHYROXINE SODIUM TAB 175 MCG                        Thyroid Agents                    30
LEVOTHYROXIN TAB 200MCG                     LEVOTHYROXINE SODIUM TAB 200 MCG                        Thyroid Agents                    30
 LEVOTHYROXIN TAB 25MCG                      LEVOTHYROXINE SODIUM TAB 25 MCG                        Thyroid Agents                    30
LEVOTHYROXIN TAB 300MCG                     LEVOTHYROXINE SODIUM TAB 300 MCG                        Thyroid Agents                    30
 LEVOTHYROXIN TAB 50MCG                      LEVOTHYROXINE SODIUM TAB 50 MCG                        Thyroid Agents                    30
 LEVOTHYROXIN TAB 75MCG                      LEVOTHYROXINE SODIUM TAB 75 MCG                        Thyroid Agents                    30
 LEVOTHYROXIN TAB 88MCG                      LEVOTHYROXINE SODIUM TAB 88 MCG                        Thyroid Agents                    30
   LEVOXYL TAB 100MCG                       LEVOTHYROXINE SODIUM TAB 100 MCG                        Thyroid Agents                    30
   LEVOXYL TAB 112MCG                       LEVOTHYROXINE SODIUM TAB 112 MCG                        Thyroid Agents                    30
   LEVOXYL TAB 125MCG                       LEVOTHYROXINE SODIUM TAB 125 MCG                        Thyroid Agents                    30
   LEVOXYL TAB 137MCG                       LEVOTHYROXINE SODIUM TAB 137 MCG                        Thyroid Agents                    30
   LEVOXYL TAB 150MCG                       LEVOTHYROXINE SODIUM TAB 150 MCG                        Thyroid Agents                    30
   LEVOXYL TAB 175MCG                       LEVOTHYROXINE SODIUM TAB 175 MCG                        Thyroid Agents                    30
   LEVOXYL TAB 200MCG                       LEVOTHYROXINE SODIUM TAB 200 MCG                        Thyroid Agents                    30
    LEVOXYL TAB 25MCG                        LEVOTHYROXINE SODIUM TAB 25 MCG                        Thyroid Agents                    30
    LEVOXYL TAB 50MCG                        LEVOTHYROXINE SODIUM TAB 50 MCG                        Thyroid Agents                    30
    LEVOXYL TAB 75MCG                        LEVOTHYROXINE SODIUM TAB 75 MCG                        Thyroid Agents                    30
    LEVOXYL TAB 88MCG                        LEVOTHYROXINE SODIUM TAB 88 MCG                        Thyroid Agents                    30
   LEXIVA       SUS 50MG/ML         FOSAMPRENAVIR CALCIUM SUSP 50 MG/ML (BASE EQUIV)           HIV Protease Inhibitors                30
     LEXIVA      TAB 700MG            FOSAMPRENAVIR CALCIUM TAB 700 MG (BASE EQUIV)            HIV Protease Inhibitors                30
     LIALDA       TAB 1.2GM               MESALAMINE TAB DELAYED RELEASE 1.2 GM               Anti-inflammatory Agents                30                                                   Prior Authorization Req'd
    LICE       LIQ TREATMEN              PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.33-4%           Scabicides and Pediculicides     120     30
        LICE BEDDING AER                          PERMETHRIN AEROSOL 0.5%                    Scabicides and Pediculicides     142     30
    LICE BEDDING AER 0.5%                         PERMETHRIN AEROSOL 0.5%                    Scabicides and Pediculicides     142     30
    LICE CONTROL AER 0.5%                         PERMETHRIN AEROSOL 0.5%                    Scabicides and Pediculicides     142     30
      LICE CRM RIN LIQ 1%                        PERMETHRIN CREME RINSE 1%                   Scabicides and Pediculicides     120     30
   LICE KILLING LIQ MAX ST               PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.33-4%           Scabicides and Pediculicides     120     30
 LICE KILLING LIQ SHAMPOO                PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.33-4%           Scabicides and Pediculicides     120     30
         LICE KILLING SHA                PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.3-3%            Scabicides and Pediculicides     120     30
          LICE SOLN KIT       PYRETH-PIPERONYL BUTOX SHAM-PERMETH AERO-NIT REMOVER GEL KIT   Scabicides and Pediculicides             30
  LICE TREATMT KIT MAX ST     PYRETH-PIPERONYL BUTOX SHAM-PERMETH AERO-NIT REMOVER GEL KIT   Scabicides and Pediculicides             30
     LICE TREATMT LOT 1%                           PERMETHRIN LOTION 1%                      Scabicides and Pediculicides             30
        LICE TRTMNT LIQ                  PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.3-3%            Scabicides and Pediculicides     120     30
      LICE TRTMNT LIQ 1%                         PERMETHRIN CREME RINSE 1%                   Scabicides and Pediculicides     120     30
LICE TRTMNT LIQ CRM RNSE                 PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.33-4%           Scabicides and Pediculicides     120     30
       LICIDE      AER 0.5%                       PERMETHRIN AEROSOL 0.5%                    Scabicides and Pediculicides     142     30
     LICIDE      LIQ MAX ST              PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.33-4%           Scabicides and Pediculicides     120     30
LICIDE COMP KIT TREATMNT      PYRETH-PIPERONYL BUTOX SHAM-PERMETH AERO-NIT REMOVER GEL KIT   Scabicides and Pediculicides             30
   LIDOCAINE SOL 2% VISC                       LIDOCAINE HCL VISCOUS SOLN 2%                      Local Anesthetics                   30                                                   Prior Authorization Req'd
   LIFESTYLES MIS COLORS                            *CONDOMS - MALE***                              Contraceptives                    30
   LIFESTYLES MIS EXT STR                           *CONDOMS - MALE***                              Contraceptives                    30
  LIFESTYLES MIS FORM FIT                           *CONDOMS - MALE***                              Contraceptives                    30
  LIFESTYLES MIS LUBRICAT                           *CONDOMS - MALE***                              Contraceptives                    30
    LIFESTYLES MIS RIBBED                           *CONDOMS - MALE***                              Contraceptives                    30
 LIFESTYLES MIS SPERM/LU                            *CONDOMS - MALE***                              Contraceptives                    30
  LIFESTYLES MIS STUDDED                            *CONDOMS - MALE***                              Contraceptives                    30
  LIFESTYLES MIS ULT/SENS                           *CONDOMS - MALE***                              Contraceptives                    30
  LIFESTYLES MIS VIBRA-RI                           *CONDOMS - MALE***                              Contraceptives                    30
 LIFESTYLES MIS XPLEASUR                            *CONDOMS - MALE***                              Contraceptives                    30
                                                                                                                                          Max Qty
                                                                                                                                            Limit   Max Max Age
                                                                                                                                          (Liquids Days    Limit    Step         Step Therapy     Specialty
    Drug/Product Name                                Generic Name                                          Therapy Class                   in mLs) Supply (Years) Required?      Requirement        Drug         Coverage Status
       LINDANE LOT 1%                               LINDANE LOTION 1%                                Scabicides and Pediculicides                   30                                                        Prior Authorization Req'd
       LINDANE SHA 1%                             LINDANE SHAMPOO 1%                                 Scabicides and Pediculicides                   30                                                        Prior Authorization Req'd
  LIORESAL INT INJ 0.05MG/1        BACLOFEN INTRATHECAL INJ 0.05 MG/ML (50 MCG/ML)          GABA DERIVATIVE SKELETAL MUSCLE RELAXANTS               30                                                        Prior Authorization Req'd
  LIORESAL INT INJ 10MG/20        BACLOFEN INTRATHECAL INJ 10 MG/20ML (500 MCG/ML)          GABA DERIVATIVE SKELETAL MUSCLE RELAXANTS               30                                                        Prior Authorization Req'd
 LIORESAL INT INJ 10MG/5ML        BACLOFEN INTRATHECAL INJ 10 MG/5ML (2000 MCG/ML)          GABA DERIVATIVE SKELETAL MUSCLE RELAXANTS               30                                                        Prior Authorization Req'd
  LIORESAL INT INJ 40MG/20        BACLOFEN INTRATHECAL INJ 40 MG/20ML (2000 MCG/ML)         GABA DERIVATIVE SKELETAL MUSCLE RELAXANTS               30                                                        Prior Authorization Req'd
  LIOTHYRONINE TAB 25MCG                   LIOTHYRONINE SODIUM TAB 25 MCG                                   Thyroid Agents                          30
  LIOTHYRONINE TAB 50MCG                   LIOTHYRONINE SODIUM TAB 50 MCG                                   Thyroid Agents                          30
   LIOTHYRONINE TAB 5MCG                    LIOTHYRONINE SODIUM TAB 5 MCG                                   Thyroid Agents                          30
      LIPITOR TAB 10MG            ATORVASTATIN CALCIUM TAB 10 MG (BASE EQUIVALENT)                  HMG-CoA Reductase Inhibitors            16      30                                                        Prior Authorization Req'd
      LIPITOR TAB 20MG            ATORVASTATIN CALCIUM TAB 20 MG (BASE EQUIVALENT)                  HMG-CoA Reductase Inhibitors            16      30                                                        Prior Authorization Req'd
      LIPITOR TAB 40MG            ATORVASTATIN CALCIUM TAB 40 MG (BASE EQUIVALENT)                  HMG-CoA Reductase Inhibitors            16      30                                                        Prior Authorization Req'd
      LIPITOR TAB 80MG            ATORVASTATIN CALCIUM TAB 80 MG (BASE EQUIVALENT)                  HMG-CoA Reductase Inhibitors            16      30                                                        Prior Authorization Req'd
        LIPRAM-PN10 CAP          AMY-LIP-PROT DR PARTICLES CAP 30000-10000-30000 UNIT                         Digestants                            30
        LIPRAM-UL20 CAP          AMY-LIP-PROT DR PARTICLES CAP 65000-20000-65000 UNIT                         Digestants                            30
LIQ ANTACID SUS MINT CRM       ALUMINUM & MAGNESIUM HYDROXIDES SUSP 225-200 MG/5ML                     Antacids and Adsorbents              480     30
    LIQ ANTACID SUS X-STR     ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 500-450-40 MG/5ML                  Antacids and Adsorbents              480     30
  LIQUICET SOL 10-500MG           HYDROCODONE-ACETAMINOPHEN SOLN 10-500 MG/15ML                            Opiate Agonists                  480     30
   LISINOP/HCTZ TAB 10-12.5        LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 10-12.5 MG             Angiotensin-Converting Enzyme Inhibitors             30
   LISINOP/HCTZ TAB 20-12.5        LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-12.5 MG             Angiotensin-Converting Enzyme Inhibitors             30
 LISINOP/HCTZ TAB 20-25MG           LISINOPRIL & HYDROCHLOROTHIAZIDE TAB 20-25 MG              Angiotensin-Converting Enzyme Inhibitors             30
     LISINOPRIL TAB 10MG                           LISINOPRIL TAB 10 MG                        Angiotensin-Converting Enzyme Inhibitors             30
     LISINOPRIL TAB 2.5MG                          LISINOPRIL TAB 2.5 MG                       Angiotensin-Converting Enzyme Inhibitors             30
     LISINOPRIL TAB 20MG                           LISINOPRIL TAB 20 MG                        Angiotensin-Converting Enzyme Inhibitors             30
     LISINOPRIL TAB 30MG                           LISINOPRIL TAB 30 MG                        Angiotensin-Converting Enzyme Inhibitors             30
     LISINOPRIL TAB 40MG                           LISINOPRIL TAB 40 MG                        Angiotensin-Converting Enzyme Inhibitors             30
      LISINOPRIL TAB 5MG                            LISINOPRIL TAB 5 MG                        Angiotensin-Converting Enzyme Inhibitors             30
         LISTERMINT SOL                       SODIUM FLUORIDE RINSE 0.02%                         Miscellaneous Therapeutic Agents                  30      18
        LO LOESTRIN TAB        NORETHIN-ETH ESTRADIOL-FE TAB 1 MG-10 MCG (24)/10 MCG (2)                    Contraceptives                          30
 LO-DOSE ASA TAB 81MG EC                   ASPIRIN TAB DELAYED RELEASE 81 MG                                   Salicylates                  31      30
       LOESTRIN 24 TAB FE     NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG (24)                   Contraceptives                          30
     LOFENE      TAB 2.5MG            DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG                         Antidiarrhea Agents                240     30
     LONOX       TAB 2.5MG            DIPHENOXYLATE W/ ATROPINE TAB 2.5-0.025 MG                         Antidiarrhea Agents                240     30
    LOPERAMIDE CAP 2MG                          LOPERAMIDE HCL CAP 2 MG                                  Antidiarrhea Agents                240     30
 LOPERAMIDE LIQ 1MG/5ML                 LOPERAMIDE HCL LIQ 1 MG/5ML (0.2 MG/ML)                          Antidiarrhea Agents                180     30
LOPERAMIDE LIQ 2MG/10ML                 LOPERAMIDE HCL LIQ 1 MG/5ML (0.2 MG/ML)                          Antidiarrhea Agents                180     30
    LOPERAMIDE TAB 2MG                          LOPERAMIDE HCL TAB 2 MG                                  Antidiarrhea Agents                 31     30
      LOPID     TAB 600MG                        GEMFIBROZIL TAB 600 MG                                 Fibric Acid Derivatives                     30
   LORADAMED TAB 10MG                             LORATADINE TAB 10 MG                            Second Generation Antihistamines                  30
 LORATADINE SOL 5MG/5ML                        LORATADINE SYRUP 5 MG/5ML                          Second Generation Antihistamines                  30
  LORATADINE SYP 10/10ML                       LORATADINE SYRUP 5 MG/5ML                          Second Generation Antihistamines                  30
 LORATADINE SYP 5MG/5ML                        LORATADINE SYRUP 5 MG/5ML                          Second Generation Antihistamines                  30
  LORATADINE SYP ALLG REL                      LORATADINE SYRUP 5 MG/5ML                          Second Generation Antihistamines                  30
    LORATADINE TAB 10MG                           LORATADINE TAB 10 MG                            Second Generation Antihistamines                  30
 LORATADINE TAB ALLG REL             LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG                  Second Generation Antihistamines                  30
 LORATADINE TAB DISINTEG             LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG                  Second Generation Antihistamines                  30




                                                                                                                                                                               USE FORMULARY
                                                                                                                                                                              GENERIC ACE INHIB
 LOSARTAN POT TAB 100MG                     LOSARTAN POTASSIUM TAB 100 MG                         Angiotensin II Receptor Antagonists               30                Y              1ST




                                                                                                                                                                               USE FORMULARY
                                                                                                                                                                              GENERIC ACE INHIB
 LOSARTAN POT TAB 25MG                      LOSARTAN POTASSIUM TAB 25 MG                          Angiotensin II Receptor Antagonists               30                Y              1ST




                                                                                                                                                                               USE FORMULARY
                                                                                                                                                                              GENERIC ACE INHIB
 LOSARTAN POT TAB 50MG                      LOSARTAN POTASSIUM TAB 50 MG                          Angiotensin II Receptor Antagonists               30                Y              1ST
                                                                                                                                    Max Qty
                                                                                                                                      Limit   Max Max Age
                                                                                                                                    (Liquids Days    Limit    Step       Step Therapy     Specialty
    Drug/Product Name                                 Generic Name                                     Therapy Class                 in mLs) Supply (Years) Required?    Requirement        Drug         Coverage Status




                                                                                                                                                                        USE FORMULARY
                                                                                                                                                                          GENERIC ACE
 LOSARTAN/HCT TAB 100-12.5    LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-12.5 MG        Angiotensin II Receptor Antagonists             30                Y        INHIB/HCTZ 1ST




                                                                                                                                                                        USE FORMULARY
                                                                                                                                                                          GENERIC ACE
 LOSARTAN/HCT TAB 100-25       LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 100-25 MG         Angiotensin II Receptor Antagonists             30                Y        INHIB/HCTZ 1ST




                                                                                                                                                                        USE FORMULARY
                                                                                                                                                                          GENERIC ACE
 LOSARTAN/HCT TAB 50-12.5       LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TAB 50-12.5 MG       Angiotensin II Receptor Antagonists             30                Y        INHIB/HCTZ 1ST
       LOSEASONIQUE TAB         LEVONORG-ETH EST TAB 0.1-0.02MG(84) & ETH EST TAB 0.01MG(7)             Contraceptives                91      91
    LOVASTATIN TAB 10MG                           LOVASTATIN TAB 10 MG                          HMG-CoA Reductase Inhibitors                  30
    LOVASTATIN TAB 20MG                           LOVASTATIN TAB 20 MG                          HMG-CoA Reductase Inhibitors                  30
    LOVASTATIN TAB 40MG                           LOVASTATIN TAB 40 MG                          HMG-CoA Reductase Inhibitors                  30
 LOVENOX INJ 100MG/ML                        ENOXAPARIN SODIUM INJ 100 MG/ML                               Heparins                            7
    LOVENOX INJ 120/0.8                    ENOXAPARIN SODIUM INJ 120 MG/0.8ML                              Heparins                            7
 LOVENOX INJ 150MG/ML                        ENOXAPARIN SODIUM INJ 150 MG/ML                               Heparins                            7
   LOVENOX INJ 30/0.3ML                     ENOXAPARIN SODIUM INJ 30 MG/0.3ML                              Heparins                            7
   LOVENOX INJ 300/3ML                      ENOXAPARIN SODIUM INJ 300 MG/3ML                               Heparins                            7
   LOVENOX INJ 40/0.4ML                     ENOXAPARIN SODIUM INJ 40 MG/0.4ML                              Heparins                            7
   LOVENOX INJ 60/0.6ML                     ENOXAPARIN SODIUM INJ 60 MG/0.6ML                              Heparins                            7
   LOVENOX INJ 80/0.8ML                     ENOXAPARIN SODIUM INJ 80 MG/0.8ML                              Heparins                            7
   LOW DOSE ASA TAB 81MG                            ASPIRIN TAB 81 MG                                     Salicylates                 31      30
   LOW-DOSE ASP TAB 81MG                            ASPIRIN TAB 81 MG                                     Salicylates                 31      30
       LOW-OGESTREL TAB              NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG                   Contraceptives                        30
     LUBRICATING LOT SKIN                         *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                  30                                                      Prior Authorization Req'd
LUBRIDERM LOT ADVANCED                            *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                  30                                                      Prior Authorization Req'd
    LUBRIDERM LOT DAILY                           *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                  30                                                      Prior Authorization Req'd
 LUBRIDERM LOT FRG/FREE                           *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                  30                                                      Prior Authorization Req'd
 LUBRIDERM LOT LGHT/FRG                           *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                  30                                                      Prior Authorization Req'd
 LUBRIDERM LOT NOURISH                            *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                  30                                                      Prior Authorization Req'd
  LUBRIDERM LOT SCENTED                           *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                  30                                                      Prior Authorization Req'd
  LUBRIDERM LOT SENSITIV                          *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                  30                                                      Prior Authorization Req'd
  LUBRIDERM LOT SKIN REP                          *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                  30                                                      Prior Authorization Req'd
  LUBRIDERM DA LOT SPF 15                         *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                  30                                                      Prior Authorization Req'd
         LUBRISILK LOT                            *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                  30                                                      Prior Authorization Req'd
         LUBRISKIN LOT                            *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                  30                                                      Prior Authorization Req'd
 LUBRISOFT LOT UNSCENTE                           *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                  30                                                      Prior Authorization Req'd
  LUDENT       CHW 0.25MG F       SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF)       Miscellaneous Therapeutic Agents                30
   LUDENT       CHW 0.5MG F        SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)        Miscellaneous Therapeutic Agents                30
     LUDENT      CHW 1MG F          SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)         Miscellaneous Therapeutic Agents                30
     LUMIGAN SOL 0.01%                        BIMATOPROST OPHTH SOLN 0.01%                       PROSTAGLANDIN ANALOGS                        30
     LUMIGAN SOL 0.03%                        BIMATOPROST OPHTH SOLN 0.03%                       PROSTAGLANDIN ANALOGS                        30
          LUTERA    TAB           LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG                  Contraceptives                        30
      LUXIQ      AER 0.12%             BETAMETHASONE VALERATE AEROSOL FOAM 0.12%                  Anti-inflammatory Agents                    30                                                      Prior Authorization Req'd
   LYBREL      TAB 90-20MCG   LEVONORGESTREL-ETHINYL ESTRADIOL (CONTINUOUS) TAB 90-20 MCG               Contraceptives                        30
    LYSODREN TAB 500MG                             MITOTANE TAB 500 MG                              Antineoplastic Agents                     30
 MAALOX        SUS ADVANCED    ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML             Antacids and Adsorbents            480     30
 MAALOX ADVAN SUS MAX ST       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML             Antacids and Adsorbents            480     30
       MAALOX MAX SUS          ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 500-450-40 MG/5ML             Antacids and Adsorbents            480     30
 MAALOX MAX SUS CHERRY         ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML             Antacids and Adsorbents            480     30
  MAALOX MAX SUS LEMON         ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML             Antacids and Adsorbents            480     30
   MAALOX MAX SUS MINT         ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML             Antacids and Adsorbents            480     30
 MAALOX MAX SUS VANILLA        ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML             Antacids and Adsorbents            480     30
MAALOX MAX SUS WILD BRY        ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML             Antacids and Adsorbents            480     30
MAALOX MULTI SUS SYMP MAX      ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML             Antacids and Adsorbents            480     30
 MAALOX PLUS SUS X-S CHER      ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 500-450-40 MG/5ML             Antacids and Adsorbents            480     30
                                                                                                                                        Max Qty
                                                                                                                                          Limit   Max Max Age
                                                                                                                                        (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                              Generic Name                                         Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
MAALOX PLUS SUS X-S LEMN      ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 500-450-40 MG/5ML               Antacids and Adsorbents              480      30
MAALOX PLUS SUS X-S MINT      ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 500-450-40 MG/5ML               Antacids and Adsorbents              480      30
     MAALOX REG SUS           ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 225-200-25 MG/5ML               Antacids and Adsorbents              480      30
MAALOX REG SUS STRENGTH       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML               Antacids and Adsorbents              480      30
     MAALOX TC SUS             ALUMINUM & MAGNESIUM HYDROXIDES CONC 600-300 MG/5ML                  Antacids and Adsorbents              480      30
MAALOX TOTAL SUS 525/15ML                BISMUTH SUBSALICYLATE SUSP 525 MG/15ML                        Antidiarrhea Agents               1800     30
 MACRODANTIN CAP 25MG                 NITROFURANTOIN MACROCRYSTALLINE CAP 25 MG                      Urinary Anti-infectives                      30
     MAG-AL PLUS LIQ          ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML               Antacids and Adsorbents               480     30
    MAG-AL PLUS LIQ XS        ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML               Antacids and Adsorbents               480     30
     MALDROXAL SUS             ALUMINUM & MAGNESIUM HYDROXIDES SUSP 225-200 MG/5ML                  Antacids and Adsorbents               480     30
   MAPAP     CAP 500MG                          ACETAMINOPHEN CAP 500 MG                        Analgesics and Antipyretics, Misc         250     30
   MAPAP      CHW 80MG                        ACETAMINOPHEN CHEW TAB 80 MG                      Analgesics and Antipyretics, Misc          60     30
  MAPAP     DRO 80/0.8ML                     ACETAMINOPHEN SUSP 80 MG/0.8ML                     Analgesics and Antipyretics, Misc          30     30
  MAPAP      LIQ 160/5ML                    ACETAMINOPHEN LIQUID 160 MG/5ML                     Analgesics and Antipyretics, Misc         240     30
   MAPAP      TAB 325MG                         ACETAMINOPHEN TAB 325 MG                        Analgesics and Antipyretics, Misc         250     30
   MAPAP      TAB 500MG                         ACETAMINOPHEN TAB 500 MG                        Analgesics and Antipyretics, Misc         250     30
 MAPAP     TAB 500MG/RR                         ACETAMINOPHEN TAB 500 MG                        Analgesics and Antipyretics, Misc         250     30
MAPAP APAP LIQ 500/15ML                     ACETAMINOPHEN LIQUID 167 MG/5ML                     Analgesics and Antipyretics, Misc         240     30
 MAPAP ARTHRI TAB 650MG                        ACETAMINOPHEN TAB CR 650 MG                      Analgesics and Antipyretics, Misc         120     30
 MAPAP CHILD SUS 160/5ML                     ACETAMINOPHEN SUSP 160 MG/5ML                      Analgesics and Antipyretics, Misc         240     30
     MARGESIC CAP                BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-325-40 MG             Analgesics and Antipyretics, Misc          20     30
 MARGESIC-H CAP 500-5MG                HYDROCODONE-ACETAMINOPHEN CAP 5-500 MG                            Opiate Agonists                  150     30
  MARTEN-TAB TAB 50-325                 BUTALBITAL-ACETAMINOPHEN TAB 50-325 MG                  Analgesics and Antipyretics, Misc          20     30
  MASANTI SUS ANTACID         ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML               Antacids and Adsorbents               480     30
 MASANTI SUS CH CREME         ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML               Antacids and Adsorbents               480     30
      MASANTI II SUS          ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML               Antacids and Adsorbents               480     30
  MASOPHEN TAB 500MG                            ACETAMINOPHEN TAB 500 MG                        Analgesics and Antipyretics, Misc         250     30
     MATERNITY TAB                *PRENATAL VIT W/ SEL-FE FUMARATE-FA TAB 27-1 MG***               Multivitamin Preparations                      30      40
    MATERNITY-90 TAB         *PRENATAL MULTIVITAMINS & MINERALS W/ IRON & FA TAB 1 MG***           Multivitamin Preparations                      30
  MATULANE CAP 50MG                             PROCARBAZINE HCL CAP 50 MG                            Antineoplastic Agents                       30
MAXAIR AUTOH AER 200MCG     PIRBUTEROL ACETATE BREATH ACTIVATED INHAL AEROSOL 200MCG/INH      Selective beta-2-Adrenergic Agonists        28      30
      MAXAM       LOT                               *EMOLLIENT - LOTION**                         Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
 MAXAPAP MS TAB 500MG                           ACETAMINOPHEN TAB 500 MG                        Analgesics and Antipyretics, Misc         250     30
  MAXAPAP RS TAB 325MG                          ACETAMINOPHEN TAB 325 MG                        Analgesics and Antipyretics, Misc         250     30
    MAXARON FORT CAP              *FE BISGLYCINATE-FE POLYSACCH-VIT C-VIT B12-FA CAP***                 Iron Preparations                         30
 MAXIFED TAB 60-400MG                 PSEUDOEPHEDRINE-GUAIFENESIN TAB 60-400 MG                            Expectorants                           30
MAX-ST STRES SUS 690/30ML                BISMUTH SUBSALICYLATE SUSP 690 MG/30ML                        Antidiarrhea Agents               1800     30
  MAXX      MIS LUBRICAT                         CONDOMS LATEX LUBRICATED                                 Contraceptives                          30
 MAXX PLUS MIS SPERMICI                          CONDOMS LATEX LUBRICATED                                 Contraceptives                          30
     M-CLEAR WC LIQ                     GUAIFENESIN-CODEINE SOLN 100-6.3 MG/5ML                            Antitussives                   180     30
MEBENDAZOLE CHW 100MG                          MEBENDAZOLE CHEW TAB 100 MG                                Anthelmintics                           30
  MECLIZINE TAB 12.5MG                            MECLIZINE HCL TAB 12.5 MG                               Antihistamines                          30
   MECLIZINE TAB 25MG                              MECLIZINE HCL TAB 25 MG                                Antihistamines                          30
  MED-DERM HC CRE 0.5%                          HYDROCORTISONE CREAM 0.5%                          Anti-inflammatory Agents                       30
   MED-DERM HC CRE 1%                            HYDROCORTISONE CREAM 1%                           Anti-inflammatory Agents                       30
MEDI-BISMUTH CHW 262MG                   BISMUTH SUBSALICYLATE CHEW TAB 262 MG                         Antidiarrhea Agents                120     30
    MEDI-CORT CRE 1%                        HYDROCORTISONE ACETATE CREAM 1%                        Anti-inflammatory Agents                30     30
     MEDIGESIC CAP               BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-325-40 MG             Analgesics and Antipyretics, Misc          20     30
MEDI-NATURAL TAB 8.6-50MG              SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                     Cathartics and Laxatives              100     30
  MEDI-PHEDRIN TAB 30MG                       PSEUDOEPHEDRINE HCL TAB 30 MG                   alpha- and beta-Adrenergic Agonists         120     30
  MEDI-PHEDRYL CAP 25MG                       DIPHENHYDRAMINE HCL CAP 25 MG                        Ethanolamine Derivatives                       30
 MEDI-PROFEN CAP 200MG                              IBUPROFEN CAP 200 MG                   Other Nonsteroidal Anti-inflammtory Agents     100     30
 MEDI-PROFEN SUS 100/5ML                        IBUPROFEN SUSP 100 MG/5ML                  Other Nonsteroidal Anti-inflammtory Agents             30      18
MEDI-PROFEN SUS 40MG/ML                           IBUPROFEN SUSP 40 MG/ML                  Other Nonsteroidal Anti-inflammtory Agents             30      18
 MEDI-PROFEN TAB 200MG                              IBUPROFEN TAB 200 MG                     Nonsteroidal Anti-inflammatory Agents                30
 MEDI-TABS DRO 80/0.8ML                      ACETAMINOPHEN SUSP 80 MG/0.8ML                     Analgesics and Antipyretics, Misc          30     30
 MEDI-TABS ELX 80/2.5ML                     ACETAMINOPHEN ELIXIR 160 MG/5ML                     Analgesics and Antipyretics, Misc         240     30
  MEDI-TABS TAB 325MG                           ACETAMINOPHEN TAB 325 MG                        Analgesics and Antipyretics, Misc         250     30
  MEDI-TABS TAB 500MG                           ACETAMINOPHEN TAB 500 MG                        Analgesics and Antipyretics, Misc         250     30
 MEDI-TABS JR CHW 160MG                      ACETAMINOPHEN CHEW TAB 160 MG                      Analgesics and Antipyretics, Misc          60     30
 MEDI-TUSS DM LIQ DBL STR        DEXTROMETHORPHAN-GUAIFENESIN LIQUID 30-200 MG/5ML                         Antitussives                   180     30
MEDI-TUSS DM LIQ DIABETIC        DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                         Antitussives                   180     30
MEDI-TUSSIN CAP SEV CONG              PSEUDOEPHEDRINE-GUAIFENESIN CAP 30-200 MG                            Expectorants                           30
 MEDI-TUSSIN SYP 100/5ML                       GUAIFENESIN SYRUP 100 MG/5ML                                Expectorants                           30
   MEDI-TUSSIN SYP DM            DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                          Antitussives                   180     30
                                                                                                                         Max Qty
                                                                                                                           Limit   Max Max Age
                                                                                                                         (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                         Generic Name                                 Therapy Class                  in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
    MEDROL     TAB 2MG                 METHYLPREDNISOLONE TAB 2 MG                              Adrenals                           30
MEDROXYPR AC INJ 150MG/ML     MEDROXYPROGESTERONE ACETATE IM SUSP 150 MG/ML                    Progestins                   1      90
  MEDROXYPR AC TAB 10MG          MEDROXYPROGESTERONE ACETATE TAB 10 MG                         Progestins                          30
  MEDROXYPR AC TAB 2.5MG         MEDROXYPROGESTERONE ACETATE TAB 2.5 MG                        Progestins                          30
  MEDROXYPR AC TAB 5MG            MEDROXYPROGESTERONE ACETATE TAB 5 MG                         Progestins                          30
 MEGESTROL POW ACETATE                  MEGESTROL ACETATE POWDER                         Pharmaceutical Aids                       30                                                   Prior Authorization Req'd
MEGESTROL AC SUS 400MG/10           MEGESTROL ACETATE SUSP 40 MG/ML                      Antineoplastic Agents                     30                                                   Prior Authorization Req'd
MEGESTROL AC SUS 40MG/ML            MEGESTROL ACETATE SUSP 40 MG/ML                      Antineoplastic Agents                     30                                                   Prior Authorization Req'd
MEGESTROL AC SUS 800MG/20           MEGESTROL ACETATE SUSP 40 MG/ML                      Antineoplastic Agents                     30                                                   Prior Authorization Req'd
  MEGESTROL AC TAB 20MG                MEGESTROL ACETATE TAB 20 MG                       Antineoplastic Agents                     30                                                   Prior Authorization Req'd
  MEGESTROL AC TAB 40MG                MEGESTROL ACETATE TAB 40 MG                       Antineoplastic Agents                     30                                                   Prior Authorization Req'd
    MENEST    TAB 0.3MG               ESTERIFIED ESTROGENS TAB 0.3 MG                          Estrogens                           30
   MENEST    TAB 0.625MG             ESTERIFIED ESTROGENS TAB 0.625 MG                         Estrogens                           30
   MENEST     TAB 1.25MG             ESTERIFIED ESTROGENS TAB 1.25 MG                          Estrogens                           30
    MENEST    TAB 2.5MG               ESTERIFIED ESTROGENS TAB 2.5 MG                          Estrogens                           30
   MEPHYTON TAB 5MG                       PHYTONADIONE TAB 5 MG                            Vitamin K Activity                      30
  MERCAPTOPUR TAB 50MG                   MERCAPTOPURINE TAB 50 MG                        Antineoplastic Agents                     30
  MERCAPTOPURI POW USP                  *BULK CHEMICALS - POWDER**                       Pharmaceutical Aids                       30
   MESALAMINE ENE 4GM                     MESALAMINE ENEMA 4 GM                       Anti-inflammatory Agents                     30
   MESNEX     TAB 400MG                      MESNA TAB 400 MG                     Miscellaneous Therapeutic Agents                 30
  METAPROTEREN NEB 0.4%           METAPROTERENOL SULFATE SOLN NEBU 0.4%          Selective beta-2-Adrenergic Agonists      125     30
  METAPROTEREN NEB 0.6%           METAPROTERENOL SULFATE SOLN NEBU 0.6%          Selective beta-2-Adrenergic Agonists      125     30
METAPROTEREN SYP 10MG/5ML        METAPROTERENOL SULFATE SYRUP 10 MG/5ML          Selective beta-2-Adrenergic Agonists              30      18
  METFORMIN TAB 1000MG                  METFORMIN HCL TAB 1000 MG                              Biguanides                          30
  METFORMIN TAB 500MG                    METFORMIN HCL TAB 500 MG                              Biguanides                          30
 METFORMIN TAB 500MG ER             METFORMIN HCL TAB SR 24HR 500 MG                           Biguanides                          30
 METFORMIN TAB 750MG ER             METFORMIN HCL TAB SR 24HR 750 MG                           Biguanides                          30
  METFORMIN TAB 850MG                    METFORMIN HCL TAB 850 MG                              Biguanides                          30
  METHADEX SUS 0.1% OP      NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH SUSP 0.1%                Corticosteroids                        30
  METHADONE TAB 10MG                     METHADONE HCL TAB 10 MG                            Opiate Agonists                90      30
  METHADONE TAB 40MG              METHADONE HCL TAB FOR ORAL SUSP 40 MG                     Opiate Agonists                90      30
   METHADONE TAB 5MG                      METHADONE HCL TAB 5 MG                            Opiate Agonists                90      30
   METHADOSE TAB 10MG                    METHADONE HCL TAB 10 MG                            Opiate Agonists                90      30
   METHADOSE TAB 40MG             METHADONE HCL TAB FOR ORAL SUSP 40 MG                     Opiate Agonists                90      30
   METHADOSE TAB 5MG                      METHADONE HCL TAB 5 MG                            Opiate Agonists                90      30
  METHAZOLAMID TAB 25MG                  METHAZOLAMIDE TAB 25 MG                  CARBONIC ANYDRASE INHIBITORS                     30
  METHAZOLAMID TAB 50MG                  METHAZOLAMIDE TAB 50 MG                  CARBONIC ANYDRASE INHIBITORS                     30
  METHIMAZOLE TAB 10MG                    METHIMAZOLE TAB 10 MG                           Antithyroid Agents                       30
   METHIMAZOLE TAB 5MG                     METHIMAZOLE TAB 5 MG                           Antithyroid Agents                       30
   METHITEST TAB 10MG              METHYLTESTOSTERONE ORAL TAB 10 MG                           Androgens                           30                                                   Prior Authorization Req'd
METHOTREXATE INJ 1GM/40ML          METHOTREXATE SODIUM INJ PF 25 MG/ML                   Antineoplastic Agents                     30
METHOTREXATE INJ 250MG/10          METHOTREXATE SODIUM INJ PF 25 MG/ML                   Antineoplastic Agents                     30
METHOTREXATE INJ 25MG/ML            METHOTREXATE SODIUM INJ 25 MG/ML                     Antineoplastic Agents                     30
METHOTREXATE INJ 50MG/2ML          METHOTREXATE SODIUM INJ PF 25 MG/ML                   Antineoplastic Agents                     30
    METHOTREXATE POW                       METHOTREXATE POWDER                           Pharmaceutical Aids                       30                                                   Prior Authorization Req'd
 METHOTREXATE TAB 2.5MG         METHOTREXATE SODIUM TAB 2.5 MG (BASE EQUIV)              Antineoplastic Agents                     30
  METHYLDOPA TAB 250MG                    METHYLDOPA TAB 250 MG                         Central Alpha-Agonists                     30
  METHYLDOPA TAB 500MG                    METHYLDOPA TAB 500 MG                         Central Alpha-Agonists                     30
  METHYLDOPA TAB 125MG                    METHYLDOPA TAB 125MG                          Central Alpha-Agonists                     30
   METHYLIN CHW 10MG               METHYLPHENIDATE HCL CHEW TAB 10 MG          Anorexigenics & Resp & Cereb Stim, Misc    180      30      20                                           Prior Authorization Req'd
   METHYLIN CHW 2.5MG              METHYLPHENIDATE HCL CHEW TAB 2.5 MG         Anorexigenics & Resp & Cereb Stim, Misc    180      30      20                                           Prior Authorization Req'd
    METHYLIN CHW 5MG               METHYLPHENIDATE HCL CHEW TAB 5 MG           Anorexigenics & Resp & Cereb Stim, Misc    180      30      20                                           Prior Authorization Req'd
 METHYLIN SOL 10MG/5ML             METHYLPHENIDATE HCL SOLN 10 MG/5ML          Anorexigenics & Resp & Cereb Stim, Misc    900      30      20                                           Prior Authorization Req'd
  METHYLIN SOL 5MG/5ML             METHYLPHENIDATE HCL SOLN 5 MG/5ML           Anorexigenics & Resp & Cereb Stim, Misc    1800     30      20                                           Prior Authorization Req'd
   METHYLIN TAB 10MG                  METHYLPHENIDATE HCL TAB 10 MG            Anorexigenics & Resp & Cereb Stim, Misc     90      30      20
   METHYLIN TAB 20MG                  METHYLPHENIDATE HCL TAB 20 MG            Anorexigenics & Resp & Cereb Stim, Misc     90      30      20
    METHYLIN TAB 5MG                   METHYLPHENIDATE HCL TAB 5 MG            Anorexigenics & Resp & Cereb Stim, Misc     90      30      20
   METHYLIN ER TAB 10MG             METHYLPHENIDATE HCL TAB CR 10 MG           Anorexigenics & Resp & Cereb Stim, Misc     90      30      20
   METHYLIN ER TAB 20MG             METHYLPHENIDATE HCL TAB CR 20 MG           Anorexigenics & Resp & Cereb Stim, Misc     90      30      20
METHYLPHENID SOL 10MG/5ML          METHYLPHENIDATE HCL SOLN 10 MG/5ML          Anorexigenics & Resp & Cereb Stim, Misc    900      30      20                                           Prior Authorization Req'd
METHYLPHENID SOL 5MG/5ML           METHYLPHENIDATE HCL SOLN 5 MG/5ML           Anorexigenics & Resp & Cereb Stim, Misc    1800     30      20                                           Prior Authorization Req'd
  METHYLPHENID TAB 10MG               METHYLPHENIDATE HCL TAB 10 MG            Anorexigenics & Resp & Cereb Stim, Misc     90      30      20
  METHYLPHENID TAB 20MG               METHYLPHENIDATE HCL TAB 20 MG            Anorexigenics & Resp & Cereb Stim, Misc     90      30      20
 METHYLPHENID TAB 20MG CR           METHYLPHENIDATE HCL TAB CR 20 MG           Anorexigenics & Resp & Cereb Stim, Misc     90      30      20
 METHYLPHENID TAB 20MG ER           METHYLPHENIDATE HCL TAB CR 20 MG           Anorexigenics & Resp & Cereb Stim, Misc     90      30      20
                                                                                                                                       Max Qty
                                                                                                                                         Limit   Max Max Age
                                                                                                                                       (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                              Generic Name                                        Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
METHYLPHENID TAB 20MG SR                  METHYLPHENIDATE HCL TAB CR 20 MG                 Anorexigenics & Resp & Cereb Stim, Misc       90      30      20
  METHYLPHENID TAB 5MG                      METHYLPHENIDATE HCL TAB 5 MG                   Anorexigenics & Resp & Cereb Stim, Misc       90      30      20
   METHYLPRED PAK 4MG                  METHYLPREDNISOLONE TAB 4 MG DOSE PACK                                 Adrenals                            30
  METHYLPRED TAB 16MG                       METHYLPREDNISOLONE TAB 16 MG                                     Adrenals                            30
  METHYLPRED TAB 32MG                       METHYLPREDNISOLONE TAB 32 MG                                     Adrenals                            30
   METHYLPRED TAB 4MG                       METHYLPREDNISOLONE TAB 4 MG                                      Adrenals                            30
   METHYLPRED TAB 8MG                       METHYLPREDNISOLONE TAB 8 MG                                      Adrenals                            30
  METIPRANOLOL SOL 0.3%                     METIPRANOLOL OPHTH SOLN 0.3%                    BETA ADRENERGIC BLOCKING AGENTS                      30
METIPRANOLOL SOL 0.3% OPH                   METIPRANOLOL OPHTH SOLN 0.3%                    BETA ADRENERGIC BLOCKING AGENTS                      30
METOCLOPRAM SOL 10/10ML            METOCLOPRAMIDE HCL SOLN 5 MG/5ML (10 MG/10ML)                       Prokinetic Agents                         30      18
METOCLOPRAM SOL 1MG/1ML            METOCLOPRAMIDE HCL SOLN 5 MG/5ML (10 MG/10ML)                       Prokinetic Agents                         30      18
METOCLOPRAM SOL 5MG/5ML            METOCLOPRAMIDE HCL SOLN 5 MG/5ML (10 MG/10ML)                       Prokinetic Agents                         30      18
METOCLOPRAM SYP 5MG/5ML                  METOCLOPRAMIDE HCL SYRUP 5 MG/5ML                             Prokinetic Agents                         30      18
 METOCLOPRAM TAB 10MG                       METOCLOPRAMIDE HCL TAB 10 MG                               Prokinetic Agents                         30
  METOCLOPRAM TAB 5MG                       METOCLOPRAMIDE HCL TAB 5 MG                                Prokinetic Agents                         30
  METOLAZONE TAB 10MG                            METOLAZONE TAB 10 MG                                Thiazide-like Diuretics                     30
  METOLAZONE TAB 2.5MG                          METOLAZONE TAB 2.5 MG                                Thiazide-like Diuretics                     30
  METOLAZONE TAB 5MG                             METOLAZONE TAB 5 MG                                 Thiazide-like Diuretics                     30
 METOPROL TAR TAB 100MG                    METOPROLOL TARTRATE TAB 100 MG                      Beta-Adrenergic Blocking Agents                   30
  METOPROL TAR TAB 25MG                     METOPROLOL TARTRATE TAB 25 MG                      Beta-Adrenergic Blocking Agents                   30
  METOPROL TAR TAB 50MG                     METOPROLOL TARTRATE TAB 50 MG                      Beta-Adrenergic Blocking Agents                   30
METOPROLOL TAB 100MG ER               METOPROLOL SUCCINATE TAB SR 24HR 100 MG                  Beta-Adrenergic Blocking Agents                   30
METOPROLOL TAB 200MG ER               METOPROLOL SUCCINATE TAB SR 24HR 200 MG                  Beta-Adrenergic Blocking Agents                   30
 METOPROLOL TAB 25MG ER                METOPROLOL SUCCINATE TAB SR 24HR 25 MG                  Beta-Adrenergic Blocking Agents                   30
 METOPROLOL TAB 50MG ER                METOPROLOL SUCCINATE TAB SR 24HR 50 MG                  Beta-Adrenergic Blocking Agents                   30
 METROGEL-VAG GEL 0.75%                    METRONIDAZOLE VAGINAL GEL 0.75%                               Antibacterials                  70      30
METRONIDAZOL GEL 0.75%VAG                  METRONIDAZOLE VAGINAL GEL 0.75%                               Antibacterials                  70      30
 METRONIDAZOL TAB 250MG                       METRONIDAZOLE TAB 250 MG                           Antiprotozoals, Miscellaneous                   30
 METRONIDAZOL TAB 500MG                       METRONIDAZOLE TAB 500 MG                           Antiprotozoals, Miscellaneous                   30
  MEXILETINE CAP 150MG                         MEXILETINE HCL CAP 150 MG                           Class Ib Antiarrhythmics                      30
  MEXILETINE CAP 200MG                         MEXILETINE HCL CAP 200 MG                           Class Ib Antiarrhythmics                      30
  MEXILETINE CAP 250MG                         MEXILETINE HCL CAP 250 MG                           Class Ib Antiarrhythmics                      30
  MIACALCIN INJ 200/ML                   CALCITONIN (SALMON) INJ 200 UNIT/ML                               Parathyroid                           30                                                   Prior Authorization Req'd
      MI-ACID SUS            ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML               Antacids and Adsorbents               480     30
   MI-ACID SUS MAX ST        ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML               Antacids and Adsorbents               480     30
 MICRHOGAM PL INJ 50MCG             RHO D IMMUNE GLOBULIN (HUMAN) IM INJ 50 MCG                              Serums                              30                                                   Prior Authorization Req'd
  MICROGESTIN TAB 1.5/30       NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1.5 MG-30 MCG                   Contraceptives                          30
   MICROGESTIN TAB 1/20         NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1 MG-20 MCG                    Contraceptives                          30
 MICROGESTIN TAB FE 1/20      NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1 MG-20 MCG                   Contraceptives                          30
 MICROGESTIN TAB FE1.5/30    NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TAB 1.5 MG-30 MCG                  Contraceptives                          30
 MIDOL CRAMP TAB MAX ST                          IBUPROFEN TAB 200 MG                     Other Nonsteroidal Anti-inflammtory Agents             30
      MIGQUIN CAP            ACETAMINOPHEN-ISOMETHEPTENE-DICHLORAL CAP 325-65-100 MG          Antimigraine Agents, Miscellaneous          6      30
     MIGRATINE CAP           ACETAMINOPHEN-ISOMETHEPTENE-DICHLORAL CAP 325-65-100 MG          Antimigraine Agents, Miscellaneous          6      30
     MIGRAZONE CAP           ACETAMINOPHEN-ISOMETHEPTENE-DICHLORAL CAP 325-65-100 MG          Antimigraine Agents, Miscellaneous          6      30
   MILANTEX SUS EX ST        ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML               Antacids and Adsorbents               480     30
 MILANTEX SUS ORIGINAL       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML               Antacids and Adsorbents               480     30
      MINERIN LOT                                *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
  MINIPRIN LOW TAB 81MG                    ASPIRIN TAB DELAYED RELEASE 81 MG                                Salicylates                  31      30
  MINITABS TAB 81MG EC                     ASPIRIN TAB DELAYED RELEASE 81 MG                                Salicylates                  31      30
 MINITRAN DIS 0.1MG/HR                  NITROGLYCERIN TD PATCH 24HR 0.1 MG/HR                         Nitrates and Nitrites                      30
 MINITRAN DIS 0.2MG/HR                  NITROGLYCERIN TD PATCH 24HR 0.2 MG/HR                         Nitrates and Nitrites                      30
 MINITRAN DIS 0.4MG/HR                  NITROGLYCERIN TD PATCH 24HR 0.4 MG/HR                         Nitrates and Nitrites                      30
 MINITRAN DIS 0.6MG/HR                  NITROGLYCERIN TD PATCH 24HR 0.6 MG/HR                         Nitrates and Nitrites                      30
   MINOXIDIL TAB 10MG                             MINOXIDIL TAB 10 MG                                 Direct Vasodilators                        30
   MINOXIDIL TAB 2.5MG                            MINOXIDIL TAB 2.5 MG                                Direct Vasodilators                        30
      MINTOX    SUS          ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML               Antacids and Adsorbents               480     30
   MINTOX    SUS MAX ST      ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML               Antacids and Adsorbents               480     30
MINTOX XTRA SUS STRENGTH     ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 500-450-40 MG/5ML               Antacids and Adsorbents               480     30
     MINTUSS HC SYP         PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 10-2-2.5 MG/5ML                      Antitussives                   178     30
  MINTUSS HD SYP 10-4-2.5   PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 10-4-2.5 MG/5ML                      Antitussives                   178     30
     MINTUSS MR LIQ           PHENYLEPH-PYRILAMINE W/ HYDROCODONE SYRUP 5-5-5 MG/5ML                      Antitussives                   178     30
  MINTUSS MS SYP 10-2-5      PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 10-2-5 MG/5ML                       Antitussives                   178     30
 MIRAPHEN PSE TAB 120-600        PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-600 MG                       Expectorants                    31     30
 MISOPROSTOL TAB 100MCG                        MISOPROSTOL TAB 100 MCG                                   Prostaglandins                          30
 MISOPROSTOL TAB 200MCG                        MISOPROSTOL TAB 200 MCG                                   Prostaglandins                          30
                                                                                                                                        Max Qty
                                                                                                                                          Limit   Max Max Age
                                                                                                                                        (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                               Generic Name                                        Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
  MM ASPIRIN TAB 325MG                               ASPIRIN TAB 325 MG                                    Salicylates                    31      30
   MOIST VIT E LOT /ALOE                           *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
      MOISTUREL LOT                                *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
     MOISTURIZING LOT                              *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
  MOISTURIZING LOT EX DRY                          *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
MOISTURIZING LOT OATMEAL                           *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
MOISTURIZING LOT XTRA-DRY                          *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
  MOMETASONE CRE 0.1%                      MOMETASONE FUROATE CREAM 0.1%                           Anti-inflammatory Agents                       30                                                   Prior Authorization Req'd
  MOMETASONE OIN 0.1%                        MOMETASONE FUROATE OINT 0.1%                          Anti-inflammatory Agents                       30                                                   Prior Authorization Req'd
  MOMETASONE SOL 0.1%                 MOMETASONE FUROATE SOLUTION 0.1% (LOTION)                    Anti-inflammatory Agents                       30                                                   Prior Authorization Req'd
    MONISTAT CRE 1%                             HYDROCORTISONE CREAM 1%                            Anti-inflammatory Agents                       30
     MONONESSA TAB               NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG                     Contraceptives                           30
MORPHINE SUL INJ 0.5MG/ML                  MORPHINE SULFATE INJ PF 0.5 MG/ML                            Opiate Agonists                           30                                                   Prior Authorization Req'd
 MORPHINE SUL INJ 10MG/ML                    MORPHINE SULFATE INJ 10 MG/ML                              Opiate Agonists                           30                                                   Prior Authorization Req'd
 MORPHINE SUL INJ 15MG/ML                    MORPHINE SULFATE INJ 15 MG/ML                              Opiate Agonists                           30                                                   Prior Authorization Req'd
 MORPHINE SUL INJ 1MG/ML                   MORPHINE SULFATE IV SOLN 1 MG/ML                             Opiate Agonists                           30                                                   Prior Authorization Req'd
 MORPHINE SUL INJ 25MG/ML                  MORPHINE SULFATE IV SOLN 25 MG/ML                            Opiate Agonists                           30                                                   Prior Authorization Req'd
 MORPHINE SUL INJ 4MG/ML                      MORPHINE SULFATE INJ 4 MG/ML                              Opiate Agonists                           30                                                   Prior Authorization Req'd
 MORPHINE SUL INJ 50MG/ML                  MORPHINE SULFATE IV SOLN 50 MG/ML                            Opiate Agonists                           30                                                   Prior Authorization Req'd
 MORPHINE SUL INJ 5MG/ML                   MORPHINE SULFATE IV SOLN 5 MG/ML                             Opiate Agonists                           30                                                   Prior Authorization Req'd
 MORPHINE SUL INJ 8MG/ML                      MORPHINE SULFATE INJ 8 MG/ML                              Opiate Agonists                           30                                                   Prior Authorization Req'd
MORPHINE SUL SOL 10/0.5ML        MORPHINE SULFATE (CONCENTRATE) ORAL SOLN 20 MG/ML                      Opiate Agonists                           30
MORPHINE SUL SOL 10MG/5ML                MORPHINE SULFATE ORAL SOLN 10 MG/5ML                           Opiate Agonists                           30
MORPHINE SUL SOL 20MG/10                 MORPHINE SULFATE ORAL SOLN 10 MG/5ML                           Opiate Agonists                           30
MORPHINE SUL SOL 20MG/5ML                MORPHINE SULFATE ORAL SOLN 20 MG/5ML                           Opiate Agonists                           30
MORPHINE SUL SOL 20MG/ML         MORPHINE SULFATE (CONCENTRATE) ORAL SOLN 20 MG/ML                      Opiate Agonists                           30
MORPHINE SUL SOL 5/0.25ML        MORPHINE SULFATE (CONCENTRATE) ORAL SOLN 20 MG/ML                      Opiate Agonists                           30
MORPHINE SUL TAB 100MG CR                 MORPHINE SULFATE TAB SR 12HR 100 MG                           Opiate Agonists                           30                                                   Prior Authorization Req'd
MORPHINE SUL TAB 100MG ER                 MORPHINE SULFATE TAB SR 12HR 100 MG                           Opiate Agonists                           30                                                   Prior Authorization Req'd
  MORPHINE SUL TAB 15MG                        MORPHINE SULFATE TAB 15 MG                               Opiate Agonists                   90      30
 MORPHINE SUL TAB 15MG CR                 MORPHINE SULFATE TAB SR 12HR 15 MG                            Opiate Agonists                           30                                                   Prior Authorization Req'd
 MORPHINE SUL TAB 15MG ER                 MORPHINE SULFATE TAB SR 12HR 15 MG                            Opiate Agonists                           30                                                   Prior Authorization Req'd
MORPHINE SUL TAB 200MG CR                 MORPHINE SULFATE TAB SR 12HR 200 MG                           Opiate Agonists                           30                                                   Prior Authorization Req'd
MORPHINE SUL TAB 200MG ER                 MORPHINE SULFATE TAB SR 12HR 200 MG                           Opiate Agonists                           30                                                   Prior Authorization Req'd
  MORPHINE SUL TAB 30MG                        MORPHINE SULFATE TAB 30 MG                               Opiate Agonists                   90      30
 MORPHINE SUL TAB 30MG CR                 MORPHINE SULFATE TAB SR 12HR 30 MG                            Opiate Agonists                           30                                                   Prior Authorization Req'd
 MORPHINE SUL TAB 30MG ER                 MORPHINE SULFATE TAB SR 12HR 30 MG                            Opiate Agonists                           30                                                   Prior Authorization Req'd
 MORPHINE SUL TAB 60MG CR                 MORPHINE SULFATE TAB SR 12HR 60 MG                            Opiate Agonists                           30                                                   Prior Authorization Req'd
 MORPHINE SUL TAB 60MG ER                 MORPHINE SULFATE TAB SR 12HR 60 MG                            Opiate Agonists                           30                                                   Prior Authorization Req'd
     MOTHERS FRIE LIQ                              *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
   MOTRIN IB TAB 200MG                             IBUPROFEN TAB 200 MG                    Other Nonsteroidal Anti-inflammtory Agents             30
  MP ACETAMIN CHW 80MG                       ACETAMINOPHEN CHEW TAB 80 MG                       Analgesics and Antipyretics, Misc         60      30
  MP ALLER MED CAP 25MG                      DIPHENHYDRAMINE HCL CAP 25 MG                         Ethanolamine Derivatives                       30
  MP ANTACID SUS EX STR       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 500-450-40 MG/5ML              Antacids and Adsorbents                480     30
  MP ANTACID SUS REG STR       ALUMINUM & MAGNESIUM HYDROXIDES SUSP 225-200 MG/5ML                 Antacids and Adsorbents                480     30
     MP ANTACID M SUS         ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML              Antacids and Adsorbents                480     30
 MP ANTACID M SUS MAX ST      ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML              Antacids and Adsorbents                480     30
   MP ASPIRIN TAB 325MG                              ASPIRIN TAB 325 MG                                    Salicylates                     31     30
   MP CLOTRIMAZ CRE 1%                            CLOTRIMAZOLE CREAM 1%                                       Azoles                       30     30
  MP HYDROCORT CRE 0.5%                        HYDROCORTISONE CREAM 0.5%                           Anti-inflammatory Agents                       30
   MP HYDROCORT CRE 1%                          HYDROCORTISONE CREAM 1%                            Anti-inflammatory Agents                       30
MP HYDROCORT CRE 1%MAX ST                       HYDROCORTISONE CREAM 1%                            Anti-inflammatory Agents                       30
   MP HYDROCORT OIN 1%                           HYDROCORTISONE OINT 1%                            Anti-inflammatory Agents                       30
 MP IBUPROFEN TAB 200MG                            IBUPROFEN TAB 200 MG                    Other Nonsteroidal Anti-inflammtory Agents             30
     MP LICETROL AER                             PERMETHRIN AEROSOL 0.5%                          Scabicides and Pediculicides            142     30
 MP REGRIPRIN TAB 81MG EC                   ASPIRIN TAB DELAYED RELEASE 81 MG                              Salicylates                     31     30
    MP SENALAX TAB SS                  SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                     Cathartics and Laxatives              100     30
 MP TUSSIN DM SYP 100-10/5       DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                         Antitussives                    180     30
 MP TUSSIN PE SYP 30-100/5        PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 30-100 MG/5ML                         Expectorants                            30
MTEST HS/EST TAB ESTROGEN    ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 0.625-1.25 MG                    Estrogens                             30
 MTEST/EST TAB ESTROGEN       ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TAB 1.25-2.5 MG                     Estrogens                             30
 MUCINEX CGH LIQ 5-100MG         DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML                         Antitussives                    180     30
 MUCINEX DM TAB 30-600ER        DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 30-600 MG                        Antitussives                     31     30
 MUCINEX DM TAB 60-1200         DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 60-1200 MG                       Antitussives                     31     30
MUCOSA DM TAB 20-400MG               DEXTROMETHORPHAN-GUAIFENESIN TAB 20-400 MG                           Antitussives                     31     30
                                                                                                                                          Max Qty
                                                                                                                                            Limit   Max Max Age
                                                                                                                                          (Liquids Days    Limit    Step         Step Therapy      Specialty
    Drug/Product Name                                Generic Name                                         Therapy Class                    in mLs) Supply (Years) Required?      Requirement         Drug         Coverage Status
 MUCUS RELIEF LIQ 5-100MG           DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML                        Antitussives                    180     30
   MUCUS RELIEF TAB DM                  DEXTROMETHORPHAN-GUAIFENESIN TAB 20-400 MG                          Antitussives                     31     30
MUCUS RELIEF TAB DM COUGH               DEXTROMETHORPHAN-GUAIFENESIN TAB 20-400 MG                          Antitussives                     31     30
   MUCUSRELIEF TAB DM                   DEXTROMETHORPHAN-GUAIFENESIN TAB 20-400 MG                          Antitussives                     31     30
 MULT VIT-BET CHW /FL 1MG      *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 1 MG***             Multivitamin Preparations                      30
 MULT VIT-BET CHW FE/FL0.5      *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE CHEW TAB 0.5-12 MG**           Multivitamin Preparations                      30
MULT VIT-BET CHW FE/FL1MG        *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE CHEW TAB 1-12 MG**            Multivitamin Preparations                      30
MULT VIT-BET CHW FL 0.5MG     *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG***            Multivitamin Preparations                      30
MULT VIT-BET CHW FL0.25MG    *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG***            Multivitamin Preparations                      30
   MULTI ANTIBI CRE PLUS                NEOMYCIN-POLYMYXIN W/ PRAMOXINE CREAM 1%                           Antibacterials                   15      30
 MULTI VIT/FL CHW 0.25MG     *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG***            Multivitamin Preparations                      30
   MULTI VIT/FL CHW 1MG        *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 1 MG***             Multivitamin Preparations                      30
  MULTI VIT/FL DRO 0.25MG    *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.25 MG/ML***             Multivitamin Preparations                      30      18
     MULTI-ANTIBI CRE              NEOMYCIN-POLYMYXIN CREAM 3.5 MG/GM-10000 UNIT/GM                        Antibacterials                   15      30
     MULTI-ANTIBI OIN                         *BACITRACIN-POLYMYXIN B OINT***                              Antibacterials                           30
 MULTIFOL PLU TAB 65-1MG               *PRENATAL VIT W/ FE FUMARATE-FA TAB 65-1 MG***                Multivitamin Preparations                      30     40
  MULTI-NATE PAK 30 DHA       *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA 3 CAP 400 PK**           Multivitamin Preparations                      30     40
 MULTI-NATE PAK DHA EXTR      *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA CAP DR 400 PK*           Multivitamin Preparations                      30     40
    MULTI-NATE TAB 30           *PRENATAL VIT W/ FE BISGLYC-FE PROT SUCC-FA TAB 29-1 MG***           Multivitamin Preparations                      30     40
      MULTI-VIT DRO                   *PEDIATRIC MULTIPLE VITAMIN W/ C SOLN 35 MG/ML**               Multivitamin Preparations                      30      1
    MULTI-VIT DRO /FE             *PEDIATRIC MULTIPLE VITAMINS W/ IRON DROPS 10 MG/ML**              Multivitamin Preparations                      30     0.5
 MULTI-VIT/FE DRO /FL 0.25     *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE DROPS 0.25-10 MG/ML**           Multivitamin Preparations                      30     18
  MULTI-VIT/FE DRO /FL 0.5     *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE DROPS 0.5-10 MG/ML**            Multivitamin Preparations                      30     18
  MULTI-VIT/FE DRO FL 0.25     *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE DROPS 0.25-10 MG/ML**           Multivitamin Preparations                      30     18
 MULTIVIT/FL CHW 0.25MG      *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG***            Multivitamin Preparations                      30
 MULTIVIT/FL CHW 0.5/FE12       *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE CHEW TAB 0.5-12 MG**           Multivitamin Preparations                      30
  MULTIVIT/FL CHW 0.5MG       *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG***            Multivitamin Preparations                      30
   MULTIVIT/FL CHW 1MG         *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 1 MG***             Multivitamin Preparations                      30
 MULTI-VIT/FL CHW 0.25MG     *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG***            Multivitamin Preparations                      30
  MULTI-VIT/FL CHW 0.5MG      *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG***            Multivitamin Preparations                      30
   MULTI-VIT/FL CHW 1MG        *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 1 MG***             Multivitamin Preparations                      30
  MULTI-VIT/FL DRO 0.25MG    *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.25 MG/ML***             Multivitamin Preparations                      30      18
MULTI-VIT/FL DRO 0.5MG/ML     *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.5 MG/ML***             Multivitamin Preparations                      30      18
MULTIVITAMIN DRO /FLUORID    *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.25 MG/ML***             Multivitamin Preparations                      30      18
MULTIVITAMIN DRO FLUOR/FE      *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE DROPS 0.25-10 MG/ML**           Multivitamin Preparations                      30      18
  MULTIVITE/FL CHW 0.5MG      *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG***            Multivitamin Preparations                      30
  MULT-VIT/FL CHW 0.5MG       *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG***            Multivitamin Preparations                      30
    MUPIROCIN OIN 2%                                 MUPIROCIN OINT 2%                                     Antibacterials                           30
   M-VIT     TAB 27-1MG                *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***                Multivitamin Preparations                      30      40
 MYCELEX-7 KIT COMBO PK                CLOTRIMAZOLE VAGINAL TAB 100 MG & 1% CREAM KIT                         Azoles                                30                                                         Prior Authorization Req'd
  MYCI-GC SOL 100-10/5                     GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML                           Antitussives                    180     30
MYCOPHENOLAT CAP 250MG                       MYCOPHENOLATE MOFETIL CAP 250 MG                       Immunosuppressive Agents                        30
 MYCOPHENOLAT TAB 500MG                      MYCOPHENOLATE MOFETIL TAB 500 MG                       Immunosuppressive Agents                        30
  MYFERON 150 CAP FORTE             IRON POLYSACCH COMPLEX-VIT B12-FA CAP 150-0.025-1 MG                Iron Preparations                           30
    MYLERAN TAB 2MG                                  BUSULFAN TAB 2 MG                                Antineoplastic Agents                         30
      MYNATAL TAB                  *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***              Multivitamin Preparations                      30
 MYNATAL TAB ADVANCE               *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***              Multivitamin Preparations                      30
     MYNATAL PLUS TAB                  *PRENATAL VIT W/ FE FUMARATE-FA TAB 65-1 MG***                Multivitamin Preparations                      30      40
      MYNATAL-Z TAB                    *PRENATAL VIT W/ FE FUMARATE-FA TAB 65-1 MG***                Multivitamin Preparations                      30      40
   MYNATE 90 TAB PLUS              *PRENATAL VIT W/ DSS-FE FUMARATE-FA TAB CR 90-1 MG***             Multivitamin Preparations                      30
     MYPHETANE DX SYP                 PSEUDOEPHED-BROMPHEN-DM SYRUP 30-2-10 MG/5ML                          Antitussives                    178     30
 MYTUSSIN AC SYP 100-10/5                  GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML                           Antitussives                    180     30




                                                                                                                                                                               USE FORMULARY
 NABUMETONE TAB 500MG                          NABUMETONE TAB 500 MG                         Other Nonsteroidal Anti-inflammtory Agents             30                Y       GENERIC NSAIDS 1ST




                                                                                                                                                                               USE FORMULARY
 NABUMETONE TAB 750MG                          NABUMETONE TAB 750 MG                         Other Nonsteroidal Anti-inflammtory Agents             30                Y       GENERIC NSAIDS 1ST
  NADOLOL TAB 160MG                              NADOLOL TAB 160 MG                               Beta-Adrenergic Blocking Agents                   30
                                                                                                                                        Max Qty
                                                                                                                                          Limit   Max Max Age
                                                                                                                                        (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                              Generic Name                                         Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug      Coverage Status
    NADOLOL TAB 20MG                               NADOLOL TAB 20 MG                            Beta-Adrenergic Blocking Agents                   30
    NADOLOL TAB 40MG                               NADOLOL TAB 40 MG                            Beta-Adrenergic Blocking Agents                   30
    NADOLOL TAB 80MG                               NADOLOL TAB 80 MG                            Beta-Adrenergic Blocking Agents                   30
   NAFRINSE CHW 1MG F             SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)            Miscellaneous Therapeutic Agents                   30
  NAFRINSE DRO 0.125MG         SODIUM FLUORIDE SOLN 0.125 MG/DROP F (0.275 MG/DROP NAF)        Miscellaneous Therapeutic Agents                   30
  NAPROXEN SUS 125/5ML                          NAPROXEN SUSP 125 MG/5ML                   Other Nonsteroidal Anti-inflammtory Agents             30      18
   NAPROXEN TAB 250MG                             NAPROXEN TAB 250 MG                      Other Nonsteroidal Anti-inflammtory Agents             30
   NAPROXEN TAB 375MG                             NAPROXEN TAB 375 MG                      Other Nonsteroidal Anti-inflammtory Agents             30
   NAPROXEN TAB 500MG                             NAPROXEN TAB 500 MG                      Other Nonsteroidal Anti-inflammtory Agents             30
 NAPROXEN SOD TAB 220MG                       NAPROXEN SODIUM TAB 220 MG                   Other Nonsteroidal Anti-inflammtory Agents             30
 NAPROXEN SOD TAB 275MG                       NAPROXEN SODIUM TAB 275 MG                   Other Nonsteroidal Anti-inflammtory Agents             30
 NAPROXEN SOD TAB 550MG                       NAPROXEN SODIUM TAB 550 MG                   Other Nonsteroidal Anti-inflammtory Agents             30
    NARCOF    SYP 3.5-100           HYDROCODONE-GUAIFENESIN SYRUP 3.5-100 MG/5ML                          Antitussives                    178     30
NASAL DECON CAP 30-200MG              PSEUDOEPHEDRINE-GUAIFENESIN CAP 30-200 MG                          Expectorants                             30
NASAL DECON LIQ 15MG/5ML                   PSEUDOEPHEDRINE HCL LIQ 15 MG/5ML                  alpha- and beta-Adrenergic Agonists         480     30
NASAL DECON SYP 30MG/5ML                 PSEUDOEPHEDRINE HCL SYRUP 30 MG/5ML                  alpha- and beta-Adrenergic Agonists         240     30
NASAL DECONG LIQ 30MG/5ML                  PSEUDOEPHEDRINE HCL LIQ 30 MG/5ML                  alpha- and beta-Adrenergic Agonists         240     30
  NASAL DECONG TAB 30MG                      PSEUDOEPHEDRINE HCL TAB 30 MG                    alpha- and beta-Adrenergic Agonists         120     30
       NATACAPS CAP             *PRENATAL W/O A VIT W/ FE FUMARATE-FA CAP 106-1 MG***              Multivitamin Preparations                      30      40
 NATALCARE TAB GLOSSTAB          *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***              Multivitamin Preparations                      30
     NATALCARE TAB PIC            *PRENATAL VIT W/ FE POLYSAC CMPLX-FA TAB 60-1 MG***              Multivitamin Preparations                      30
 NATALCARE TAB PICFORTE           *PRENATAL VIT W/ FE POLYSAC CMPLX-FA TAB 60-1 MG***              Multivitamin Preparations                      30
    NATALCARE TAB PLUS              *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***                 Multivitamin Preparations                      30      40
   NATALCARE TAB THREE              *PRENATAL VIT W/ FE FUMARATE-FA TAB 28-1 MG***                 Multivitamin Preparations                      30      40
      NATALCARE RX TAB             *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.5 MG***                Multivitamin Preparations                      30
      NATATAB CFE TAB              *PRENATAL VIT W/ IRON CARBONYL-FA TAB 50-1 MG***                Multivitamin Preparations                      30      40
      NATATAB FA TAB                *PRENATAL VIT W/ FE FUMARATE-FA TAB 29-1 MG***                 Multivitamin Preparations                      30      40
  NATATAB RX TAB 29-1MG            *PRENATAL VIT W/ IRON CARBONYL-FA TAB 29-1 MG***                Multivitamin Preparations                      30      40
       NATAZIA TAB            ESTRADIOL VALERATE-DIENOGEST TAB 3 MG /2-2 MG/2-3 MG/1 MG                 Contraceptives                            30
NATURALYTE SOL BUBBLEGM                      *ORAL ELECTROLYTE SOLUTION***                         Replacement Preparations                       30      18
   NATURALYTE SOL FRUIT                      *ORAL ELECTROLYTE SOLUTION***                         Replacement Preparations                       30      18
   NATURALYTE SOL GRAPE                      *ORAL ELECTROLYTE SOLUTION***                         Replacement Preparations                       30      18
NATURALYTE SOL UNFLAVOR                      *ORAL ELECTROLYTE SOLUTION***                         Replacement Preparations                       30      18
  NATURE-THROI TAB 130MG                           THYROID TAB 130 MG                                   Thyroid Agents                            30
 NATURE-THROI TAB 16.25MG                         THYROID TAB 16.25 MG                                  Thyroid Agents                            30
  NATURE-THROI TAB 195MG                           THYROID TAB 195 MG                                   Thyroid Agents                            30
  NATURE-THROI TAB 260MG                           THYROID TAB 260 MG                                   Thyroid Agents                            30
 NATURE-THROI TAB 32.5MG                           THYROID TAB 32.5 MG                                  Thyroid Agents                            30
  NATURE-THROI TAB 325MG                       THYROID TAB 325 MG (5 GRAIN)                             Thyroid Agents                            30
 NATURE-THROI TAB 48.75MG                    THYROID TAB 48.75 MG (3/4 GRAIN)                           Thyroid Agents                            30
  NATURE-THROI TAB 65MG                             THYROID TAB 65 MG                                   Thyroid Agents                            30
 NATURE-THROI TAB 97.5MG                           THYROID TAB 97.5 MG                                  Thyroid Agents                            30
     NEBUSAL NEB 6%                          SODIUM CHLORIDE SOLN NEBU 6%                              Mucolytic Agents                           30
    NECON     TAB 0.5/35         NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG                    Contraceptives                            30
    NECON    TAB 1/35-28          NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG                     Contraceptives                            30
    NECON    TAB 1/50-28             NORETHINDRONE & MESTRANOL TAB 1 MG-50 MCG                          Contraceptives                            30
   NECON     TAB 10/11-28     NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35 MG-MCG (10/11)                Contraceptives                            30
   NECON 7/7/7 TAB 28 DAY    NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG                 Contraceptives                            30
NEO/BAC/POLY OIN /HC 1%OP          BACITRACIN-POLYMYXIN-NEOMYCIN-HC OPHTH OINT 1%                       Corticosteroids                           30
    NEO/BAC/POLY OIN OP     NEOMYCIN-BACITRAC ZN-POLYMYX 5(3.5)MG-400UNT-10000UNT OP OIN                 Antibacterials                           30
NEO/POLY/BAC OIN /HC 1%OP          BACITRACIN-POLYMYXIN-NEOMYCIN-HC OPHTH OINT 1%                       Corticosteroids                           30
    NEO/POLY/BAC OIN OP     NEOMYCIN-BACITRAC ZN-POLYMYX 5(3.5)MG-400UNT-10000UNT OP OIN                 Antibacterials                           30
 NEO/POLY/DEX OIN 0.1% OP        NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH OINT 0.1%                       Corticosteroids                           30
 NEO/POLY/DEX SUS 0.1% OP        NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH SUSP 0.1%                       Corticosteroids                           30
    NEO/POLY/GRA SOL OP              NEOMYCIN-POLYMYXIN B-GRAMICIDIN OPHTH SOLN                          Antibacterials                           30
 NEO/POLY/HC SOL 1% OTIC                  NEOMYCIN-POLYMYXIN-HC OTIC SOLN 1%                            Corticosteroids                           30
 NEO/POLY/HC SUS 1% OTIC     NEOMYCIN-POLYMYXIN-HC OTIC SUSP 3.5 MG/ML-10000 UNIT/ML-1%                 Corticosteroids                           30
    NEO/POLY/HC SUS OP                    NEOMYCIN-POLYMYXIN-HC OPHTH SUSP                              Corticosteroids                           30
      NEOCIN    OIN OP      NEOMYCIN-BACITRAC ZN-POLYMYX 5(3.5)MG-400UNT-10000UNT OP OIN                 Antibacterials                           30
     NEOCIN-PG SOL OP                NEOMYCIN-POLYMYXIN B-GRAMICIDIN OPHTH SOLN                          Antibacterials                           30
  NEO-FRADIN SOL 125/5ML                    NEOMYCIN SULFATE SOLN 25 MG/ML                             Aminoglycosides                            14      18
   NEOMYCIN TAB 500MG                         NEOMYCIN SULFATE TAB 500 MG                              Aminoglycosides                            14
NEOSPORIN+PN OIN RELF MAX         NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%                        Antibacterials                    15     30
       NEOTUSS LIQ               DEXTROMETHORPHAN-GUAIFENESIN LIQUID 30-200 MG/5ML                        Antitussives                    180     30
    NERVINE TAB 25MG                         DIPHENHYDRAMINE HCL TAB 25 MG                         Ethanolamine Derivatives                       30
                                                                                                                      Max Qty
                                                                                                                        Limit   Max Max Age
                                                                                                                      (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                          Generic Name                               Therapy Class                in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
  NEURO-K-250 TAB 250MG                   PYRIDOXINE HCL TAB 250 MG                       Vitamin B Complex                     30
       NEURO-K-50 TAB                      PYRIDOXINE HCL TAB 50 MG                       Vitamin B Complex                     30
      NEURO-K-500 TAB                     PYRIDOXINE HCL TAB 500 MG                       Vitamin B Complex                     30
    NEUT T/SCALP SOL 1%                    HYDROCORTISONE SOLN 1%                     Anti-inflammatory Agents          120     30
   NEUTRAGARD GEL 1.1%                SODIUM FLUORIDE GEL 1.1% (0.5% F)           Miscellaneous Therapeutic Agents              30      18
 NEUTROGENA LOT SENS SKN                     *EMOLLIENT - LOTION**                   Basic Lotions and Liniments                30                                                   Prior Authorization Req'd
  NEXT CHOICE TAB 0.75MG                 LEVONORGESTREL TAB 0.75 MG                         Contraceptives                      30
   NIACIN    TAB 250MG SR                     NIACIN TAB CR 250 MG                        Vitamin B Complex             62      30
   NIACIN    TAB 250MG TR                     NIACIN TAB CR 250 MG                        Vitamin B Complex             62      30
  NIACIN     TAB 500MG CR                     NIACIN TAB CR 500 MG                        Vitamin B Complex             62      30
  NIACIN     TAB 500MG TD                     NIACIN TAB CR 500 MG                        Vitamin B Complex             62      30
   NIACIN    TAB 500MG TR                     NIACIN TAB CR 500 MG                        Vitamin B Complex             62      30
   NIACIN    TAB 750MG TR                     NIACIN TAB CR 750 MG                        Vitamin B Complex             62      30
   NIACIN TR TAB 1000MG                      NIACIN TAB CR 1000 MG                        Vitamin B Complex             62      30
  NIACINAMIDE TAB 100MG                     NIACINAMIDE TAB 100 MG                        Vitamin B Complex             62      30
  NIACINAMIDE TAB 500MG                     NIACINAMIDE TAB 500 MG                        Vitamin B Complex             62      30
    NIACOR     TAB 500MG                       NIACIN TAB 500 MG                          Vitamin B Complex             60      30
   NIASPAN TAB 1000 ER           NIACIN TAB CR 1000 MG (ANTIHYPERLIPIDEMIC)       Antilipemic Agents, Miscellaneous             30
  NIASPAN TAB 500MG ER           NIACIN TAB CR 500 MG (ANTIHYPERLIPIDEMIC)        Antilipemic Agents, Miscellaneous             30
  NIASPAN TAB 750MG ER           NIACIN TAB CR 750 MG (ANTIHYPERLIPIDEMIC)        Antilipemic Agents, Miscellaneous             30
NICORELIEF GUM 2MG MINT                 NICOTINE POLACRILEX GUM 2 MG              Autonomic Drugs, Miscellaneous                30
 NICORELIEF GUM 2MG ORIG                NICOTINE POLACRILEX GUM 2 MG              Autonomic Drugs, Miscellaneous                30
NICORELIEF GUM 4MG MINT                 NICOTINE POLACRILEX GUM 4 MG              Autonomic Drugs, Miscellaneous                30
 NICORELIEF GUM 4MG ORIG                NICOTINE POLACRILEX GUM 4 MG              Autonomic Drugs, Miscellaneous                30
  NICOTINE DIS 14MG/24H              NICOTINE TD PATCH 24HR 14 MG/24HR            Autonomic Drugs, Miscellaneous                30
  NICOTINE DIS 21MG/24H              NICOTINE TD PATCH 24HR 21 MG/24HR            Autonomic Drugs, Miscellaneous                30
  NICOTINE DIS 7MG/24HR               NICOTINE TD PATCH 24HR 7 MG/24HR            Autonomic Drugs, Miscellaneous                30
    NICOTINE GUM 2MG                    NICOTINE POLACRILEX GUM 2 MG              Autonomic Drugs, Miscellaneous                30
 NICOTINE GUM 2MGFRUIT                  NICOTINE POLACRILEX GUM 2 MG              Autonomic Drugs, Miscellaneous                30
    NICOTINE GUM 4MG                    NICOTINE POLACRILEX GUM 4 MG              Autonomic Drugs, Miscellaneous                30
   NICOTINE POL GUM 2MG                 NICOTINE POLACRILEX GUM 2 MG              Autonomic Drugs, Miscellaneous                30
NICOTINE POL GUM 2MG CINN               NICOTINE POLACRILEX GUM 2 MG              Autonomic Drugs, Miscellaneous                30
NICOTINE POL GUM 2MG MINT               NICOTINE POLACRILEX GUM 2 MG              Autonomic Drugs, Miscellaneous                30
NICOTINE POL GUM 2MG ORIG               NICOTINE POLACRILEX GUM 2 MG              Autonomic Drugs, Miscellaneous                30
 NICOTINE POL GUM 2MG REF               NICOTINE POLACRILEX GUM 2 MG              Autonomic Drugs, Miscellaneous                30
NICOTINE POL GUM 2MG STRT               NICOTINE POLACRILEX GUM 2 MG              Autonomic Drugs, Miscellaneous                30
NICOTINE POL GUM 2MGFRUIT               NICOTINE POLACRILEX GUM 2 MG              Autonomic Drugs, Miscellaneous                30
   NICOTINE POL GUM 4MG                 NICOTINE POLACRILEX GUM 4 MG              Autonomic Drugs, Miscellaneous                30
NICOTINE POL GUM 4MG MINT               NICOTINE POLACRILEX GUM 4 MG              Autonomic Drugs, Miscellaneous                30
NICOTINE POL GUM 4MG ORIG               NICOTINE POLACRILEX GUM 4 MG              Autonomic Drugs, Miscellaneous                30
 NICOTINE POL GUM 4MG REF               NICOTINE POLACRILEX GUM 4 MG              Autonomic Drugs, Miscellaneous                30
NICOTINE POL GUM 4MG REG                NICOTINE POLACRILEX GUM 4 MG              Autonomic Drugs, Miscellaneous                30
NICOTINE POL GUM 4MG STRT               NICOTINE POLACRILEX GUM 4 MG              Autonomic Drugs, Miscellaneous                30
NICOTINE POL GUM 4MGFRUIT               NICOTINE POLACRILEX GUM 4 MG              Autonomic Drugs, Miscellaneous                30
 NICOTINE TD DIS 14MG/24H            NICOTINE TD PATCH 24HR 14 MG/24HR            Autonomic Drugs, Miscellaneous                30
 NICOTINE TD DIS 21MG/24H            NICOTINE TD PATCH 24HR 21 MG/24HR            Autonomic Drugs, Miscellaneous                30
 NICOTINE TD DIS 7MG/24HR             NICOTINE TD PATCH 24HR 7 MG/24HR            Autonomic Drugs, Miscellaneous                30
  NIFEDIAC CC TAB 30MG ER                NIFEDIPINE TAB SR 24HR 30 MG                      Dihydropyridines                     30
  NIFEDIAC CC TAB 60MG ER                NIFEDIPINE TAB SR 24HR 60 MG                      Dihydropyridines                     30
  NIFEDIAC CC TAB 90MG ER                NIFEDIPINE TAB SR 24HR 90 MG                      Dihydropyridines                     30
   NIFEDICAL XL TAB 30MG            NIFEDIPINE TAB SR 24HR OSMOTIC 30 MG                   Dihydropyridines                     30
   NIFEDICAL XL TAB 60MG            NIFEDIPINE TAB SR 24HR OSMOTIC 60 MG                   Dihydropyridines                     30
    NIFEDIPINE CAP 10MG                       NIFEDIPINE CAP 10 MG                         Dihydropyridines                     30
    NIFEDIPINE CAP 20MG                       NIFEDIPINE CAP 20 MG                         Dihydropyridines                     30
  NIFEDIPINE TAB 30MG ER                 NIFEDIPINE TAB SR 24HR 30 MG                      Dihydropyridines                     30
  NIFEDIPINE TAB 60MG ER                 NIFEDIPINE TAB SR 24HR 60 MG                      Dihydropyridines                     30
  NIFEDIPINE TAB 90MG CR                 NIFEDIPINE TAB SR 24HR 90 MG                      Dihydropyridines                     30
  NIFEDIPINE TAB 90MG ER                 NIFEDIPINE TAB SR 24HR 90 MG                      Dihydropyridines                     30
   NIFEREX-PN TAB FORTE     *PRENATAL VIT W/ FE POLYSAC CMPLX-FA TAB 60-1 MG***       Multivitamin Preparations                 30
  NILANDRON TAB 150MG                       NILUTAMIDE TAB 150 MG                        Antineoplastic Agents                  30
   NIMODIPINE CAP 30MG                       NIMODIPINE CAP 30 MG                          Dihydropyridines                     30
   NITREK    DIS 0.2MG/HR          NITROGLYCERIN TD PATCH 24HR 0.2 MG/HR                 Nitrates and Nitrites                  30
   NITREK    DIS 0.4MG/HR          NITROGLYCERIN TD PATCH 24HR 0.4 MG/HR                 Nitrates and Nitrites                  30
   NITREK    DIS 0.6MG/HR          NITROGLYCERIN TD PATCH 24HR 0.6 MG/HR                 Nitrates and Nitrites                  30
     NITRO-BID OIN 2%                       NITROGLYCERIN OINT 2%                        Nitrates and Nitrites                  30
                                                                                                                            Max Qty
                                                                                                                              Limit   Max Max Age
                                                                                                                            (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                             Generic Name                                  Therapy Class                in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
 NITROFUR MAC CAP 100MG             NITROFURANTOIN MACROCRYSTALLINE CAP 100 MG                Urinary Anti-infectives                 30
  NITROFUR MAC CAP 50MG             NITROFURANTOIN MACROCRYSTALLINE CAP 50 MG                 Urinary Anti-infectives                 30
 NITROFURANTN CAP 100MG             NITROFURANTOIN MACROCRYSTALLINE CAP 100 MG                Urinary Anti-infectives                 30
 NITROFURANTO CAP 100MG             NITROFURANTOIN MACROCRYSTALLINE CAP 100 MG                Urinary Anti-infectives                 30
 NITROGLYCER CAP 2.5MG CR                     NITROGLYCERIN CAP CR 2.5 MG                      Nitrates and Nitrites                  30
 NITROGLYCER CAP 2.5MG ER                     NITROGLYCERIN CAP CR 2.5 MG                      Nitrates and Nitrites                  30
 NITROGLYCER CAP 2.5MG SR                     NITROGLYCERIN CAP CR 2.5 MG                      Nitrates and Nitrites                  30
 NITROGLYCER CAP 2.5MG TD                     NITROGLYCERIN CAP CR 2.5 MG                      Nitrates and Nitrites                  30
 NITROGLYCER CAP 6.5MG CR                     NITROGLYCERIN CAP CR 6.5 MG                      Nitrates and Nitrites                  30
 NITROGLYCER CAP 6.5MG ER                     NITROGLYCERIN CAP CR 6.5 MG                      Nitrates and Nitrites                  30
 NITROGLYCER CAP 6.5MG SR                     NITROGLYCERIN CAP CR 6.5 MG                      Nitrates and Nitrites                  30
 NITROGLYCER CAP 6.5MG TD                     NITROGLYCERIN CAP CR 6.5 MG                      Nitrates and Nitrites                  30
  NITROGLYCER CAP 9MG CR                       NITROGLYCERIN CAP CR 9 MG                       Nitrates and Nitrites                  30
  NITROGLYCER CAP 9MG ER                       NITROGLYCERIN CAP CR 9 MG                       Nitrates and Nitrites                  30
  NITROGLYCER CAP 9MG TD                       NITROGLYCERIN CAP CR 9 MG                       Nitrates and Nitrites                  30
 NITROGLYCER DIS 0.1MG/HR               NITROGLYCERIN TD PATCH 24HR 0.1 MG/HR                  Nitrates and Nitrites                  30
 NITROGLYCER DIS 0.2MG/HR               NITROGLYCERIN TD PATCH 24HR 0.2 MG/HR                  Nitrates and Nitrites                  30
 NITROGLYCER DIS 0.4MG/HR               NITROGLYCERIN TD PATCH 24HR 0.4 MG/HR                  Nitrates and Nitrites                  30
 NITROGLYCER DIS 0.6MG/HR               NITROGLYCERIN TD PATCH 24HR 0.6 MG/HR                  Nitrates and Nitrites                  30
    NITROGLYCER OIN 2%                           NITROGLYCERIN OINT 2%                         Nitrates and Nitrites                  30
  NITROGLYCER SUB 0.3MG                       NITROGLYCERIN SL TAB 0.3 MG                      Nitrates and Nitrites                  30
  NITROGLYCER SUB 0.4MG                       NITROGLYCERIN SL TAB 0.4 MG                      Nitrates and Nitrites                  30
  NITROGLYCER SUB 0.6MG                       NITROGLYCERIN SL TAB 0.6 MG                      Nitrates and Nitrites                  30
 NITROGLYCERI DIS 0.6MG/HR              NITROGLYCERIN TD PATCH 24HR 0.6 MG/HR                  Nitrates and Nitrites                  30
 NITROGLYCRN SPR LINGUAL         NITROGLYCERIN TL SOLN 0.4 MG/SPRAY (400 MCG/SPRAY)            Nitrates and Nitrites                  30
NITROLINGUAL SPR DUO PACK        NITROGLYCERIN TL SOLN 0.4 MG/SPRAY (400 MCG/SPRAY)            Nitrates and Nitrites                  30
NITROLINGUAL SPR PUMPSPRA        NITROGLYCERIN TL SOLN 0.4 MG/SPRAY (400 MCG/SPRAY)            Nitrates and Nitrites                  30
   NITROQUICK SUB 0.3MG                       NITROGLYCERIN SL TAB 0.3 MG                      Nitrates and Nitrites                  30
   NITROQUICK SUB 0.4MG                       NITROGLYCERIN SL TAB 0.4 MG                      Nitrates and Nitrites                  30
   NITROQUICK SUB 0.6MG                       NITROGLYCERIN SL TAB 0.6 MG                      Nitrates and Nitrites                  30
   NITROSTAT SUB 0.3MG                        NITROGLYCERIN SL TAB 0.3 MG                      Nitrates and Nitrites                  30
   NITROSTAT SUB 0.4MG                        NITROGLYCERIN SL TAB 0.4 MG                      Nitrates and Nitrites                  30
   NITROSTAT SUB 0.6MG                        NITROGLYCERIN SL TAB 0.6 MG                      Nitrates and Nitrites                  30
 NITRO-TIME CAP 2.5MG CR                      NITROGLYCERIN CAP CR 2.5 MG                      Nitrates and Nitrites                  30
 NITRO-TIME CAP 6.5MG CR                      NITROGLYCERIN CAP CR 6.5 MG                      Nitrates and Nitrites                  30
  NITRO-TIME CAP 9MG CR                        NITROGLYCERIN CAP CR 9 MG                       Nitrates and Nitrites                  30
        NIVEA    LOT                             *EMOLLIENT - LOTION**                     Basic Lotions and Liniments                30                                                   Prior Authorization Req'd
   NIVEA     LOT EXFOLIAT                        *EMOLLIENT - LOTION**                     Basic Lotions and Liniments                30                                                   Prior Authorization Req'd
     NIVEA    LOT EXTRA                          *EMOLLIENT - LOTION**                     Basic Lotions and Liniments                30                                                   Prior Authorization Req'd
     NIVEA     LOT LIGHT                         *EMOLLIENT - LOTION**                     Basic Lotions and Liniments                30                                                   Prior Authorization Req'd
   NIVEA     LOT ORIGINAL                        *EMOLLIENT - LOTION**                     Basic Lotions and Liniments                30                                                   Prior Authorization Req'd
      NIVEA VISAGE LOT                           *EMOLLIENT - LOTION**                     Basic Lotions and Liniments                30                                                   Prior Authorization Req'd
   NIX LICE SPR CONTROL                       PERMETHRIN LIQ SPRAY 0.25%                   Scabicides and Pediculicides       120     30
  NOBLE FORMUL CRE HC 1%                      HYDROCORTISONE CREAM 1%                       Anti-inflammatory Agents                  30
  NOBLE FORMUL SPR HC 1%                       HYDROCORTISONE SOLN 1%                       Anti-inflammatory Agents          120     30
      NODOLOR CAP            ACETAMINOPHEN-ISOMETHEPTENE-DICHLORAL CAP 325-65-100 MG   Antimigraine Agents, Miscellaneous      6      30
      NOMUC-PE CAP                 PSEUDOEPHEDRINE-GUAIFENESIN CAP CR 60-200 MG                    Expectorants                31     30
  NON ASPIRIN ELX 160/5ML                  ACETAMINOPHEN ELIXIR 160 MG/5ML              Analgesics and Antipyretics, Misc     240     30
  NON ASPIRIN SUS 160/5ML                  ACETAMINOPHEN SUSP 160 MG/5ML                Analgesics and Antipyretics, Misc     240     30
 NON ASPIRIN TAB 650MG ER                    ACETAMINOPHEN TAB CR 650 MG                Analgesics and Antipyretics, Misc     120     30
NON-ASA CHLD DRO 80/0.8ML                   ACETAMINOPHEN SOLN 100 MG/ML                Analgesics and Antipyretics, Misc      30     30
 NON-ASA CHLD ELX 160/5ML                  ACETAMINOPHEN ELIXIR 160 MG/5ML              Analgesics and Antipyretics, Misc     240     30
 NON-ASA CHLD LIQ 160/5ML                 ACETAMINOPHEN LIQUID 160 MG/5ML               Analgesics and Antipyretics, Misc     240     30
 NON-ASA CHLD SUS 160/5ML                  ACETAMINOPHEN SUSP 160 MG/5ML                Analgesics and Antipyretics, Misc     240     30
NON-ASA INFA DRO 80/0.8ML                  ACETAMINOPHEN SUSP 80 MG/0.8ML               Analgesics and Antipyretics, Misc      30     30
 NON-ASA PAIN SUS 160/5ML                  ACETAMINOPHEN SUSP 160 MG/5ML                Analgesics and Antipyretics, Misc     240     30
  NON-ASPIRIN CAP 500MG                       ACETAMINOPHEN CAP 500 MG                  Analgesics and Antipyretics, Misc     250     30
NON-ASPIRIN CHW 160MG JR                   ACETAMINOPHEN CHEW TAB 160 MG                Analgesics and Antipyretics, Misc      60     30
  NON-ASPIRIN CHW 80MG                      ACETAMINOPHEN CHEW TAB 80 MG                Analgesics and Antipyretics, Misc      60     30
 NON-ASPIRIN DRO 80/0.8ML                  ACETAMINOPHEN SUSP 80 MG/0.8ML               Analgesics and Antipyretics, Misc      30     30
  NON-ASPIRIN ELX 160/5ML                  ACETAMINOPHEN ELIXIR 160 MG/5ML              Analgesics and Antipyretics, Misc     240     30
   NON-ASPIRIN SOL EX STR                  ACETAMINOPHEN SOLN 160 MG/5ML                Analgesics and Antipyretics, Misc     240     30
 NON-ASPIRIN SUS 160/5ML                   ACETAMINOPHEN SUSP 160 MG/5ML                Analgesics and Antipyretics, Misc     240     30
   NON-ASPIRIN SUS CHILD                   ACETAMINOPHEN SUSP 160 MG/5ML                Analgesics and Antipyretics, Misc     240     30
  NON-ASPIRIN TAB 325MG                       ACETAMINOPHEN TAB 325 MG                  Analgesics and Antipyretics, Misc     250     30
                                                                                                                                        Max Qty
                                                                                                                                          Limit   Max Max Age
                                                                                                                                        (Liquids Days    Limit    Step      Step Therapy   Specialty
   Drug/Product Name                               Generic Name                                         Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
 NON-ASPIRIN TAB 500MG                          ACETAMINOPHEN TAB 500 MG                        Analgesics and Antipyretics, Misc         250     30
 NON-ASPIRIN TAB 650MG                        ACETAMINOPHEN TAB CR 650 MG                       Analgesics and Antipyretics, Misc         120     30
  NON-DRYING CAP SINUS              PSEUDOEPHEDRINE-GUAIFENESIN CAP 30-200 MG                             Expectorants                            30
  NORA-BE TAB 0.35MG                            NORETHINDRONE TAB 0.35 MG                                Contraceptives                           30
  NORETHIN ACE TAB 5MG                     NORETHINDRONE ACETATE TAB 5 MG                                  Progestins                             30
NORETHINDRON TAB 0.35MG                         NORETHINDRONE TAB 0.35 MG                                Contraceptives                           30
 NORGEST/ETH TAB ESTRAD          NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30 MCG                        Contraceptives                           30
 NORTEMP SOL 160/5ML                       ACETAMINOPHEN SOLN 160 MG/5ML                        Analgesics and Antipyretics, Misc         240     30
 NORTEMP SUS 160/5ML                        ACETAMINOPHEN SUSP 160 MG/5ML                       Analgesics and Antipyretics, Misc         240     30
   NORTHYX TAB 10MG                               METHIMAZOLE TAB 10 MG                                Antithyroid Agents                         30
    NORTHYX TAB 5MG                               METHIMAZOLE TAB 5 MG                                 Antithyroid Agents                         30
   NORTREL (21) TAB 1/35        NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG                        Contraceptives                           30
   NORTREL (28) TAB 1/35        NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG                        Contraceptives                           30
  NORTREL 28 TAB 0.5/35        NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5 MG-35 MCG                       Contraceptives                           30
NORTREL7/7/7 TAB 28 DAYS    NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.75-35/1-35 MG-MCG                   Contraceptives                           30
   NORVIR    CAP 100MG                             RITONAVIR CAP 100 MG                             HIV Protease Inhibitors                       30
 NORVIR     SOL 80MG/ML                      RITONAVIR ORAL SOLN 80 MG/ML                           HIV Protease Inhibitors                       30
   NORVIR    TAB 100MG                              RITONAVIR TAB 100 MG                            HIV Protease Inhibitors                       30
 NORWICH ASA TAB 325MG                               ASPIRIN TAB 325 MG                                    Salicylates                    31      30
    NOVOLIN INJ 70/30        INSULIN ISOPHANE & REGULAR (HUMAN) INJ 100 UNIT/ML (70-30)                      Insulins                             30
 NOVOLIN 70/ INJ 30 INNLT    INSULIN ISOPHANE & REGULAR (HUMAN) INJ 100 UNIT/ML (70-30)                      Insulins                             30
 NOVOLIN 70/ INJ 30 PNFIL    INSULIN ISOPHANE & REGULAR (HUMAN) INJ 100 UNIT/ML (70-30)                      Insulins                             30
 NOVOLIN N INJ INNOLET                 INSULIN ISOPHANE (HUMAN) INJ 100 UNIT/ML                              Insulins                             30
  NOVOLIN N INJ PENFILL                INSULIN ISOPHANE (HUMAN) INJ 100 UNIT/ML                              Insulins                             30
   NOVOLIN N INJ U-100                 INSULIN ISOPHANE (HUMAN) INJ 100 UNIT/ML                              Insulins                             30
  NOVOLIN R INJ INNOLET                 INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML                              Insulins                             30
  NOVOLIN R INJ PENFILL                 INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML                              Insulins                             30
   NOVOLIN R INJ U-100                  INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML                              Insulins                             30
  NOVOLOG INJ 100/ML                          INSULIN ASPART INJ 100 UNIT/ML                                 Insulins                             30
  NOVOLOG INJ FLEXPEN                         INSULIN ASPART INJ 100 UNIT/ML                                 Insulins                             30
  NOVOLOG INJ PENFILL                         INSULIN ASPART INJ 100 UNIT/ML                                 Insulins                             30
  NOVOLOG MIX INJ 70/30     INSULIN ASPART PROT & ASPART (HUMAN) INJ 100 UNIT/ML (70-30)                     Insulins                             30
NOVOLOG MIX INJ FLEXPEN     INSULIN ASPART PROT & ASPART (HUMAN) INJ 100 UNIT/ML (70-30)                     Insulins                             30
 NOVOLOG MIX INJ PENFILL    INSULIN ASPART PROT & ASPART (HUMAN) INJ 100 UNIT/ML (70-30)                     Insulins                             30
  NP THYROID TAB 30MG                          THYROID TAB 30 MG (1/2 GRAIN)                             Thyroid Agents                           30
  NP THYROID TAB 60MG                           THYROID TAB 60 MG (1 GRAIN)                              Thyroid Agents                           30
  NP THYROID TAB 90MG                        THYROID TAB 90 MG (1 1/2 GRAIN)                             Thyroid Agents                           30
     NUMOBID DX TAB            DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 30-675 MG                         Antitussives                     31     30
   NUPRIN    CAP 200MG                             IBUPROFEN CAP 200 MG                    Other Nonsteroidal Anti-inflammtory Agents     100     30
     NUTRADERM LOT                                 *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
    NUTRADERM-30 LOT                               *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
     NUTRINATE CHW             *PRENATAL VIT W/ FE FUMARATE-FA CHEW TAB 29-1 MG***                 Multivitamin Preparations                      30      40
      NUTRISPIRE TAB           *PRENATAL W/O A VIT W/ FE CARBONYL-FA TAB 29-1 MG***                Multivitamin Preparations                      30      40
      NUVARING MIS          ETONOGESTREL-ETHINYL ESTRADIOL VA RING 0.120-0.015 MG/24HR                   Contraceptives                           30
  NYAMYC     POW 100000                        *NYSTATIN TOPICAL POWDER**                                   Polyenes                              30                                                   Prior Authorization Req'd
     NYSTAT/TRIAM CRE           NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%                  Anti-inflammatory Agents                       30
     NYSTAT/TRIAM OIN            NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%                  Anti-inflammatory Agents                       30
   NYSTATIN CRE 100000                       NYSTATIN CREAM 100000 UNIT/GM                                  Polyenes                      30      30
   NYSTATIN OIN 100000                        NYSTATIN OINT 100000 UNIT/GM                                  Polyenes                      30      30
      NYSTATIN POW                                NYSTATIN (BULK) POWDER                              Pharmaceutical Aids                         30                                                   Prior Authorization Req'd
  NYSTATIN POW 100000                          *NYSTATIN TOPICAL POWDER**                                   Polyenes                              30                                                   Prior Authorization Req'd
  NYSTATIN POW 100MU                              NYSTATIN (BULK) POWDER                              Pharmaceutical Aids                         30                                                   Prior Authorization Req'd
   NYSTATIN POW 10BU                              NYSTATIN (BULK) POWDER                              Pharmaceutical Aids                         30                                                   Prior Authorization Req'd
    NYSTATIN POW 1BU                              NYSTATIN (BULK) POWDER                              Pharmaceutical Aids                         30                                                   Prior Authorization Req'd
    NYSTATIN POW 2BU                              NYSTATIN (BULK) POWDER                              Pharmaceutical Aids                         30                                                   Prior Authorization Req'd
  NYSTATIN POW 500MU                              NYSTATIN (BULK) POWDER                              Pharmaceutical Aids                         30                                                   Prior Authorization Req'd
   NYSTATIN POW 50MU                              NYSTATIN (BULK) POWDER                              Pharmaceutical Aids                         30                                                   Prior Authorization Req'd
    NYSTATIN POW 5BU                              NYSTATIN (BULK) POWDER                              Pharmaceutical Aids                         30                                                   Prior Authorization Req'd
NYSTATIN POW DOMESTIC                             NYSTATIN (BULK) POWDER                              Pharmaceutical Aids                         30                                                   Prior Authorization Req'd
 NYSTATIN POW FOREIGN                             NYSTATIN (BULK) POWDER                              Pharmaceutical Aids                         30                                                   Prior Authorization Req'd
    NYSTATIN POW USP                              NYSTATIN (BULK) POWDER                              Pharmaceutical Aids                         30                                                   Prior Authorization Req'd
   NYSTATIN SUS 100000                         NYSTATIN SUSP 100000 UNIT/ML                                 Polyenes                      200     30
  NYSTATIN TAB 500000                            NYSTATIN TAB 500000 UNIT                                   Polyenes                              30
 NYSTAT-RX POW 150MU                              NYSTATIN (BULK) POWDER                              Pharmaceutical Aids                         30                                                   Prior Authorization Req'd
   NYSTAT-RX POW 1BU                              NYSTATIN (BULK) POWDER                              Pharmaceutical Aids                         30                                                   Prior Authorization Req'd
                                                                                                                        Max Qty
                                                                                                                          Limit   Max Max Age
                                                                                                                        (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                              Generic Name                                 Therapy Class            in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
    NYSTAT-RX POW 2BU                           NYSTATIN (BULK) POWDER                        Pharmaceutical Aids                 30                                                   Prior Authorization Req'd
   NYSTAT-RX POW 500MU                          NYSTATIN (BULK) POWDER                        Pharmaceutical Aids                 30                                                   Prior Authorization Req'd
   NYSTAT-RX POW 50MU                           NYSTATIN (BULK) POWDER                        Pharmaceutical Aids                 30                                                   Prior Authorization Req'd
   NYSTOP    POW 100000                      *NYSTATIN TOPICAL POWDER**                              Polyenes                     30                                                   Prior Authorization Req'd
OB-NATAL ONE CAP 20-7-1MG   *PRENATAL W/FE CBNYL-FE ASP GLYC-FA-DSS-OMEGA CAP 20-7-1 MG*    Multivitamin Preparations             30      40
 OB-NATAL ONE CAP 27-1MG    *PRENATAL VIT W/ FE CBN-FE ASP GLYC-FA-OMEGA 3 CAP 27-1MG***    Multivitamin Preparations             30      40
      OBSTETRIX EC TAB          *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 29-1 MG***        Multivitamin Preparations             30
   OCELLA   TAB 3-0.03MG            DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG                  Contraceptives                  30
   OCUSULF-10 SOL 10% OP               SULFACETAMIDE SODIUM OPHTH SOLN 10%                        Antibacterials                  30
  OFLOXACIN DRO 0.3% OP                       OFLOXACIN OPHTH SOLN 0.3%                           Antibacterials                  30
 OFLOXACIN DRO 0.3%OTIC                        OFLOXACIN OTIC SOLN 0.3%                           Antibacterials                  30
   OFLOXACIN TAB 200MG                           OFLOXACIN TAB 200 MG                               Quinolones                    14
   OFLOXACIN TAB 300MG                           OFLOXACIN TAB 300 MG                               Quinolones                    14
   OFLOXACIN TAB 400MG                           OFLOXACIN TAB 400 MG                               Quinolones                    14
       OGESTREL TAB               NORGESTREL & ETHINYL ESTRADIOL TAB 0.5 MG-50 MCG                Contraceptives                  30
   OMEPRAZOLE CAP 10MG                  OMEPRAZOLE CAP DELAYED RELEASE 10 MG                 Proton-pump Inhibitors       30      30
   OMEPRAZOLE CAP 20MG                  OMEPRAZOLE CAP DELAYED RELEASE 20 MG                 Proton-pump Inhibitors       30      30
       OMNIFLEX DPR                                *DIAPHRAGMS***                                 Contraceptives                  30
ONDANSETRON SOL 4MG/5ML                 ONDANSETRON HCL ORAL SOLN 4 MG/5ML                 5-HT3 Receptor Antagonists             30      18                                           Prior Authorization Req'd
  ONDANSETRON TAB 24MG                       ONDANSETRON HCL TAB 24 MG                     5-HT3 Receptor Antagonists             30                                                   Prior Authorization Req'd
   ONDANSETRON TAB 4MG                        ONDANSETRON HCL TAB 4 MG                     5-HT3 Receptor Antagonists      9      30
ONDANSETRON TAB 4MG ODT             ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG             5-HT3 Receptor Antagonists      9      30
   ONDANSETRON TAB 8MG                        ONDANSETRON HCL TAB 8 MG                     5-HT3 Receptor Antagonists      9      30
ONDANSETRON TAB 8MG ODT             ONDANSETRON ORALLY DISINTEGRATING TAB 8 MG             5-HT3 Receptor Antagonists      9      30
    ONETOUCH KIT BASIC              *BLOOD GLUCOSE MONITORING KIT W/ DEVICE***                        Devices                     30
   ONETOUCH KIT PROFILE             *BLOOD GLUCOSE MONITORING KIT W/ DEVICE***                        Devices                     30
  ONETOUCH KIT ULT SMRT             *BLOOD GLUCOSE MONITORING KIT W/ DEVICE***                        Devices                     30
    ONETOUCH KIT ULTRA              *BLOOD GLUCOSE MONITORING KIT W/ DEVICE***                        Devices                     30
 OPTICHAMBER MIS ADV LRG           *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***                       Devices              2      30
 OPTICHAMBER MIS ADV MED           *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***                       Devices              2      30
 OPTICHAMBER MIS ADV SM            *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***                       Devices              2      30
OPTICHAMBER MIS ADVANTAG           *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***                       Devices              2      30
OPTICHAMBER MIS FACE MAS           *SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE***                       Devices              2      30
     ORALONE PST 0.1%                TRIAMCINOLONE ACETONIDE DENTAL PASTE 0.1%              Anti-inflammatory Agents              30                                                   Prior Authorization Req'd
       ORALYTE SOL                          *ORAL ELECTROLYTE SOLUTION***                   Replacement Preparations              30      18
    ORALYTE SOL FREEZE                      *ORAL ELECTROLYTE SOLUTION***                   Replacement Preparations              30      18
  ORAMORPH SR TAB 100MG                  MORPHINE SULFATE TAB SR 12HR 100 MG                     Opiate Agonists                  30                                                   Prior Authorization Req'd
  ORAMORPH SR TAB 15MG                   MORPHINE SULFATE TAB SR 12HR 15 MG                      Opiate Agonists                  30                                                   Prior Authorization Req'd
  ORAMORPH SR TAB 30MG                   MORPHINE SULFATE TAB SR 12HR 30 MG                      Opiate Agonists                  30                                                   Prior Authorization Req'd
  ORAMORPH SR TAB 60MG                   MORPHINE SULFATE TAB SR 12HR 60 MG                      Opiate Agonists                  30                                                   Prior Authorization Req'd
   ORGAN-I NR TAB 200MG                         GUAIFENESIN TAB 200 MG                             Expectorants           180     30
  ORGANIDIN NR TAB 200MG                        GUAIFENESIN TAB 200 MG                             Expectorants           180     30
   ORTHO COIL DPR KIT 100                 DIAPHRAGM COIL SPRING KIT 100 MM                        Contraceptives                  30
   ORTHO COIL DPR KIT 105                 DIAPHRAGM COIL SPRING KIT 105 MM                        Contraceptives                  30
   ORTHO COIL DPR KIT 50                  DIAPHRAGM COIL SPRING KIT 50 MM                         Contraceptives                  30
    ORTHO EVRA DIS WEEK      NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-20 MCG/24HR             Contraceptives                  30
   ORTHO FLAT DPR KIT 55                  DIAPHRAGM FLAT SPRING KIT 55 MM                         Contraceptives                  30
   ORTHO FLAT DPR KIT 60                  DIAPHRAGM FLAT SPRING KIT 60 MM                         Contraceptives                  30
   ORTHO FLAT DPR KIT 65                  DIAPHRAGM FLAT SPRING KIT 65 MM                         Contraceptives                  30
   ORTHO FLAT DPR KIT 70                  DIAPHRAGM FLAT SPRING KIT 70 MM                         Contraceptives                  30
   ORTHO FLAT DPR KIT 75                  DIAPHRAGM FLAT SPRING KIT 75 MM                         Contraceptives                  30
   ORTHO FLAT DPR KIT 80                  DIAPHRAGM FLAT SPRING KIT 80 MM                         Contraceptives                  30
   ORTHO FLAT DPR KIT 85                  DIAPHRAGM FLAT SPRING KIT 85 MM                         Contraceptives                  30
   ORTHO FLAT DPR KIT 90                  DIAPHRAGM FLAT SPRING KIT 90 MM                         Contraceptives                  30
   ORTHO FLAT DPR KIT 95                  DIAPHRAGM FLAT SPRING KIT 95 MM                         Contraceptives                  30
   ORTHO FLEX DPR 55MM                     DIAPHRAGM ARC-SPRING KIT 55 MM                         Contraceptives                  30
   ORTHO FLEX DPR 60MM                     DIAPHRAGM ARC-SPRING KIT 60 MM                         Contraceptives                  30
   ORTHO FLEX DPR 65MM                       DIAPHRAGM ARC-SPRING 65 MM                           Contraceptives                  30
   ORTHO FLEX DPR 70MM                       DIAPHRAGM ARC-SPRING 70 MM                           Contraceptives                  30
   ORTHO FLEX DPR 75MM                       DIAPHRAGM ARC-SPRING 75 MM                           Contraceptives                  30
   ORTHO FLEX DPR 80MM                       DIAPHRAGM ARC-SPRING 80 MM                           Contraceptives                  30
   ORTHO FLEX DPR 85MM                     DIAPHRAGM ARC-SPRING KIT 85 MM                         Contraceptives                  30
   ORTHO FLEX DPR 90MM                     DIAPHRAGM ARC-SPRING KIT 90 MM                         Contraceptives                  30
   ORTHO FLEX DPR 95MM                     DIAPHRAGM ARC-SPRING KIT 95 MM                         Contraceptives                  30
  ORTHO TRI- TAB CYCLN LO    NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG          Contraceptives                  30
                                                                                                                                       Max Qty
                                                                                                                                         Limit   Max Max Age
                                                                                                                                       (Liquids Days    Limit    Step         Step Therapy      Specialty
    Drug/Product Name                              Generic Name                                        Therapy Class                    in mLs) Supply (Years) Required?      Requirement         Drug         Coverage Status
   ORTHO-EST TAB 0.625                     ESTROPIPATE TAB 0.75 MG                                       Estrogens                               30
   ORTHO-EST TAB 1.25                       ESTROPIPATE TAB 1.5 MG                                       Estrogens                               30
    OTOGESIC SOL OTIC               BENZOCAINE-ANTIPYRINE OTIC SOLN 1.4-5.4%                          Local Anesthetics                          30
     OVCON 50 TAB 28           NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG-50 MCG                       Contraceptives                            30




                                                                                                                                                                            USE FORMULARY
   OXAPROZIN TAB 600MG                          OXAPROZIN TAB 600 MG                      Other Nonsteroidal Anti-inflammtory Agents             30                Y       GENERIC NSAIDS 1ST
OXCARBAZEPIN SUS 300MG/5M           OXCARBAZEPINE SUSP 300 MG/5ML (60 MG/ML)                    Anticonvulsants, Miscellaneous                   30      18                                                 Prior Authorization Req'd
  OXCARBAZEPIN TAB 150MG                      OXCARBAZEPINE TAB 150 MG                          Anticonvulsants, Miscellaneous                   30                                                         Prior Authorization Req'd
  OXCARBAZEPIN TAB 300MG                      OXCARBAZEPINE TAB 300 MG                          Anticonvulsants, Miscellaneous                   30                                                         Prior Authorization Req'd
  OXCARBAZEPIN TAB 600MG                      OXCARBAZEPINE TAB 600 MG                          Anticonvulsants, Miscellaneous                   30                                                         Prior Authorization Req'd
       OXISTAT CRE 1%                     OXICONAZOLE NITRATE CREAM 1%                                        Azoles                             30                                                         Prior Authorization Req'd
       OXISTAT LOT 1%                     OXICONAZOLE NITRATE LOTION 1%                                       Azoles                             30                                                         Prior Authorization Req'd
 OXYBUTYNIN SYP 5MG/5ML                OXYBUTYNIN CHLORIDE SYRUP 5 MG/5ML                   Genitourinary Smooth Muscle Relaxants                30
     OXYBUTYNIN TAB 5MG                    OXYBUTYNIN CHLORIDE TAB 5 MG                     Genitourinary Smooth Muscle Relaxants                30
 OXYCOD/APAP TAB 5-325MG           OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG                             Opiate Agonists                   120     30
       OXYCOD/ASA TAB                OXYCODONE W/ ASPIRIN TAB FULL STRENGTH                            Opiate Agonists                   120     30
    OXYCODONE CAP 5MG                          OXYCODONE HCL CAP 5 MG                                  Opiate Agonists                   120     30
   OXYCODONE TAB 10MG                         OXYCODONE HCL TAB 10 MG                                  Opiate Agonists                   120     30
   OXYCODONE TAB 15MG                         OXYCODONE HCL TAB 15 MG                                  Opiate Agonists                   120     30
   OXYCODONE TAB 20MG                         OXYCODONE HCL TAB 20 MG                                  Opiate Agonists                   120     30
   OXYCODONE TAB 30MG                         OXYCODONE HCL TAB 30 MG                                  Opiate Agonists                   120     30
    OXYCODONE TAB 5MG                          OXYCODONE HCL TAB 5 MG                                  Opiate Agonists                   120     30
    PACERONE TAB 200MG                      AMIODARONE HCL TAB 200 MG                              Class III Antiarrhythmics                     30
  PAIN & FEVER SOL 160/5ML               ACETAMINOPHEN SOLN 160 MG/5ML                         Analgesics and Antipyretics, Misc         240     30
    PAIN EX STR TAB 500MG                    ACETAMINOPHEN TAB 500 MG                          Analgesics and Antipyretics, Misc         250     30
   PAIN REL 8HR TAB 650MG                  ACETAMINOPHEN TAB CR 650 MG                         Analgesics and Antipyretics, Misc         120     30
    PAIN RELIEF CAP 500MG                    ACETAMINOPHEN CAP 500 MG                          Analgesics and Antipyretics, Misc         250     30
 PAIN RELIEF CHW 160MG JR                ACETAMINOPHEN CHEW TAB 160 MG                         Analgesics and Antipyretics, Misc          60     30
    PAIN RELIEF CHW 80MG                 ACETAMINOPHEN CHEW TAB 80 MG                          Analgesics and Antipyretics, Misc          60     30
 PAIN RELIEF DRO 100MG/ML                ACETAMINOPHEN SOLN 100 MG/ML                          Analgesics and Antipyretics, Misc          30     30
  PAIN RELIEF DRO 80/0.8ML              ACETAMINOPHEN SUSP 80 MG/0.8ML                         Analgesics and Antipyretics, Misc          30     30
   PAIN RELIEF DRO INFANTS              ACETAMINOPHEN SUSP 80 MG/0.8ML                         Analgesics and Antipyretics, Misc          30     30
   PAIN RELIEF LIQ 160/5ML              ACETAMINOPHEN LIQUID 160 MG/5ML                        Analgesics and Antipyretics, Misc         240     30
   PAIN RELIEF SUS 160/5ML               ACETAMINOPHEN SUSP 160 MG/5ML                         Analgesics and Antipyretics, Misc         240     30
     PAIN RELIEF SUS CHILD               ACETAMINOPHEN SUSP 160 MG/5ML                         Analgesics and Antipyretics, Misc         240     30
    PAIN RELIEF TAB 325MG                    ACETAMINOPHEN TAB 325 MG                          Analgesics and Antipyretics, Misc         250     30
    PAIN RELIEF TAB 500MG                    ACETAMINOPHEN TAB 500 MG                          Analgesics and Antipyretics, Misc         250     30
  PAIN RELIEF TAB 500MG/RR                   ACETAMINOPHEN TAB 500 MG                          Analgesics and Antipyretics, Misc         250     30
    PAIN RELIEF TAB 650MG                  ACETAMINOPHEN TAB CR 650 MG                         Analgesics and Antipyretics, Misc         120     30
  PAIN RELIEF TAB 650MG CR                 ACETAMINOPHEN TAB CR 650 MG                         Analgesics and Antipyretics, Misc         120     30
   PAIN RELIEVE CAP 500MG                    ACETAMINOPHEN CAP 500 MG                          Analgesics and Antipyretics, Misc         250     30
   PAIN RELIEVE CHW 160MG                ACETAMINOPHEN CHEW TAB 160 MG                         Analgesics and Antipyretics, Misc          60     30
 PAIN RELIEVE CHW 160MG JR               ACETAMINOPHEN CHEW TAB 160 MG                         Analgesics and Antipyretics, Misc          60     30
 PAIN RELIEVE DRO 80/0.8ML              ACETAMINOPHEN SUSP 80 MG/0.8ML                         Analgesics and Antipyretics, Misc          30     30
  PAIN RELIEVE SUS 160/5ML               ACETAMINOPHEN SUSP 160 MG/5ML                         Analgesics and Antipyretics, Misc         240     30
   PAIN RELIEVE TAB 160MG                    ACETAMINOPHEN TAB 160 MG                          Analgesics and Antipyretics, Misc         250     30
   PAIN RELIEVE TAB 325MG                    ACETAMINOPHEN TAB 325 MG                          Analgesics and Antipyretics, Misc         250     30
   PAIN RELIEVE TAB 500MG                    ACETAMINOPHEN TAB 500 MG                          Analgesics and Antipyretics, Misc         250     30
 PAIN RELIEVE TAB 500MG/RR                   ACETAMINOPHEN TAB 500 MG                          Analgesics and Antipyretics, Misc         250     30
   PAIN RELIEVR CHW 80MG                 ACETAMINOPHEN CHEW TAB 80 MG                          Analgesics and Antipyretics, Misc          60     30
        PALCAPS 10 CAP         AMY-LIP-PROT DR PARTICLES CAP 33200-10000-37500 UNIT                        Digestants                            30
        PALCAPS 20 CAP         AMY-LIP-PROT DR PARTICLES CAP 66400-20000-75000 UNIT                        Digestants                            30
 PANCREAZE CAP 10500UNT      PANCRELIPASE (LIP-PROT-AMYL) DR CAP 10500-25000-43750 UNIT                    Digestants                            30
 PANCREAZE CAP 16800UNT      PANCRELIPASE (LIP-PROT-AMYL) DR CAP 16800-40000-70000 UNIT                    Digestants                            30
 PANCREAZE CAP 21000UNT      PANCRELIPASE (LIP-PROT-AMYL) DR CAP 21000-37000-61000 UNIT                    Digestants                            30
  PANCREAZE CAP 4200UNIT     PANCRELIPASE (LIP-PROT-AMYL) DR CAP 4200-10000-17500 UNIT                     Digestants                            30
 PANCRELIPASE CAP 5000UNIT   PANCRELIPASE (LIP-PROT-AMYL) DR CAP 5000-17000-27000 UNIT                     Digestants                            30
      PANCRON 10 CAP EC        AMY-LIP-PROT DR PARTICLES CAP 33200-10000-37500 UNIT                        Digestants                            30
       PANCRON 20 CAP          AMY-LIP-PROT DR PARTICLES CAP 66400-20000-75000 UNIT                        Digestants                            30
       PANGES CN 10 CAP        AMY-LIP-PROT DR PARTICLES CAP 33200-10000-37500 UNIT                        Digestants                            30
       PANGES CN 20 CAP        AMY-LIP-PROT DR PARTICLES CAP 66400-20000-75000 UNIT                        Digestants                            30
                                                                                                                                   Max Qty
                                                                                                                                     Limit   Max Max Age
                                                                                                                                   (Liquids Days    Limit    Step         Step Therapy     Specialty
    Drug/Product Name                                 Generic Name                                     Therapy Class                in mLs) Supply (Years) Required?      Requirement        Drug         Coverage Status
    PANGES MT 16 CAP               AMY-LIP-PROT DR PARTICLES CAP 48000-16000-48000 UNIT                  Digestants                          30
     PANGES UL 12 CAP              AMY-LIP-PROT DR PARTICLES CAP 39000-12000-39000 UNIT                  Digestants                          30
     PANGES UL 18 CAP              AMY-LIP-PROT DR PARTICLES CAP 58500-18000-58500 UNIT                  Digestants                          30
     PANGES UL 20 CAP              AMY-LIP-PROT DR PARTICLES CAP 65000-20000-65000 UNIT                  Digestants                          30
    PANGESTYM EC CAP               AMY-LIP-PROT DR PARTICLES CAP 20000-4500-25000 UNIT                   Digestants                          30
    PANOKASE-16 TAB                AMYLASE-LIPASE-PROTEASE TAB 60000-16000-60000 UNIT                    Digestants                          30




                                                                                                                                                                       USE OMEPRAZOLE 20
 PANTOPRAZOLE TAB 20MG                PANTOPRAZOLE SODIUM EC TAB 20 MG (BASE EQUIV)                Proton-pump Inhibitors                    30                Y        MG CAPSULES 1ST




                                                                                                                                                                       USE OMEPRAZOLE 20
  PANTOPRAZOLE TAB 40MG                PANTOPRAZOLE SODIUM EC TAB 40 MG (BASE EQUIV)               Proton-pump Inhibitors                    30                Y        MG CAPSULES 1ST
  PB-HYOS ELX 16MG/5ML             BELLADONNA ALKALOIDS-PHENOBARBITAL ELIXIR 16 MG/5ML         Antimuscarinics/Antispasmodics         60     30      18
       PBM ALLERGY SYP               PSEUDOEPHED-BROMPHEN-DM SYRUP 30-3-15 MG/5ML                        Antitussives                178     30
    PC PED ELECT SOL FRUIT                      *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
    PC PED ELECT SOL GRAPE                      *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
 PC PEDIATRIC SOL ELECTROL                      *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
       PE/HCOD/CPM LIQ           PHENYLEPH-CHLORPHEN W/ HYDROCODONE LIQD 5-2-5 MG/5ML                    Antitussives                        30
        PE/PYRIL/HYD SYP      PHENYLEPH-PYRILAMINE W/ HYDROCODONE SYRUP 5-8.33-1.66 MG/5ML               Antitussives                178     30
       PED ELCTRLYT SOL                         *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
    PED ELCTRLYT SOL APPLE                      *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
PED ELCTRLYT SOL BUBBLEGM                       *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
PED ELCTRLYT SOL BUBBLGUM                       *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
 PED ELCTRLYT SOL FLAVORD                       *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
   PED ELCTRLYT SOL FREEZE                      *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
  PED ELCTRLYT SOL FREEZER                      *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
 PED ELCTRLYT SOL FREEZPOP                      *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
    PED ELCTRLYT SOL FRUIT                      *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
   PED ELCTRLYT SOL GRAPE                       *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
  PED ELCTRLYT SOL MANGO                        *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
PED ELCTRLYT SOL STRAWBRY                       *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
PED ELCTRLYT SOL UNFLAVRD                       *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
 PED FORMULA LIQ 100-10/5          DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                     Antitussives                180     30
   PEDIA RELIEF DRO 7.5/0.8                PSEUDOEPHEDRINE HCL SOLN 7.5 MG/0.8ML             alpha- and beta-Adrenergic Agonists      15     30
    PEDIA VANCE SOL APPLE                       *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
   PEDIA VANCE SOL GRAPE                        *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
   PEDIACARE LIQ ALLERGY                  DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                  Ethanolamine Derivatives                   30
  PEDIACARE LIQ CHILD NT                  DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                  Ethanolamine Derivatives                   30
         PEDIA-POP SOL                          *ORAL ELECTROLYTE SOLUTION***                     Replacement Preparations                   30      18
    PEDI-DRI POW 100000                          *NYSTATIN TOPICAL POWDER**                                Polyenes                          30                                                        Prior Authorization Req'd
   PEG 3350 SOL ELECTROL          PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 240 GM           Cathartics and Laxatives         4000     30
  PEG-3350 SOL ELECTROL           PEG 3350-KCL-NA BICARB-NACL-NA SULFATE FOR SOLN 236 GM           Cathartics and Laxatives         4000     30
  PENICILLN VK SOL 125/5ML               PENICILLIN V POTASSIUM FOR SOLN 125 MG/5ML                   Natural Penicillins                    14      18
  PENICILLN VK SOL 250/5ML               PENICILLIN V POTASSIUM FOR SOLN 250 MG/5ML                   Natural Penicillins                    14      18
   PENICILLN VK TAB 250MG                     PENICILLIN V POTASSIUM TAB 250 MG                       Natural Penicillins                    14
   PENICILLN VK TAB 500MG                     PENICILLIN V POTASSIUM TAB 500 MG                       Natural Penicillins                    14
  PENTASA CAP 250MG CR                            MESALAMINE CAP CR 250 MG                        Anti-inflammatory Agents                   30                                                        Prior Authorization Req'd
  PENTASA CAP 500MG CR                            MESALAMINE CAP CR 500 MG                        Anti-inflammatory Agents                   30                                                        Prior Authorization Req'd
 PENTOPAK TAB 400MG CR                           PENTOXIFYLLINE TAB CR 400 MG                      Hemorrheologic Agents                     30
 PENTOXIFYLLI TAB 400MG CR                       PENTOXIFYLLINE TAB CR 400 MG                      Hemorrheologic Agents                     30
 PENTOXIFYLLI TAB 400MG ER                       PENTOXIFYLLINE TAB CR 400 MG                      Hemorrheologic Agents                     30
  PENTOXIL TAB 400MG CR                          PENTOXIFYLLINE TAB CR 400 MG                      Hemorrheologic Agents                     30
   PEPTIC RELF CHW 262MG                   BISMUTH SUBSALICYLATE CHEW TAB 262 MG                     Antidiarrhea Agents            120      30
   PEPTIC RELF CHW 300MG                   BISMUTH SUBSALICYLATE CHEW TAB 300 MG                     Antidiarrhea Agents            120      30
  PEPTIC RELF SUS 527/30ML                BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                     Antidiarrhea Agents            1800     30
    PEPTIC RELIE TAB 262MG                    BISMUTH SUBSALICYLATE TAB 262 MG                       Antidiarrhea Agents            120      30
 PERI-COLACE TAB 8.6-50MG                SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                  Cathartics and Laxatives         100      30
    PERIOGARD SOL 0.12%                     CHLORHEXIDINE GLUCONATE SOLN 0.12%               EENT Anti-infectives, Miscellaneous             30
     PERISOL SOL 0.12%                      CHLORHEXIDINE GLUCONATE SOLN 0.12%               EENT Anti-infectives, Miscellaneous             30
     PERMETHRIN CRE 5%                               PERMETHRIN CREAM 5%                         Scabicides and Pediculicides         60     30
     PERMETHRIN LIQ 1%                            PERMETHRIN CREME RINSE 1%                      Scabicides and Pediculicides        120     30
                                                                                                                                 Max Qty
                                                                                                                                   Limit   Max Max Age
                                                                                                                                 (Liquids Days    Limit    Step      Step Therapy   Specialty
   Drug/Product Name                               Generic Name                                     Therapy Class                 in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
     PERMETHRIN LOT 1%                            PERMETHRIN LOTION 1%                        Scabicides and Pediculicides                 30
   PERTUSSIN LIQ 3.5-25/5       DEXTROMETHORPHAN-GUAIFENESIN LIQUID 3.5-25 MG/5ML                      Antitussives                180     30
  PHANASIN SYP 100/5ML                       GUAIFENESIN SYRUP 100 MG/5ML                             Expectorants                         30
PHANATUSS DM SYP 100-10/5       DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                       Antitussives                180     30
   PHARBEDRYL CAP 25MG                     DIPHENHYDRAMINE HCL CAP 25 MG                       Ethanolamine Derivatives                    30
   PHARBEDRYL CAP 50MG                     DIPHENHYDRAMINE HCL CAP 50 MG                       Ethanolamine Derivatives                    30
   PHARBETOL TAB 325MG                        ACETAMINOPHEN TAB 325 MG                      Analgesics and Antipyretics, Misc      250     30
   PHARBETOL TAB 500MG                        ACETAMINOPHEN TAB 500 MG                      Analgesics and Antipyretics, Misc      250     30
 PHARMAFLUR CHW 0.5MG           SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)        Miscellaneous Therapeutic Agents                30
 PHARMAFLUR CHW 2.2MG            SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)         Miscellaneous Therapeutic Agents                30
 PHARMASIN SYP 100/5ML                       GUAIFENESIN SYRUP 100 MG/5ML                             Expectorants                         30
 PHARMATUSS SYP 100-10/5        DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                       Antitussives                180     30
      PHEN/CHLOR SYP HC     PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 5-2-2.5 MG/5ML                    Antitussives                178     30
  PHENADOZ SUP 12.5MG                     PROMETHAZINE HCL SUPPOS 12.5 MG                      Phenothiazine Derivatives                   30
    PHENADOZ SUP 25MG                      PROMETHAZINE HCL SUPPOS 25 MG                       Phenothiazine Derivatives                   30
 PHENAZ/BUTAB TAB /HYOSC    PHENAZOPYRIDINE-BUTABARBITAL-HYOSCYAMINE TAB 150-15-0.3 MG     Antipruritics and Local Anesthetics             30
    PHENAZO TAB 200MG                      PHENAZOPYRIDINE HCL TAB 200 MG                  Antipruritics and Local Anesthetics             30
   PHENAZOFORTE TAB PLUS    PHENAZOPYRIDINE-BUTABARBITAL-HYOSCYAMINE TAB 150-15-0.3 MG     Antipruritics and Local Anesthetics             30
 PHENAZOPYRID TAB 100MG                    PHENAZOPYRIDINE HCL TAB 100 MG                  Antipruritics and Local Anesthetics             30
 PHENAZOPYRID TAB 200MG                    PHENAZOPYRIDINE HCL TAB 200 MG                  Antipruritics and Local Anesthetics             30
   PHENAZOPYRID TAB PLUS    PHENAZOPYRIDINE-BUTABARBITAL-HYOSCYAMINE TAB 150-15-0.3 MG     Antipruritics and Local Anesthetics             30
PHENOBARB ELX 20MG/5ML                      PHENOBARBITAL ELIXIR 20 MG/5ML                             Barbiturates                        30      18
       PHENOBARB POW                             PHENOBARBITAL POWDER                             Pharmaceutical Aids                      30                                                   Prior Authorization Req'd
    PHENOBARB POW USP                            PHENOBARBITAL POWDER                             Pharmaceutical Aids                      30                                                   Prior Authorization Req'd
  PHENOBARB POW USP NF                           PHENOBARBITAL POWDER                             Pharmaceutical Aids                      30                                                   Prior Authorization Req'd
  PHENOBARB TAB 100MG                          PHENOBARBITAL TAB 100 MG                                Barbiturates                        30
   PHENOBARB TAB 15MG                           PHENOBARBITAL TAB 15 MG                                Barbiturates                        30
  PHENOBARB TAB 16.2MG                        PHENOBARBITAL TAB 16.2 MG                                Barbiturates                        30
   PHENOBARB TAB 30MG                           PHENOBARBITAL TAB 30 MG                                Barbiturates                        30
  PHENOBARB TAB 32.4MG                        PHENOBARBITAL TAB 32.4 MG                                Barbiturates                        30
   PHENOBARB TAB 60MG                           PHENOBARBITAL TAB 60 MG                                Barbiturates                        30
  PHENOBARB TAB 64.8MG                        PHENOBARBITAL TAB 64.8 MG                                Barbiturates                        30
  PHENOBARB TAB 97.2MG                        PHENOBARBITAL TAB 97.2 MG                                Barbiturates                        30
      PHENOBARB NA POW                      PHENOBARBITAL SODIUM POWDER                           Pharmaceutical Aids                      30                                                   Prior Authorization Req'd
PHENOBARB NA POW USP NF                     PHENOBARBITAL SODIUM POWDER                           Pharmaceutical Aids                      30                                                   Prior Authorization Req'd
     PHENYLEPHRIN LIQ HD              PHENYLEPH-HYDROCODONE LIQ 5-2.5 MG/5ML                           Antitussives                        30
  PHENYTOIN SUS 100/4ML                       PHENYTOIN SUSP 125 MG/5ML                                Hydantoins                          30      18
  PHENYTOIN SUS 125/5ML                       PHENYTOIN SUSP 125 MG/5ML                                Hydantoins                          30      18
  PHENYTOIN EX CAP 100MG               PHENYTOIN SODIUM EXTENDED CAP 100 MG                            Hydantoins                          30
  PHENYTOIN EX CAP 200MG               PHENYTOIN SODIUM EXTENDED CAP 200 MG                            Hydantoins                          30
  PHENYTOIN EX CAP 300MG               PHENYTOIN SODIUM EXTENDED CAP 300 MG                            Hydantoins                          30
     PHILLIPS CAP 100MG                      DOCUSATE SODIUM CAP 100 MG                         Cathartics and Laxatives           100     30
    PHILLIPS CAP LIQ-GEL                     DOCUSATE SODIUM CAP 100 MG                         Cathartics and Laxatives           100     30
         PHLEMEX TAB           DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 20-1200 MG                     Antitussives                 31     30
        PHLUORIVIT DRO      *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.25 MG/ML***        Multivitamin Preparations                   30      18
      PHLUORIVIT + DRO FE    *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE DROPS 0.25-10 MG/ML**       Multivitamin Preparations                   30      18
     PHOS-FLUR GEL 1.1%                    SODIUM FLUORIDE GEL 1.1% (0.5% F)               Miscellaneous Therapeutic Agents                30      18
PHYTONADIONE INJ 1MG/0.5                       PHYTONADIONE INJ 2 MG/ML                            Vitamin K Activity                      30
PHYTONADIONE INJ 2MG/ML                        PHYTONADIONE INJ 2 MG/ML                            Vitamin K Activity                      30
     PILOCAR SOL 1% OP                      PILOCARPINE HCL OPHTH SOLN 1%                                MIOTICS                           30
     PILOCAR SOL 2% OP                      PILOCARPINE HCL OPHTH SOLN 2%                                MIOTICS                           30
     PILOCAR SOL 4% OP                      PILOCARPINE HCL OPHTH SOLN 4%                                MIOTICS                           30
     PILOCAR SOL 6% OP                      PILOCARPINE HCL OPHTH SOLN 6%                                MIOTICS                           30
   PILOCARPINE SOL 1% OP                    PILOCARPINE HCL OPHTH SOLN 1%                                MIOTICS                           30
   PILOCARPINE SOL 2% OP                    PILOCARPINE HCL OPHTH SOLN 2%                                MIOTICS                           30
   PILOCARPINE SOL 3% OP                    PILOCARPINE HCL OPHTH SOLN 3%                                MIOTICS                           30
   PILOCARPINE SOL 4% OP                    PILOCARPINE HCL OPHTH SOLN 4%                                MIOTICS                           30
   PILOCARPINE SOL 6% OP                    PILOCARPINE HCL OPHTH SOLN 6%                                MIOTICS                           30
     PILOPTIC-1 SOL 1% OP                   PILOCARPINE HCL OPHTH SOLN 1%                                MIOTICS                           30
     PILOPTIC-2 SOL 2% OP                   PILOCARPINE HCL OPHTH SOLN 2%                                MIOTICS                           30
     PILOPTIC-4 SOL 4% OP                   PILOCARPINE HCL OPHTH SOLN 4%                                MIOTICS                           30
     PILOPTIC-6 SOL 6% OP                   PILOCARPINE HCL OPHTH SOLN 6%                                MIOTICS                           30
    PINDOLOL TAB 10MG                              PINDOLOL TAB 10 MG                       Beta-Adrenergic Blocking Agents                30
     PINDOLOL TAB 5MG                               PINDOLOL TAB 5 MG                       Beta-Adrenergic Blocking Agents                30
 PINK BIS MS SUS 525/15ML              BISMUTH SUBSALICYLATE SUSP 525 MG/15ML                     Antidiarrhea Agents             1800     30
                                                                                                                                          Max Qty
                                                                                                                                            Limit   Max Max Age
                                                                                                                                          (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                                Generic Name                                         Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
 PINK BISMUTH CHW 262MG                   BISMUTH SUBSALICYLATE CHEW TAB 262 MG                          Antidiarrhea Agents               120      30
 PINK BISMUTH CHW 300MG                   BISMUTH SUBSALICYLATE CHEW TAB 300 MG                          Antidiarrhea Agents               120      30
PINK BISMUTH SUS 262/15ML                BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                          Antidiarrhea Agents               1800     30
PINK BISMUTH SUS 524/30ML                BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                          Antidiarrhea Agents               1800     30
PINK BISMUTH SUS 525/15ML                BISMUTH SUBSALICYLATE SUSP 525 MG/15ML                          Antidiarrhea Agents               1800     30
PINK BISMUTH SUS 527/30ML                BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                          Antidiarrhea Agents               1800     30
PINK BISMUTH SUS 690/30ML                BISMUTH SUBSALICYLATE SUSP 690 MG/30ML                          Antidiarrhea Agents               1800     30
 PINK BISMUTH SUS MAX STR                BISMUTH SUBSALICYLATE SUSP 525 MG/15ML                          Antidiarrhea Agents               1800     30
  PINK BISMUTH TAB 262MG                      BISMUTH SUBSALICYLATE TAB 262 MG                           Antidiarrhea Agents               120      30
    PIROXICAM CAP 10MG                               PIROXICAM CAP 10 MG                     Other Nonsteroidal Anti-inflammtory Agents             30
    PIROXICAM CAP 20MG                               PIROXICAM CAP 20 MG                     Other Nonsteroidal Anti-inflammtory Agents             30
     PLAN B     TAB 1.5MG                        LEVONORGESTREL TAB 1.5 MG                                   Contraceptives                         30
     PLARETASE TAB 8000              AMYLASE-LIPASE-PROTEASE TAB 30000-8000-30000 UNIT                         Digestants                           30
    PLASBUMIN-25 INJ 25%                           ALBUMIN HUMAN INJ 25%                                   Blood Derivatives                        30                                                   Prior Authorization Req'd
     PLAVIX     TAB 300MG              CLOPIDOGREL BISULFATE TAB 300 MG (BASE EQUIV)                Platelet-Aggregation Inhibitors                 30
      PLAVIX     TAB 75MG              CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)                 Platelet-Aggregation Inhibitors                 30
  PNEUMOVAX 23 INJ 25/0.5           PNEUMOCOCCAL VACCINE POLYVALENT INJ 25 MCG/0.5ML                            Vaccines                            30
         PNV-DHA CAP         *PRENAT W/O A W/ FE FUM-METHYLFOL-FA-DHA CAP 27-0.6-0.4 MG**             Multivitamin Preparations                     30      40
        PNV-SELECT TAB        *PRENATAL VIT W/ FE FUM-METHYLFOLATE-FA TAB 27-0.6-0.4 MG***            Multivitamin Preparations                     30      40
    PODOFILOX SOL 0.5%                               PODOFILOX SOLN 0.5%                      Skin and Mucous Membrane Agents, Misc                 30
        POLY BACITRA OIN                       *BACITRACIN-POLYMYXIN B OINT***                                Antibacterials                        30
        POLY IRON PN TAB            *PRENATAL VIT W/ FE POLYSAC CMPLX-FA TAB 60-1 MG***               Multivitamin Preparations                     30
   POLY IRON PN TAB FORTE           *PRENATAL VIT W/ FE POLYSAC CMPLX-FA TAB 60-1 MG***               Multivitamin Preparations                     30
  POLY/IRON CAP 150 FORT           IRON POLYSACCH COMPLEX-VIT B12-FA CAP 150-0.025-1 MG                    Iron Preparations                        30
       POLYCIN B OIN OP                      BACITRACIN-POLYMYXIN B OPHTH OINT                                Antibacterials                        30
   POLY-DEX OIN 0.1% OP            NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH OINT 0.1%                          Corticosteroids                        30
   POLY-DEX SUS 0.1% OP            NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH SUSP 0.1%                          Corticosteroids                        30
 POLYETH GLYC POW 3350 NF                 POLYETHYLENE GLYCOL 3350 ORAL POWDER                         Cathartics and Laxatives                     30      12
  POLYGESIC CAP 500-5MG                 HYDROCODONE-ACETAMINOPHEN CAP 5-500 MG                              Opiate Agonists                 150     30
       POLYMY/BACIT OIN                        *BACITRACIN-POLYMYXIN B OINT***                                Antibacterials                        30
POLYMYXIN B/ SOL TRIMETHP       POLYMYXIN B-TRIMETHOPRIM OPHTH SOLN 10000 UNIT/ML-0.1%                        Antibacterials                        30
   POLYSACCHARI CAP IRON           IRON POLYSACCH COMPLEX-VIT B12-FA CAP 150-0.025-1 MG                    Iron Preparations                        30
  POLY-VIT W/F DRO 0.25MG     *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.25 MG/ML***             Multivitamin Preparations                     30      18
  POLY-VIT/FE CHW /FL 1MG        *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE CHEW TAB 1-12 MG**             Multivitamin Preparations                     30
  POLY-VIT/FE DRO /FL 0.25     *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE DROPS 0.25-10 MG/ML**            Multivitamin Preparations                     30      18
   POLY-VIT/FE DRO /FL 0.5      *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE DROPS 0.5-10 MG/ML**            Multivitamin Preparations                     30      18
 POLYVIT/FL DRO 0.5MG/ML       *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.5 MG/ML***             Multivitamin Preparations                     30      18
   POLY-VIT/FL CHW 0.5MG      *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.5 MG***             Multivitamin Preparations                     30
   POLY-VIT/FL DRO 0.25MG     *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.25 MG/ML***             Multivitamin Preparations                     30     18
   POLY-VIT/FL DRO 0.5MG       *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN 0.5 MG/ML***             Multivitamin Preparations                     30     18
       POLYVITAMIN DRO               *PEDIATRIC MULTIPLE VITAMIN W/ C SOLN 35 MG/ML**                 Multivitamin Preparations                     30      1
   POLYVITAMIN DRO /IRON          *PEDIATRIC MULTIPLE VITAMINS W/ IRON DROPS 10 MG/ML**               Multivitamin Preparations                     30     0.5
       POLY-VITAMIN DRO              *PEDIATRIC MULTIPLE VITAMIN W/ C SOLN 35 MG/ML**                 Multivitamin Preparations                     30      1
  POLY-VITAMIN DRO /IRON          *PEDIATRIC MULTIPLE VITAMINS W/ IRON DROPS 10 MG/ML**               Multivitamin Preparations                     30     0.5
 POLYVITES/FL CHW 0.25MG     *PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB 0.25 MG***             Multivitamin Preparations                     30
   POLYVITS/FE DRO 0.25/FL     *PEDIATRIC MULTIPLE VITAMINS W/ FL-FE DROPS 0.25-10 MG/ML**            Multivitamin Preparations                     30      18
         PORTIA-28 TAB            LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG                      Contraceptives                         30
POT CHLORIDE CAP 10MEQ CR                    POTASSIUM CHLORIDE CAP CR 10 MEQ                         Replacement Preparations                      30
POT CHLORIDE CAP 10MEQ ER                    POTASSIUM CHLORIDE CAP CR 10 MEQ                         Replacement Preparations                      30
    POT CHLORIDE LIQ 10%              POTASSIUM CHLORIDE ORAL LIQ 10% (20 MEQ/15ML)                   Replacement Preparations                      30      18
   POT CHLORIDE LIQ 10% SF            POTASSIUM CHLORIDE ORAL LIQ 10% (20 MEQ/15ML)                   Replacement Preparations                      30      18
    POT CHLORIDE LIQ 20%              POTASSIUM CHLORIDE ORAL LIQ 20% (40 MEQ/15ML)                   Replacement Preparations                      30      18
   POT CHLORIDE LIQ 20% SF            POTASSIUM CHLORIDE ORAL LIQ 20% (40 MEQ/15ML)                   Replacement Preparations                      30      18
 POT CHLORIDE POW 20MEQ                 POTASSIUM CHLORIDE POWDER PACKET 20 MEQ                       Replacement Preparations                      30
  POT CHLORIDE SOL 10% SF             POTASSIUM CHLORIDE ORAL LIQ 10% (20 MEQ/15ML)                   Replacement Preparations                      30      18
POT CHLORIDE TAB 10MEQ CR                    POTASSIUM CHLORIDE TAB CR 10 MEQ                         Replacement Preparations                      30
POT CHLORIDE TAB 10MEQ ER                    POTASSIUM CHLORIDE TAB CR 10 MEQ                         Replacement Preparations                      30
POT CHLORIDE TAB 10MEQ SR                    POTASSIUM CHLORIDE TAB CR 10 MEQ                         Replacement Preparations                      30
POT CHLORIDE TAB 25MEQ EF              POT BICARBONATE & CHLORIDE EFFER TAB 25 MEQ                    Replacement Preparations                      30
POT CL MICRO TAB 10MEQ CR      POTASSIUM CHLORIDE MICROENCAPSULATED CRYS CR TAB 10 MEQ                Replacement Preparations                      30
POT CL MICRO TAB 10MEQ ER      POTASSIUM CHLORIDE MICROENCAPSULATED CRYS CR TAB 10 MEQ                Replacement Preparations                      30
POT CL MICRO TAB 20MEQ CR      POTASSIUM CHLORIDE MICROENCAPSULATED CRYS CR TAB 20 MEQ                Replacement Preparations                      30
POT CL MICRO TAB 20MEQ ER      POTASSIUM CHLORIDE MICROENCAPSULATED CRYS CR TAB 20 MEQ                Replacement Preparations                      30
 POT GLUCONAT TAB 595MG                     POTASSIUM GLUCONATE TAB CR 2.5 MEQ                        Replacement Preparations                      30
POT/CHLORIDE TAB 25MEQ EF              POT BICARBONATE & CHLORIDE EFFER TAB 25 MEQ                    Replacement Preparations                      30
                                                                                                                                Max Qty
                                                                                                                                  Limit   Max Max Age
                                                                                                                                (Liquids Days    Limit    Step        Step Therapy     Specialty
    Drug/Product Name                                Generic Name                                    Therapy Class               in mLs) Supply (Years) Required?     Requirement        Drug         Coverage Status
   POTASSIMIN TAB 75MG                            POTASSIUM TAB 75 MG                           Replacement Preparations                  30
   POTASSIUM TAB 95MG             POTASSIUM GLUCONATE TAB CR 570 MG (95 MG EQUIV K)             Replacement Preparations                  30
   POTASSIUM TAB 99MG                             POTASSIUM TAB 99 MG                           Replacement Preparations                  30
     PR NATAL 400 PAK         *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA 3 CAP 400 PK**      Multivitamin Preparations                 30      40
    PR NATAL 400 PAK EC       *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA CAP DR 400 PK*      Multivitamin Preparations                 30      40
     PR NATAL 430 PAK         *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA 3 CAP 430 PK**      Multivitamin Preparations                 30      40
    PR NATAL 430 PAK EC       *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA CAP DR 430 PK*      Multivitamin Preparations                 30      40
    PR NATAL 440 MIS EC       *PRENATAL W/ SOD FEREDETATE-FA TAB 30-1 & OMEGA 3 CAP DR***       Multivitamin Preparations                 30      40
 PRAMIPEXOLE TAB 0.125MG              PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.125 MG                 Dopamine Receptor Agonists                 30
 PRAMIPEXOLE TAB 0.25MG                PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.25 MG                 Dopamine Receptor Agonists                 30
  PRAMIPEXOLE TAB 0.5MG                 PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.5 MG                 Dopamine Receptor Agonists                 30
 PRAMIPEXOLE TAB 0.75MG                PRAMIPEXOLE DIHYDROCHLORIDE TAB 0.75 MG                 Dopamine Receptor Agonists                 30
  PRAMIPEXOLE TAB 1.5MG                 PRAMIPEXOLE DIHYDROCHLORIDE TAB 1.5 MG                 Dopamine Receptor Agonists                 30
   PRAMIPEXOLE TAB 1MG                   PRAMIPEXOLE DIHYDROCHLORIDE TAB 1 MG                  Dopamine Receptor Agonists                 30




                                                                                                                                                                     USE METFORMIN
                                                                                                                                                                         AND/OR
   PRANDIN    TAB 0.5MG                         REPAGLINIDE TAB 0.5 MG                                 Meglitinides                       30                Y       SULFONYLUREA 1ST




                                                                                                                                                                     USE METFORMIN
                                                                                                                                                                         AND/OR
    PRANDIN   TAB 1MG                            REPAGLINIDE TAB 1 MG                                  Meglitinides                       30                Y       SULFONYLUREA 1ST




                                                                                                                                                                     USE METFORMIN
                                                                                                                                                                         AND/OR
      PRANDIN TAB 2MG                               REPAGLINIDE TAB 2 MG                                Meglitinides                      30                Y       SULFONYLUREA 1ST
    PRAVASTATIN TAB 10MG                       PRAVASTATIN SODIUM TAB 10 MG                   HMG-CoA Reductase Inhibitors                30
    PRAVASTATIN TAB 20MG                       PRAVASTATIN SODIUM TAB 20 MG                   HMG-CoA Reductase Inhibitors                30
    PRAVASTATIN TAB 40MG                       PRAVASTATIN SODIUM TAB 40 MG                   HMG-CoA Reductase Inhibitors                30
    PRAVASTATIN TAB 80MG                       PRAVASTATIN SODIUM TAB 80 MG                   HMG-CoA Reductase Inhibitors                30
     PRAZOSIN HCL CAP 1MG                          PRAZOSIN HCL CAP 1 MG                     Alpha-Adrenergic Blocking Agents             30
     PRAZOSIN HCL CAP 2MG                          PRAZOSIN HCL CAP 2 MG                     Alpha-Adrenergic Blocking Agents             30
     PRAZOSIN HCL CAP 5MG                          PRAZOSIN HCL CAP 5 MG                     Alpha-Adrenergic Blocking Agents             30
   PRED SOD PHO SOL 1% OP            PREDNISOLONE SODIUM PHOSPHATE OPHTH SOLN 1%                       Corticosteroids                    30
 PRED SOD PHO SOL 5MG/5ML    PREDNISOLONE SOD PHOSPH ORAL SOLN 6.7 MG/5ML (5 MG/5ML BASE)                 Adrenals                        30
  PRED SOD PHO SOL 6.7/5ML   PREDNISOLONE SOD PHOSPH ORAL SOLN 6.7 MG/5ML (5 MG/5ML BASE)                 Adrenals                        30
    PREDNICARBAT CRE 0.1%                        PREDNICARBATE CREAM 0.1%                        Anti-inflammatory Agents                 30                                                       Prior Authorization Req'd
    PREDNICARBAT OIN 0.1%                         PREDNICARBATE OINT 0.1%                        Anti-inflammatory Agents                 30                                                       Prior Authorization Req'd
      PREDNIS/SULF SUS OP       SULFACETAMIDE SODIUM-PREDNISOLONE OPHTH SUSP 10-0.2%                   Corticosteroids                    30
PREDNISOLONE SOL 15MG/5ML       PREDNISOLONE SYRUP 15 MG/5ML (USP SOLUTION EQUIVALENT)                    Adrenals                        30      18
   PREDNISOLONE SUS 1% OP                  PREDNISOLONE ACETATE OPHTH SUSP 1%                          Corticosteroids                    30
PREDNISOLONE SYP 15MG/5ML       PREDNISOLONE SYRUP 15 MG/5ML (USP SOLUTION EQUIVALENT)                    Adrenals                        30      18
 PREDNISOLONE SYP 5MG/5ML                      PREDNISOLONE SYRUP 5 MG/5ML                                Adrenals                        30      18
    PREDNISONE TAB 10MG                            PREDNISONE TAB 10 MG                                   Adrenals                        30
     PREDNISONE TAB 1MG                             PREDNISONE TAB 1 MG                                   Adrenals                        30
    PREDNISONE TAB 2.5MG                           PREDNISONE TAB 2.5 MG                                  Adrenals                        30
    PREDNISONE TAB 20MG                            PREDNISONE TAB 20 MG                                   Adrenals                        30
    PREDNISONE TAB 50MG                            PREDNISONE TAB 50 MG                                   Adrenals                        30
     PREDNISONE TAB 5MG                             PREDNISONE TAB 5 MG                                   Adrenals                        30
    PREMARIN TAB 0.3MG                       ESTROGENS CONJUGATED TAB 0.3 MG                              Estrogens                       30
   PREMARIN TAB 0.45MG                      ESTROGENS CONJUGATED TAB 0.45 MG                              Estrogens                       30
  PREMARIN TAB 0.625MG                     ESTROGENS CONJUGATED TAB 0.625 MG                              Estrogens                       30
    PREMARIN TAB 0.9MG                       ESTROGENS CONJUGATED TAB 0.9 MG                              Estrogens                       30
   PREMARIN TAB 1.25MG                      ESTROGENS CONJUGATED TAB 1.25 MG                              Estrogens                       30
 PREMARIN VAG CRE 0.625MG          ESTROGENS CONJUGATED VAGINAL CREAM 0.625 MG/GM                         Estrogens              42.5     30
   PREMARIN VAG CRE REFILL         ESTROGENS CONJUGATED VAGINAL CREAM 0.625 MG/GM                         Estrogens              42.5     30
        PREMPHASE TAB          CONJ EST 0.625(14)/CONJ EST-MEDROXYPRO AC TAB 0.625-5MG(14)                Estrogens                       30
   PREMPRO TAB .625-2.5      CONJUGATED ESTROGEN-MEDROXYPROGEST ACETATE TAB 0.625-2.5 MG                  Estrogens                       30
    PREMPRO TAB 0.3-1.5       CONJUGATED ESTROGEN-MEDROXYPROGEST ACETATE TAB 0.3-1.5 MG                   Estrogens                       30
                                                                                                                                         Max Qty
                                                                                                                                           Limit   Max Max Age
                                                                                                                                         (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                               Generic Name                                         Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug      Coverage Status
   PREMPRO TAB 0.45-1.5      CONJUGATED ESTROGEN-MEDROXYPROGEST ACETATE TAB 0.45-1.5 MG                       Estrogens                            30
   PREMPRO TAB 0.625-5       CONJUGATED ESTROGEN-MEDROXYPROGEST ACETATE TAB 0.625-5 MG                        Estrogens                            30
         PRENACARE TAB            *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***              Multivitamin Preparations                      30
         PRENAPLUS TAB               *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***                 Multivitamin Preparations                      30      40
        PRENATAB CBF TAB            *PRENATAL VIT W/ IRON CARBONYL-FA TAB 50-1 MG***                Multivitamin Preparations                      30      40
     PRENATABS TAB OBN            *PRENATAL W/O A VIT W/ FE CARBONYL-FA TAB 29-1 MG***              Multivitamin Preparations                      30      40
        PRENATABS FA TAB             *PRENATAL VIT W/ FE FUMARATE-FA TAB 29-1 MG***                 Multivitamin Preparations                      30      40
        PRENATABS RX TAB            *PRENATAL VIT W/ IRON CARBONYL-FA TAB 29-1 MG***                Multivitamin Preparations                      30      40
          PRENATAL TAB              *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.8 MG***                Multivitamin Preparations                      30      40
  PRENATAL TAB 27-0.8MG             *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.8 MG***                Multivitamin Preparations                      30      40
  PRENATAL TAB FORMULA               *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***                 Multivitamin Preparations                      30      40
  PRENATAL TAB LOW IRON              *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***                 Multivitamin Preparations                      30      40
   PRENATAL TAB MUTIVIT           *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***              Multivitamin Preparations                      30
      PRENATAL TAB PLUS              *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***                 Multivitamin Preparations                      30      40
   PRENATAL TAB PLUS/FE              *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***                 Multivitamin Preparations                      30      40
    PRENATAL 1 TAB PLUS 1            *PRENATAL VIT W/ FE FUMARATE-FA TAB 65-1 MG***                 Multivitamin Preparations                      30      40
     PRENATAL 19 CHW TAB          *PRENATAL VIT W/ FE FUMARATE-FA CHEW TAB 29-1 MG***               Multivitamin Preparations                      30      40
         PRENATAL 19 TAB           *PRENATAL VIT W/ DSS-FE FUMARATE-FA TAB 29-1 MG***               Multivitamin Preparations                      30
        PRENATAL AD TAB           *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***              Multivitamin Preparations                      30
        PRENATAL ADV TAB          *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***              Multivitamin Preparations                      30
         PRENATAL FA TAB            *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.8 MG***                Multivitamin Preparations                      30      40
  PRENATAL FOR TAB 28-1MG            *PRENATAL VIT W/ FE FUMARATE-FA TAB 28-1 MG***                 Multivitamin Preparations                      30      40
    PRENATAL MR TAB 90 FE         *PRENATAL VIT W/ DSS-FE FUMARATE-FA TAB CR 90-1 MG***             Multivitamin Preparations                      30
PRENATAL MTR TAB SELENIUM          *PRENATAL VIT W/ SEL-FE FUMARATE-FA TAB 27-1 MG***               Multivitamin Preparations                      30      40
 PRENATAL PLS TAB /BETACAR   *PRENATAL MULTIVITAMINS & MINERALS W/ IRON & FA TAB 1 MG***            Multivitamin Preparations                      30
   PRENATAL PLS TAB /IRON            *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***                 Multivitamin Preparations                      30      40
        PRENATAL RX TAB             *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.5 MG***                Multivitamin Preparations                      30
        PRENATAL RX1 TAB             *PRENATAL VIT W/ FE FUMARATE-FA TAB 60-1 MG***                 Multivitamin Preparations                      30
         PRENATAL S TAB             *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.8 MG***                Multivitamin Preparations                      30      40
         PRENATAL Z TAB              *PRENATAL VIT W/ FE FUMARATE-FA TAB 65-1 MG***                 Multivitamin Preparations                      30      40
        PRENATAL/FA TAB              *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***                 Multivitamin Preparations                      30      40
         PRENATAL-H CAP          *PRENATAL W/O A VIT W/ FE FUMARATE-FA CAP 106-1 MG***              Multivitamin Preparations                      30      40
        PRENATE PLUS TAB             *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***                 Multivitamin Preparations                      30
       PREP H HC CRE 1%                          HYDROCORTISONE CREAM 1%                            Anti-inflammatory Agents                       30
     PREVALITE POW 4GM                  CHOLESTYRAMINE LIGHT POWDER 4 GM/DOSE                          Bile Acid Sequestrants                      30
   PREVALITE POW 4GM PK                CHOLESTYRAMINE LIGHT POWDER PACKETS 4 GM                        Bile Acid Sequestrants                      30
          PREVIFEM TAB            NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG                      Contraceptives                          30
          PREVITE RX TAB         *PRENATAL W/ CALCIUM CARBONATE-B6-B12-FA TAB 1 MG***               Multivitamin Preparations                      30      40
           PREVNAR INJ         PNEUMOCOCCAL 7-VALENT CONJUGATE VACCINE INJ 16 MCG/0.5ML                       Vaccines                             30
          PREVNAR 13 INJ             PNEUMOCOCCAL 13-VALENT CONJUGATE VACCINE INJ                             Vaccines                             30
          PREVPAC MIS         AMOXICILLIN CAP-CLARITHRO TAB-LANSOPRAZ CAP DR THERAPY PACK             Proton-pump Inhibitors                       30
     PREZISTA TAB 150MG               DARUNAVIR ETHANOLATE TAB 150 MG (BASE EQUIV)                    HIV Protease Inhibitors                      30
     PREZISTA TAB 400MG               DARUNAVIR ETHANOLATE TAB 400 MG (BASE EQUIV)                    HIV Protease Inhibitors                      30
     PREZISTA TAB 600MG               DARUNAVIR ETHANOLATE TAB 600 MG (BASE EQUIV)                    HIV Protease Inhibitors                      30
      PREZISTA TAB 75MG               DARUNAVIR ETHANOLATE TAB 75 MG (BASE EQUIV)                     HIV Protease Inhibitors                      30
PRIMAQUINE POW PHOSPHAT                       PRIMAQUINE PHOSPHATE POWDER                               Pharmaceutical Aids                        30
  PRIMAQUINE TAB 26.3MG                     PRIMAQUINE PHOSPHATE TAB 26.3 MG                                Antimalarials                          30
   PRIMIDONE TAB 250MG                             PRIMIDONE TAB 250 MG                            Anticonvulsant Barbiturates                     30
    PRIMIDONE TAB 50MG                              PRIMIDONE TAB 50 MG                            Anticonvulsant Barbiturates                     30
         PROAIR HFA AER       ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV)      Selective beta-2-Adrenergic Agonists                30
 PROBEN/COLCH TAB 500-0.5               COLCHICINE W/ PROBENECID TAB 0.5-500 MG                           Uricosuric Agents                        30
   PROBENECID TAB 500MG                            PROBENECID TAB 500 MG                                  Uricosuric Agents                        30
 PROCAINAMIDE CAP 250MG                        PROCAINAMIDE HCL CAP 250 MG                            Class Ia Antiarrhythmics                     30
 PROCAINAMIDE CAP 500MG                        PROCAINAMIDE HCL CAP 500 MG                            Class Ia Antiarrhythmics                     30
 PROCAINAMIDE TAB 1000 ER                    PROCAINAMIDE HCL TAB CR 1000 MG                          Class Ia Antiarrhythmics                     30
PROCAINAMIDE TAB 500MG CR                    PROCAINAMIDE HCL TAB CR 500 MG                           Class Ia Antiarrhythmics                     30
PROCAINAMIDE TAB 500MG SR                    PROCAINAMIDE HCL TAB CR 500 MG                           Class Ia Antiarrhythmics                     30
PROCAINAMIDE TAB 750MG ER                    PROCAINAMIDE HCL TAB CR 750 MG                           Class Ia Antiarrhythmics                     30
 PROCANBID TAB 1000 MG                    PROCAINAMIDE HCL TAB SR 12HR 1000 MG                        Class Ia Antiarrhythmics                     30
 PROCANBID TAB 500MG CR                    PROCAINAMIDE HCL TAB SR 12HR 500 MG                        Class Ia Antiarrhythmics                     30
   PROCHLORPER SUP 25MG                      PROCHLORPERAZINE SUPPOS 25 MG                                 Phenothiazines                          30
   PROCHLORPER TAB 10MG                   PROCHLORPERAZINE MALEATE TAB 10 MG                               Phenothiazines                          30
    PROCHLORPER TAB 5MG                    PROCHLORPERAZINE MALEATE TAB 5 MG                               Phenothiazines                          30
       PROCTO-KIT CRE 1%                         HYDROCORTISONE CREAM 1%                            Anti-inflammatory Agents                       30
   PROFEN IB SUS 100/5ML                        IBUPROFEN SUSP 100 MG/5ML                   Other Nonsteroidal Anti-inflammtory Agents             30      18
                                                                                                                                            Max Qty
                                                                                                                                              Limit   Max Max Age
                                                                                                                                            (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                                 Generic Name                                          Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
     PROFEN IB TAB 200MG                              IBUPROFEN TAB 200 MG                     Other Nonsteroidal Anti-inflammtory Agents             30
      PROLEUKIN INJ 22MU                    ALDESLEUKIN FOR IV SOLN 22000000 UNIT                          Antineoplastic Agents                      30                                       Specialty   Prior Authorization Req'd
  PROMETH VC/ SYP CODEINE     PHENYLEPHRINE-PROMETHAZINE W/ CODEINE SYRUP 5-6.25-10 MG/5ML                      Antitussives                          30
  PROMETH/COD SYP 6.25-10              PROMETHAZINE W/ CODEINE SYRUP 6.25-10 MG/5ML                             Antitussives                  178     30
 PROMETHAZINE SOL 6.25/5ML                   PROMETHAZINE HCL SYRUP 6.25 MG/5ML                         Phenothiazine Derivatives                     30      18
  PROMETHAZINE SUP 12.5MG                      PROMETHAZINE HCL SUPPOS 12.5 MG                          Phenothiazine Derivatives                     30
   PROMETHAZINE SUP 25MG                        PROMETHAZINE HCL SUPPOS 25 MG                           Phenothiazine Derivatives                     30
   PROMETHAZINE SUP 50MG                        PROMETHAZINE HCL SUPPOS 50 MG                           Phenothiazine Derivatives                     30
 PROMETHAZINE SYP 6.25/5ML                   PROMETHAZINE HCL SYRUP 6.25 MG/5ML                         Phenothiazine Derivatives                     30      18
     PROMETHAZINE SYP DM                   PROMETHAZINE-DM SYRUP 6.25-15 MG/5ML                                 Antitussives                          30
  PROMETHAZINE TAB 12.5MG                        PROMETHAZINE HCL TAB 12.5 MG                           Phenothiazine Derivatives                     30
   PROMETHAZINE TAB 25MG                          PROMETHAZINE HCL TAB 25 MG                            Phenothiazine Derivatives                     30
   PROMETHAZINE TAB 50MG                          PROMETHAZINE HCL TAB 50 MG                            Phenothiazine Derivatives                     30
 PROMETHEGAN SUP 12.5MG                        PROMETHAZINE HCL SUPPOS 12.5 MG                          Phenothiazine Derivatives                     30
   PROMETHEGAN SUP 25MG                         PROMETHAZINE HCL SUPPOS 25 MG                           Phenothiazine Derivatives                     30
   PROMETHEGAN SUP 50MG                         PROMETHAZINE HCL SUPPOS 50 MG                           Phenothiazine Derivatives                     30
   PROMETRIUM CAP 100MG                     PROGESTERONE MICRONIZED CAP 100 MG                                   Progestins                           30
   PROMETRIUM CAP 200MG                     PROGESTERONE MICRONIZED CAP 200 MG                                   Progestins                           30
    PRONESTYL CAP 375MG                          PROCAINAMIDE HCL CAP 375 MG                             Class Ia Antiarrhythmics                     30
   PRONTO PLUS LIQ MOUSSE                 PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.33-4%                    Scabicides and Pediculicides           120     30
    PRO-OTIC SOL 1.4-5.4%                  BENZOCAINE-ANTIPYRINE OTIC SOLN 1.4-5.4%                          Local Anesthetics                        30
  PROPAFENONE TAB 150MG                           PROPAFENONE HCL TAB 150 MG                             Class Ic Antiarrhythmics                     30
  PROPAFENONE TAB 225MG                           PROPAFENONE HCL TAB 225 MG                             Class Ic Antiarrhythmics                     30
  PROPAFENONE TAB 300MG                           PROPAFENONE HCL TAB 300 MG                             Class Ic Antiarrhythmics                     30
     PROPINE SOL 0.1% OP                         DIPIVEFRIN HCL OPHTH SOLN 0.1%                                  Mydriatics                           30
  PROPO-N/APAP TAB 100-650           PROPOXYPHENE-N W/ ACETAMINOPHEN TAB 100-650 MG                           Opiate Agonists                 120     30
PROPOXY/APAP TAB 65-650MG           PROPOXYPHENE HCL W/ ACETAMINOPHEN TAB 65-650 MG                           Opiate Agonists                         30
   PROPRANOLOL TAB 10MG                            PROPRANOLOL HCL TAB 10 MG                         Beta-Adrenergic Blocking Agents                  30
   PROPRANOLOL TAB 20MG                            PROPRANOLOL HCL TAB 20 MG                         Beta-Adrenergic Blocking Agents                  30
   PROPRANOLOL TAB 40MG                            PROPRANOLOL HCL TAB 40 MG                         Beta-Adrenergic Blocking Agents                  30
   PROPRANOLOL TAB 60MG                            PROPRANOLOL HCL TAB 60 MG                         Beta-Adrenergic Blocking Agents                  30
   PROPRANOLOL TAB 80MG                            PROPRANOLOL HCL TAB 80 MG                         Beta-Adrenergic Blocking Agents                  30
   PROPYLTHIOUR TAB 50MG                          PROPYLTHIOURACIL TAB 50 MG                                Antithyroid Agents                        30
      PROVIL    TAB 200MG                             IBUPROFEN TAB 200 MG                     Other Nonsteroidal Anti-inflammtory Agents             30
         PRUET DHA PAK          *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA 3 CAP 400 PK**            Multivitamin Preparations                     30      40
        PRUET DHAEC PAK         *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA CAP DR 400 PK*            Multivitamin Preparations                     30      40
        PSE BROM DM SYP               PSEUDOEPHED-BROMPHEN-DM SYRUP 60-4-30 MG/5ML                              Antitussives                  178     30
    PSE/CPM CAP 120-8 SA           CHLORPHENIRAMINE & PSEUDOEPHEDRINE CAP CR 8-120 MG                     Proplamine Derivatives               31     30
    PSE/CPM CAP 120-8MG            CHLORPHENIRAMINE & PSEUDOEPHEDRINE CAP CR 8-120 MG                     Proplamine Derivatives               31     30
    PSE/GG     TAB 120/1200        PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-1200 MG                         Expectorants                    31     30
     PSE/GG     TAB 120-600         PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-600 MG                         Expectorants                    31     30
    PSE/GG     TAB 85-795MG          PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 85-795 MG                         Expectorants                    31     30
    PSE/GG CR TAB 120-600           PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-600 MG                         Expectorants                    31     30
  PSE/GG CR TAB 60-600MG             PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 60-600 MG                         Expectorants                    31     30
    PSE/GG LA TAB 120-600           PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-600 MG                         Expectorants                    31     30
   PSE/GG LA TAB 45-800MG            PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 45-800 MG                         Expectorants                    31     30
    PSE/GG SR TAB 50-1200           PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 50-1200 MG                         Expectorants                    31     30
   PSE/GG SR TAB 60-500MG            PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 60-500 MG                         Expectorants                    31     30
   PSE/GG SR TAB 60-600MG            PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 60-600 MG                         Expectorants                    31     30
 PSEUDO GG TR TAB 48-595MG           PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 48-595 MG                         Expectorants                    31     30
        PSEUDO MAX TAB               PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 80-700 MG                         Expectorants                    31     30
    PSEUDO/GG LA TAB 12HR            PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 85-795 MG                         Expectorants                    31     30
PSEUDOEPH/GG TAB 80/800MG            PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 80-800 MG                         Expectorants                    31     30
PSEUDOEPHEDR LIQ 30MG/5ML                     PSEUDOEPHEDRINE HCL LIQ 30 MG/5ML                    alpha- and beta-Adrenergic Agonists        240     30
PSEUDOEPHEDR SYP 30MG/5ML                   PSEUDOEPHEDRINE HCL SYRUP 30 MG/5ML                    alpha- and beta-Adrenergic Agonists        240     30
   PSEUDOEPHEDR TAB 30MG                        PSEUDOEPHEDRINE HCL TAB 30 MG                      alpha- and beta-Adrenergic Agonists        120     30
   PSEUDOEPHEDR TAB 60MG                        PSEUDOEPHEDRINE HCL TAB 60 MG                      alpha- and beta-Adrenergic Agonists         60     30
      PSEUDOVENT CAP CR                PSEUDOEPHEDRINE-GUAIFENESIN CAP CR 120-250 MG                           Expectorants                    31     30
   PSEUDOVENT CAP PED CR               PSEUDOEPHEDRINE-GUAIFENESIN CAP CR 60-300 MG                            Expectorants                    31     30
       PSORIATEC CRE 1%                                ANTHRALIN CREAM 1%                       Skin and Mucous Membrane Agents, Misc                 30
     PSUDATABS TAB 30MG                         PSEUDOEPHEDRINE HCL TAB 30 MG                      alpha- and beta-Adrenergic Agonists        120     30
   PULEXN DM SYP 100-10/5          DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                             Antitussives                  180     30
   PULMICORT INH 180MCG        BUDESONIDE INHAL AERO POWD 180 MCG/ACT (BREATH ACTIVATED)                          Adrenals                            30
   PULMICORT INH 200MCG        BUDESONIDE INHAL AERO POWD 200 MCG/INH (BREATH ACTIVATED)                          Adrenals                            30
    PULMICORT INH 90MCG         BUDESONIDE INHAL AERO POWD 90 MCG/ACT (BREATH ACTIVATED)                          Adrenals                            30
                                                                                                                                           Max Qty
                                                                                                                                             Limit   Max Max Age
                                                                                                                                           (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                                Generic Name                                          Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
 PULMICORT SUS 1MG/2ML                    BUDESONIDE INHALATION SUSP 1 MG/2ML                                   Adrenals                             30
       PURPOSE MOIS LOT                             *EMOLLIENT - LOTION**                            Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
    PX ALLERGY CAP 25MG                       DIPHENHYDRAMINE HCL CAP 25 MG                           Ethanolamine Derivatives                       30
  PX ALLERGY LIQ 12.5/5ML               DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                        Ethanolamine Derivatives                       30
   PX ALLERGY SOL 1MG/ML                 CETIRIZINE HCL SYRUP 1 MG/ML (5 MG/5ML)                  Second Generation Antihistamines                   30      9
    PX ALLERGY TAB 10MG               LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG                 Second Generation Antihistamines                   30
    PX ALLERGY TAB 25MG                       DIPHENHYDRAMINE HCL TAB 25 MG                           Ethanolamine Derivatives                       30
   PX ANTACID SUS MAX ST       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML                 Antacids and Adsorbents               480     30
    PX ANTACID SUS REG ST      ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML                 Antacids and Adsorbents               480     30
    PX ASPIRIN CHW 81MG                            ASPIRIN CHEW TAB 81 MG                                      Salicylates                    31     30
    PX ASPIRIN TAB 325MG                              ASPIRIN TAB 325 MG                                       Salicylates                    31     30
   PX ASPIRIN TAB 81MG EC                    ASPIRIN TAB DELAYED RELEASE 81 MG                                 Salicylates                    31     30
  PX ATHLETIC CRE 1% FOOT                          CLOTRIMAZOLE CREAM 1%                                         Azoles                       30     30
  PX IBUPROFEN TAB 200MG                            IBUPROFEN TAB 200 MG                      Other Nonsteroidal Anti-inflammtory Agents             30
  PX PROFEN IB DRO 50/1.25                        IBUPROFEN SUSP 40 MG/ML                     Other Nonsteroidal Anti-inflammtory Agents             30      18
  PX PROFEN IB SUS 100/5ML                      IBUPROFEN SUSP 100 MG/5ML                     Other Nonsteroidal Anti-inflammtory Agents             30      18
  PX STOMACH CHW 262MG                   BISMUTH SUBSALICYLATE CHEW TAB 262 MG                           Antidiarrhea Agents                120      30
 PX STOMACH SUS 262/15ML                BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                           Antidiarrhea Agents                1800     30
 PX STOMACH SUS 525/15ML                BISMUTH SUBSALICYLATE SUSP 525 MG/15ML                           Antidiarrhea Agents                1800     30
  PX TUSSIN DM LIQ 100-10/5       DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                           Antitussives                  180      30
  PYRAZINAMIDE TAB 500MG                          PYRAZINAMIDE TAB 500 MG                              Antituberculosis Agents                       30
       PYRE/PIPERON LIQ                 PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.2-2%                     Scabicides and Pediculicides            120     30
        PYRELLE H.B. TAB      PHENAZOPYRIDINE-BUTABARBITAL-HYOSCYAMINE TAB 150-15-0.3 MG          Antipruritics and Local Anesthetics                30
     PYRI 500 TAB 500MG                          PYRIDOXINE HCL TAB 500 MG                                Vitamin B Complex                          30
   PYRIDOSTIGM TAB 60MG                     PYRIDOSTIGMINE BROMIDE TAB 60 MG                  Parasympathomimetic (Cholinergic) Agents               30
   PYRIDOXINE TAB 100MG                          PYRIDOXINE HCL TAB 100 MG                                Vitamin B Complex                          30
    PYRIDOXINE TAB 50MG                           PYRIDOXINE HCL TAB 50 MG                                Vitamin B Complex                          30
   QC ALCOHOL PAD SWABS                              *ALCOHOL SWABS***                                          Devices                              30
  QC ALLERGY SYP CHILDREN                CETIRIZINE HCL SYRUP 1 MG/ML (5 MG/5ML)                  Second Generation Antihistamines                   30      9
    QC ALLERGY TAB 10MG                            CETIRIZINE HCL TAB 10 MG                       Second Generation Antihistamines                   30
    QC ALLERGY TAB 50MG                       DIPHENHYDRAMINE HCL TAB 50 MG                           Ethanolamine Derivatives                       30
        QC ANTACID SUS         ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML                 Antacids and Adsorbents               480     30
  QC ANTACID SUS ANTI-GAS      ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML                 Antacids and Adsorbents               480     30
     QC ANTACID SUS PLUS       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML                 Antacids and Adsorbents               480     30
 QC ARTHRITIS TAB 650MG CR                     ACETAMINOPHEN TAB CR 650 MG                         Analgesics and Antipyretics, Misc         120     30
    QC ASPIRIN TAB 325MG                              ASPIRIN TAB 325 MG                                       Salicylates                    31     30
     QC ASPIRIN TAB 81MG                     ASPIRIN TAB DELAYED RELEASE 81 MG                                 Salicylates                    31     30
   QC CHILD ASA CHW 81MG                           ASPIRIN CHEW TAB 81 MG                                      Salicylates                    31     30
    QC HYDROCORT CRE 1%                          HYDROCORTISONE CREAM 1%                              Anti-inflammatory Agents                       30
QC HYDROCORT CRE 1%MAX ST                        HYDROCORTISONE CREAM 1%                              Anti-inflammatory Agents                       30
  QC IBUPROFEN CAP 200MG                            IBUPROFEN CAP 200 MG                      Other Nonsteroidal Anti-inflammtory Agents     100     30
 QC IBUPROFEN DRO INFANTS                         IBUPROFEN SUSP 40 MG/ML                     Other Nonsteroidal Anti-inflammtory Agents             30      18
  QC IBUPROFEN TAB 200MG                            IBUPROFEN TAB 200 MG                      Other Nonsteroidal Anti-inflammtory Agents             30
 QC INFANTS DRO 80/0.8ML                     ACETAMINOPHEN SUSP 80 MG/0.8ML                        Analgesics and Antipyretics, Misc          30     30
   QC MEDIFIN TAB 200MG                            GUAIFENESIN TAB 200 MG                                    Expectorants                    180     30
      QC MEDIFIN TAB DM              DEXTROMETHORPHAN-GUAIFENESIN TAB 20-400 MG                               Antitussives                    31     30
 QC NON-ASA SUS CHILDREN                     ACETAMINOPHEN SUSP 160 MG/5ML                         Analgesics and Antipyretics, Misc         240     30
  QC SENNA-S TAB 8.6-50MG              SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                        Cathartics and Laxatives              100     30
  QC TRIACTIN SYP CHST CON          PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 15-50 MG/5ML                           Expectorants                            30
   QC TRIPLE OIN ANTIOBIO          NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%                           Antibacterials                  15      30
      Q-DRYL     CAP 25MG                     DIPHENHYDRAMINE HCL CAP 25 MG                           Ethanolamine Derivatives                       30
    Q-DRYL     LIQ 12.5/5ML             DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                        Ethanolamine Derivatives                       30
     Q-PAP     LIQ 160/5ML                  ACETAMINOPHEN LIQUID 160 MG/5ML                        Analgesics and Antipyretics, Misc         240     30
     Q-PAP      TAB 325MG                       ACETAMINOPHEN TAB 325 MG                           Analgesics and Antipyretics, Misc         250     30
  Q-PAP CHILD SUS 160/5ML                    ACETAMINOPHEN SUSP 160 MG/5ML                         Analgesics and Antipyretics, Misc         240     30
   Q-PAP CHILD SUS CHERRY                    ACETAMINOPHEN SUSP 160 MG/5ML                         Analgesics and Antipyretics, Misc         240     30
    Q-PAP EX ST TAB 500MG                       ACETAMINOPHEN TAB 500 MG                           Analgesics and Antipyretics, Misc         250     30
 Q-PAP INFANT DRO 80/0.8ML                    ACETAMINOPHEN SOLN 100 MG/ML                         Analgesics and Antipyretics, Misc          30     30
   Q-TUSSIN SYP 100/5ML                        GUAIFENESIN SYRUP 100 MG/5ML                                  Expectorants                            30
  Q-TUSSIN DM SYP 100-10/5        DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                            Antitussives                   180     30
    Q-TUSSIN PE SYP PE -AF         PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 30-100 MG/5ML                           Expectorants                            30
        QUASENSE TAB           LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG                 Contraceptives                   91      91
     QUINAPRIL TAB 10MG                            QUINAPRIL HCL TAB 10 MG                     Angiotensin-Converting Enzyme Inhibitors              30
     QUINAPRIL TAB 20MG                            QUINAPRIL HCL TAB 20 MG                     Angiotensin-Converting Enzyme Inhibitors              30
     QUINAPRIL TAB 40MG                            QUINAPRIL HCL TAB 40 MG                     Angiotensin-Converting Enzyme Inhibitors              30
                                                                                                                                      Max Qty
                                                                                                                                        Limit   Max Max Age
                                                                                                                                      (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                              Generic Name                                       Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
      QUINAPRIL TAB 5MG                             QUINAPRIL HCL TAB 5 MG                Angiotensin-Converting Enzyme Inhibitors              30
        QUINDAL-HD SYP        PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 7.5-2-2 MG/5ML                    Antitussives                   178     30
 QUINIDINE GL TAB 324MG CR                 QUINIDINE GLUCONATE TAB CR 324 MG                      Class Ia Antiarrhythmics                      30
 QUINIDINE GL TAB 324MG ER                 QUINIDINE GLUCONATE TAB CR 324 MG                      Class Ia Antiarrhythmics                      30
 QUINIDINE GL TAB 324MG SA                 QUINIDINE GLUCONATE TAB CR 324 MG                      Class Ia Antiarrhythmics                      30
   QUINIDINE SU TAB 200MG                     QUINIDINE SULFATE TAB 200 MG                        Class Ia Antiarrhythmics                      30
   QUINIDINE SU TAB 300MG                     QUINIDINE SULFATE TAB 300 MG                        Class Ia Antiarrhythmics                      30
 QUINIDINE SU TAB 300MG ER                   QUINIDINE SULFATE TAB CR 300 MG                      Class Ia Antiarrhythmics                      30
      QVAR       AER 40MCG     BECLOMETHASONE DIPROPIONATE INHAL AERO SOLN 40 MCG/ACT                      Adrenals                             30
      QVAR       AER 80MCG     BECLOMETHASONE DIPROPIONATE INHAL AERO SOLN 80 MCG/ACT                      Adrenals                             30
   RA ACETAMIN CHW 80MG                      ACETAMINOPHEN CHEW TAB 80 MG                     Analgesics and Antipyretics, Misc          60     30
RA ACETAMIN DRO 100MG/ML                     ACETAMINOPHEN SOLN 100 MG/ML                     Analgesics and Antipyretics, Misc          30     30
  RA ACETAMIN ELX 160/5ML                  ACETAMINOPHEN ELIXIR 160 MG/5ML                    Analgesics and Antipyretics, Misc         240     30
   RA ACETAMIN TAB 325MG                        ACETAMINOPHEN TAB 325 MG                      Analgesics and Antipyretics, Misc         250     30
   RA ACETAMIN TAB 500MG                        ACETAMINOPHEN TAB 500 MG                      Analgesics and Antipyretics, Misc         250     30
RA ACETAMIN TAB 500MG/RR                        ACETAMINOPHEN TAB 500 MG                      Analgesics and Antipyretics, Misc         250     30
 RA ACETAMIN TAB 650MG ER                     ACETAMINOPHEN TAB CR 650 MG                     Analgesics and Antipyretics, Misc         120     30
RA ADVANCED LOT RECOVERY                             *EMOLLIENT - LOTION**                      Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
   RA ALCOHOL PAD SWABS                               *ALCOHOL SWABS***                                    Devices                              30
     RA ALLERGY CAP 25MG                     DIPHENHYDRAMINE HCL CAP 25 MG                       Ethanolamine Derivatives                       30
   RA ALLERGY LIQ 12.5/5ML              DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                   Ethanolamine Derivatives                       30
     RA ALLERGY TAB 25MG                     DIPHENHYDRAMINE HCL TAB 25 MG                       Ethanolamine Derivatives                       30
    RA ALPHA HYD LOT FACE                            *EMOLLIENT - LOTION**                      Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
  RA ANTACID SUS ANTI-GAS      ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML            Antacids and Adsorbents               480     30
     RA ANTACID SUS EX ST      ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 500-450-40 MG/5ML            Antacids and Adsorbents               480     30
     RA ANTIBIOTI CRE PLUS            NEOMYCIN-POLYMYXIN W/ PRAMOXINE CREAM 1%                         Antibacterials                    15     30
    RA ASPIRIN CHW 81MG                             ASPIRIN CHEW TAB 81 MG                                Salicylates                    31     30
    RA ASPIRIN TAB 325MG                               ASPIRIN TAB 325 MG                                 Salicylates                    31     30
   RA ASPIRIN TAB 81MG EC                   ASPIRIN TAB DELAYED RELEASE 81 MG                             Salicylates                    31     30
   RA ATHENOL TAB 500MG                         ACETAMINOPHEN TAB 500 MG                      Analgesics and Antipyretics, Misc         250     30
       RA ATHLETES CRE 1%                          CLOTRIMAZOLE CREAM 1%                                    Azoles                       30     30
    RA BETA CARO CAP 15MG                         BETA CAROTENE CAP 15 MG                                 Vitamin A                             30
     RA CETIRIZIN TAB 10MG                         CETIRIZINE HCL TAB 10 MG                  Second Generation Antihistamines                   30
   RA CHILD ASA CHW 81MG                            ASPIRIN CHEW TAB 81 MG                                Salicylates                    31     30
  RA CHLD APAP ELX 160/5ML                 ACETAMINOPHEN ELIXIR 160 MG/5ML                    Analgesics and Antipyretics, Misc         240     30
      RA CLOTRIMAZ CRE 1%                          CLOTRIMAZOLE CREAM 1%                                    Azoles                       30     30
       RA CLOTRIMAZ CRE 3                    CLOTRIMAZOLE VAGINAL CREAM 2%                                  Azoles                       23     30
    RA COL-RITE CAP 100MG                     DOCUSATE SODIUM CAP 100 MG                          Cathartics and Laxatives              100     30
    RA COL-RITE CAP 250MG                     DOCUSATE SODIUM CAP 250 MG                          Cathartics and Laxatives              100     30
  RA COMPLETE CAP ALLERGY                    DIPHENHYDRAMINE HCL CAP 25 MG                       Ethanolamine Derivatives                       30
RA DECONGEST SYP PE COUGH          PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 30-100 MG/5ML                      Expectorants                            30
         RA DERMA LOT                                *EMOLLIENT - LOTION**                      Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
  RA DIPHEDRYL LIQ 12.5/5ML             DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                   Ethanolamine Derivatives                       30
  RA DOUBLE OIN ANTIBIOT                    *BACITRACIN-POLYMYXIN B OINT***                            Antibacterials                           30
RA FLUORIDE SOL CINNAMON                       SODIUM FLUORIDE RINSE 0.05%                   Miscellaneous Therapeutic Agents                   30      18
     RA FLUORIDE SOL MINT                      SODIUM FLUORIDE RINSE 0.05%                   Miscellaneous Therapeutic Agents                   30      18
 RA FLUORIDE SOL MTHWASH                       SODIUM FLUORIDE RINSE 0.02%                   Miscellaneous Therapeutic Agents                   30      18
      RA GENTLE LOT SKIN                             *EMOLLIENT - LOTION**                      Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
RA HYDROCORT CRE 1%MAX ST                        HYDROCORTISONE CREAM 1%                         Anti-inflammatory Agents                       30
RA HYDROCORT CRE 1%PLS 12                        HYDROCORTISONE CREAM 1%                         Anti-inflammatory Agents                       30
     RA HYDROCORT OIN 1%                           HYDROCORTISONE OINT 1%                        Anti-inflammatory Agents                       30
  RA IBUPROFEN CAP 200MG                             IBUPROFEN CAP 200 MG                Other Nonsteroidal Anti-inflammtory Agents     100     30
 RA IBUPROFEN DRO INFANTS                         IBUPROFEN SUSP 40 MG/ML                Other Nonsteroidal Anti-inflammtory Agents             30      18
 RA IBUPROFEN SUS 100/5ML                       IBUPROFEN SUSP 100 MG/5ML                Other Nonsteroidal Anti-inflammtory Agents             30      18
  RA IBUPROFEN TAB 200MG                             IBUPROFEN TAB 200 MG                Other Nonsteroidal Anti-inflammtory Agents             30
     RA IRON TAB 325MG              FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)                  Iron Preparations                          30
       RA JOCK ITCH CRE 1%                         CLOTRIMAZOLE CREAM 1%                                    Azoles                      30      30
   RA K-PEC SUS 262/15ML                BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                      Antidiarrhea Agents                1800     30
      RA LICE LIQ MAX ST               PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.33-4%                Scabicides and Pediculicides           120      30
   RA LIQUID SUS ANTACID       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML            Antacids and Adsorbents              480      30
 RA NICOTINE DIS 11MG/24H                  NICOTINE TD PATCH 24HR 11 MG/24HR                  Autonomic Drugs, Miscellaneous                    30
 RA NICOTINE DIS 14MG/24H                  NICOTINE TD PATCH 24HR 14 MG/24HR                  Autonomic Drugs, Miscellaneous                    30
 RA NICOTINE DIS 21MG/24H                  NICOTINE TD PATCH 24HR 21 MG/24HR                  Autonomic Drugs, Miscellaneous                    30
 RA NICOTINE DIS 22MG/24H                  NICOTINE TD PATCH 24HR 22 MG/24HR                  Autonomic Drugs, Miscellaneous                    30
 RA NICOTINE DIS 7MG/24HR                   NICOTINE TD PATCH 24HR 7 MG/24HR                  Autonomic Drugs, Miscellaneous                    30
                                                                                                                                        Max Qty
                                                                                                                                          Limit   Max Max Age
                                                                                                                                        (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                                Generic Name                                        Therapy Class                   in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
    RA NICOTINE GUM 2MG                        NICOTINE POLACRILEX GUM 2 MG                      Autonomic Drugs, Miscellaneous                   30
RA NICOTINE GUM 2MG CINN                       NICOTINE POLACRILEX GUM 2 MG                      Autonomic Drugs, Miscellaneous                   30
RA NICOTINE GUM 2MG MINT                       NICOTINE POLACRILEX GUM 2 MG                      Autonomic Drugs, Miscellaneous                   30
RA NICOTINE GUM 2MGFRUIT                       NICOTINE POLACRILEX GUM 2 MG                      Autonomic Drugs, Miscellaneous                   30
    RA NICOTINE GUM 4MG                        NICOTINE POLACRILEX GUM 4 MG                      Autonomic Drugs, Miscellaneous                   30
RA NICOTINE GUM 4MG FRUT                       NICOTINE POLACRILEX GUM 4 MG                      Autonomic Drugs, Miscellaneous                   30
RA NICOTINE GUM 4MG MINT                       NICOTINE POLACRILEX GUM 4 MG                      Autonomic Drugs, Miscellaneous                   30
  RA NON-ASA SUS 160/5ML                     ACETAMINOPHEN SUSP 160 MG/5ML                       Analgesics and Antipyretics, Misc        240     30
  RA P-COL RIT TAB 8.6-50MG            SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                      Cathartics and Laxatives             100     30
 RA PEDIATRIC SOL ELECTROL                    *ORAL ELECTROLYTE SOLUTION***                         Replacement Preparations                      30      18
  RA PINK BISM CHW 262MG                  BISMUTH SUBSALICYLATE CHEW TAB 262 MG                        Antidiarrhea Agents                120     30
   RA PINK BISM TAB 262MG                    BISMUTH SUBSALICYLATE TAB 262 MG                          Antidiarrhea Agents                120     30
       RA RENEWAL LOT                                *EMOLLIENT - LOTION**                         Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
 RA SUPHEDRIN CAP NON-DRY              PSEUDOEPHEDRINE-GUAIFENESIN CAP 30-200 MG                           Expectorants                           30
   RA SUPHEDRIN TAB 30MG                      PSEUDOEPHEDRINE HCL TAB 30 MG                    alpha- and beta-Adrenergic Agonists        120     30
   RA TUSSIN SYP 100/5ML                       GUAIFENESIN SYRUP 100 MG/5ML                                Expectorants                           30
  RA TUSSIN DM LIQ 100-10/5       DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                         Antitussives                  180     30
  RA TUSSIN PE SYP 30-100/5        PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 30-100 MG/5ML                         Expectorants                           30
     RA VIT B-6 TAB 50MG                           PYRIDOXINE HCL TAB 50 MG                             Vitamin B Complex                         30
    RAMIPRIL CAP 1.25MG                               RAMIPRIL CAP 1.25 MG                   Angiotensin-Converting Enzyme Inhibitors             30
     RAMIPRIL CAP 10MG                                 RAMIPRIL CAP 10 MG                    Angiotensin-Converting Enzyme Inhibitors             30
     RAMIPRIL CAP 2.5MG                                RAMIPRIL CAP 2.5 MG                   Angiotensin-Converting Enzyme Inhibitors             30
      RAMIPRIL CAP 5MG                                  RAMIPRIL CAP 5 MG                    Angiotensin-Converting Enzyme Inhibitors             30
  RANITIDINE SYP 150/10ML               RANITIDINE HCL SYRUP 15 MG/ML (75 MG/5ML)                   Histamine H2-Antagonists              360     30
  RANITIDINE SYP 15MG/ML                RANITIDINE HCL SYRUP 15 MG/ML (75 MG/5ML)                   Histamine H2-Antagonists              360     30
 RANITIDINE SYP 75MG/5ML                RANITIDINE HCL SYRUP 15 MG/ML (75 MG/5ML)                   Histamine H2-Antagonists              360     30
    RANITIDINE TAB 150MG                          RANITIDINE HCL TAB 150 MG                         Histamine H2-Antagonists                      30
    RANITIDINE TAB 300MG                          RANITIDINE HCL TAB 300 MG                         Histamine H2-Antagonists                      30
    RANITIDINE TAB 75MG                            RANITIDINE HCL TAB 75 MG                         Histamine H2-Antagonists              60      30
  RANITIDINE TAB AR 75MG                           RANITIDINE HCL TAB 75 MG                         Histamine H2-Antagonists              60      30
  RAPAMUNE SOL 1MG/ML                           SIROLIMUS ORAL SOLN 1 MG/ML                        Immunosuppressive Agents                       30      18
   RAPAMUNE TAB 0.5MG                                 SIROLIMUS TAB 0.5 MG                         Immunosuppressive Agents                       30
    RAPAMUNE TAB 1MG                                   SIROLIMUS TAB 1 MG                          Immunosuppressive Agents                       30
    RAPAMUNE TAB 2MG                                   SIROLIMUS TAB 2 MG                          Immunosuppressive Agents                       30
      RE DUALVIT CAP OB        *PRENATAL W/O A W/FE FUM-FE POLY-FA CAP 162.115.2-1 MG***            Multivitamin Preparations                     30      40
  RE PRENATAL CHW 29-1MG          *PRENATAL VIT W/ FE FUMARATE-FA CHEW TAB 29-1 MG***               Multivitamin Preparations                     30      40
      RE PREVIT + CAP DHA      *PRENATAL VIT W/ FE FUM-FA-OMEGA 3 CAP 28-1.25-200 MG***             Multivitamin Preparations                     30      40
   REALITY MIS LUBRICAT                          CONDOMS LATEX LUBRICATED                                 Contraceptives                          30
       REALITY SWAB PAD                                *ALCOHOL SWABS***                                      Devices                             30
        RECLIPSEN TAB              DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG                     Contraceptives                          30
   RECOFEN D LIQ 5-100MG          DEXTROMETHORPHAN-GUAIFENESIN LIQUID 5-100 MG/5ML                          Antitussives                  180     30
      RECORT PLUS CRE 1%                          HYDROCORTISONE CREAM 1%                           Anti-inflammatory Agents                      30
 RED FOX BOTT LOT O'BUTTER                           *EMOLLIENT - LOTION**                         Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
       REDERM     LOT 1%                         HYDROCORTISONE LOTION 1%                           Anti-inflammatory Agents                      30
   REFENESEN TAB 200MG                              GUAIFENESIN TAB 200 MG                                 Expectorants                   180     30
REFENESEN DM TAB 400-20MG            DEXTROMETHORPHAN-GUAIFENESIN TAB 20-400 MG                             Antitussives                   31     30
    REFRESHING LOT ALOE                              *EMOLLIENT - LOTION**                         Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
   REGULAX SS CAP 100MG                         DOCUSATE SODIUM CAP 100 MG                           Cathartics and Laxatives             100     30
       REHYDRALYTE SOL                        *ORAL ELECTROLYTE SOLUTION***                         Replacement Preparations                      30      18
 RELACON LAX TAB 30-835MG        DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 30-835 MG                         Antitussives                   31     30
         RELCOF C SOL                    GUAIFENESIN-CODEINE SOLN 100-6.3 MG/5ML                            Antitussives                  180     30
   RELENZA AER DISKHALE          ZANAMIVIR AERO POWDER BREATH ACTIVATED 5 MG/BLISTER                Neuraminidase Inhibitors                      30
   RELENZA MIS DISKHALE          ZANAMIVIR AERO POWDER BREATH ACTIVATED 5 MG/BLISTER                Neuraminidase Inhibitors                      30
  REMBRANDT SOL WHITEN                          SODIUM FLUORIDE RINSE 0.02%                     Miscellaneous Therapeutic Agents                  30      18
   RENAF      CHW 0.25MG F       SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF)          Miscellaneous Therapeutic Agents                  30
    RENAF      CHW 0.5MG F        SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)           Miscellaneous Therapeutic Agents                  30
     RENAF      CHW 1MG F          SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)            Miscellaneous Therapeutic Agents                  30
   RE-NATA 29 TAB 29-1MG          *PRENATAL W/O A VIT W/ FE CARBONYL-FA TAB 29-1 MG***              Multivitamin Preparations                     30      40
      RE-NATA 29 TAB OB             *PRENATAL VIT W/ IRON CARBONYL-FA TAB 29-1 MG***                Multivitamin Preparations                     30      40
         RENATE     TAB        *PRENATAL VIT W/ FE BISGLYC-FE PROT SUCC-FA TAB 29-1 MG***           Multivitamin Preparations                     30      40
   RENATE DHA PAK 400MG       *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA 3 CAP 400 PK**          Multivitamin Preparations                     30      40
 RENATE DHA PAK 400MG EX      *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA CAP DR 400 PK*          Multivitamin Preparations                     30      40
   RENATE DHA PAK 430MG       *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA 3 CAP 430 PK**          Multivitamin Preparations                     30      40
 RENATE DHA PAK 430MG EX      *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA CAP DR 430 PK*          Multivitamin Preparations                     30      40
         REPAN     TAB            BUTALBITAL-ACETAMINOPHEN-CAFFEINE TAB 50-325-40 MG             Analgesics and Antipyretics, Misc        20      30
                                                                                                                                              Max Qty
                                                                                                                                                Limit   Max Max Age
                                                                                                                                              (Liquids Days    Limit    Step      Step Therapy   Specialty
   Drug/Product Name                                Generic Name                                           Therapy Class                       in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
RE-PB HYOS ELX 16MG/5ML          BELLADONNA ALKALOIDS-PHENOBARBITAL ELIXIR 16 MG/5ML               Antimuscarinics/Antispasmodics               60      30      18
  RESCRIPTOR TAB 100 MG                     DELAVIRDINE MESYLATE TAB 100 MG                 Nonnucleoside Reverse Transcriptase Inhibitors              30
  RESCRIPTOR TAB 200MG                      DELAVIRDINE MESYLATE TAB 200 MG                 Nonnucleoside Reverse Transcriptase Inhibitors              30
RESPA DM TAB 28-600MG            DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 28-600 MG                           Antitussives                      31      30
     RESPAIRE-120 CAP CR            PSEUDOEPHEDRINE-GUAIFENESIN CAP CR 120-250 MG                             Expectorants                      31      30
  RETROVIR INJ 10MG/ML                         ZIDOVUDINE IV SOLN 10 MG/ML                  Nucleoside & Nucleotide Rev Transcriptase Inhib             30                                                   Prior Authorization Req'd
   REVITAL FRZR SOL POPS                     *ORAL ELECTROLYTE SOLUTION***                            Replacement Preparations                          30      18
    REVITAL JELL SOL CUPS                    *ORAL ELECTROLYTE SOLUTION***                            Replacement Preparations                          30      18
REVITAL LQD SOL SQUEEZER                     *ORAL ELECTROLYTE SOLUTION***                            Replacement Preparations                          30      18
   REYATAZ CAP 100MG                   ATAZANAVIR SULFATE CAP 100 MG (BASE EQUIV)                       HIV Protease Inhibitors                         30
   REYATAZ CAP 150MG                   ATAZANAVIR SULFATE CAP 150 MG (BASE EQUIV)                       HIV Protease Inhibitors                         30
   REYATAZ CAP 200MG                   ATAZANAVIR SULFATE CAP 200 MG (BASE EQUIV)                       HIV Protease Inhibitors                         30
   REYATAZ CAP 300MG                   ATAZANAVIR SULFATE CAP 300 MG (BASE EQUIV)                       HIV Protease Inhibitors                         30
 RHEUMATREX TAB 2.5MG              METHOTREXATE SODIUM TAB 2.5 MG (ANTIRHEUMATIC)                        Antineoplastic Agents                          30
RHOGAM PLUS INJ 300MCG               RHO D IMMUNE GLOBULIN (HUMAN) IM INJ 300 MCG                                Serums                                 30                                                   Prior Authorization Req'd
  RID LICE LIQ SHAMPOO                  PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.33-4%                    Scabicides and Pediculicides               120     30
   RIFAMPIN CAP 150MG                              RIFAMPIN CAP 150 MG                                  Antituberculosis Agents                         30
   RIFAMPIN CAP 300MG                              RIFAMPIN CAP 300 MG                                  Antituberculosis Agents                         30
         RI-GEL    SUS        ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML                  Antacids and Adsorbents                  480     30
         RI-GEL II SUS        ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML                  Antacids and Adsorbents                  480     30
        RI-MOX      SUS        ALUMINUM & MAGNESIUM HYDROXIDES SUSP 225-200 MG/5ML                     Antacids and Adsorbents                  480     30
       RI-MOX PLUS SUS        ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 225-200-25 MG/5ML                  Antacids and Adsorbents                  480     30
    RINDAL HD SYP PLUS       PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 7.5-2-3.5 MG/5ML                        Antitussives                      178     30
  RI-TUSSIN SYP 100/5ML                       GUAIFENESIN SYRUP 100 MG/5ML                                    Expectorants                              30
 RI-TUSSIN DM SYP 100-10/5       DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                             Antitussives                      180     30
  RIVASTIGMINE CAP 1.5MG                    RIVASTIGMINE TARTRATE CAP 1.5 MG                  Parasympathomimetic (Cholinergic) Agents                  30                                                   Prior Authorization Req'd
   RIVASTIGMINE CAP 3MG                      RIVASTIGMINE TARTRATE CAP 3 MG                   Parasympathomimetic (Cholinergic) Agents                  30                                                   Prior Authorization Req'd
  RIVASTIGMINE CAP 4.5MG                    RIVASTIGMINE TARTRATE CAP 4.5 MG                  Parasympathomimetic (Cholinergic) Agents                  30                                                   Prior Authorization Req'd
   RIVASTIGMINE CAP 6MG                      RIVASTIGMINE TARTRATE CAP 6 MG                   Parasympathomimetic (Cholinergic) Agents                  30                                                   Prior Authorization Req'd
  ROBAFEN SYP 100/5ML                         GUAIFENESIN SYRUP 100 MG/5ML                                    Expectorants                              30
 ROBAFEN AC SYP 100-10/5                 GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML                               Antitussives                      180     30
   ROBAFEN DM LIQ MAX            DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/5ML                            Antitussives                      180     30
ROBAFEN DM SYP 100-10/5          DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                             Antitussives                      180     30
ROBITUSSIN LIQ TO GO DM          DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                            Antitussives                      180     30
   ROC COMPLETE LOT LIFT                          *EMOLLIENT - LOTION**                               Basic Lotions and Liniments                       30                                                   Prior Authorization Req'd
   ROC CORREXIO LOT LIFT                          *EMOLLIENT - LOTION**                               Basic Lotions and Liniments                       30                                                   Prior Authorization Req'd
  ROC DEEP LOT WRINKLE                            *EMOLLIENT - LOTION**                               Basic Lotions and Liniments                       30                                                   Prior Authorization Req'd
  ROC TONE LOT PERFECT                            *EMOLLIENT - LOTION**                               Basic Lotions and Liniments                       30                                                   Prior Authorization Req'd
 ROFERON-A KIT 3MU/0.5                    INTERFERON ALFA-2A INJ KIT 3 MU/0.5 ML                         Antineoplastic Agents                          30                                       Specialty   Prior Authorization Req'd
 ROFERON-A KIT 6MU/0.5                    INTERFERON ALFA-2A INJ KIT 6 MU/0.5 ML                         Antineoplastic Agents                          30                                       Specialty   Prior Authorization Req'd
 ROFERON-A KIT 9MU/0.5                    INTERFERON ALFA-2A INJ KIT 9 MU/0.5 ML                         Antineoplastic Agents                          30                                       Specialty   Prior Authorization Req'd
 ROMILAR AC SOL 100-10/5                 GUAIFENESIN-CODEINE SOLN 100-10 MG/5ML                               Antitussives                              30
     ROMYCIN OIN OP                        ERYTHROMYCIN OPHTH OINT 5 MG/GM                                   Antibacterials                             30
  ROPINIROLE TAB 0.25MG                   ROPINIROLE HYDROCHLORIDE TAB 0.25 MG                       Dopamine Receptor Agonists                         30
   ROPINIROLE TAB 0.5MG                   ROPINIROLE HYDROCHLORIDE TAB 0.5 MG                        Dopamine Receptor Agonists                         30
    ROPINIROLE TAB 1MG                     ROPINIROLE HYDROCHLORIDE TAB 1 MG                         Dopamine Receptor Agonists                         30
    ROPINIROLE TAB 2MG                     ROPINIROLE HYDROCHLORIDE TAB 2 MG                         Dopamine Receptor Agonists                         30
    ROPINIROLE TAB 3MG                     ROPINIROLE HYDROCHLORIDE TAB 3 MG                         Dopamine Receptor Agonists                         30
    ROPINIROLE TAB 4MG                     ROPINIROLE HYDROCHLORIDE TAB 4 MG                         Dopamine Receptor Agonists                         30
    ROPINIROLE TAB 5MG                     ROPINIROLE HYDROCHLORIDE TAB 5 MG                         Dopamine Receptor Agonists                         30
      ROVIN-NV DHA CAP       *PRENAT W/FE FUM-L METHYLFOLATE-FA-DHA CAP 27-1.13-0.4 MG***             Multivitamin Preparations                         30      40
  ROXICET TAB 5-325MG                 OXYCODONE W/ ACETAMINOPHEN TAB 5-325 MG                               Opiate Agonists                     120     30
         RULOX     SUS         ALUMINUM & MAGNESIUM HYDROXIDES SUSP 225-200 MG/5ML                     Antacids and Adsorbents                  480     30
       RULOX PLUS SUS         ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 500-450-40 MG/5ML                  Antacids and Adsorbents                  480     30
RU-TUSS DM TAB 60-800MG          DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 60-800 MG                           Antitussives                       31     30
 RU-TUSS JR TAB 45-600MG          PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 45-600 MG                           Expectorants                       31     30
      SAFE TUSSIN LIQ 30         DEXTROMETHORPHAN-GUAIFENESIN LIQUID 30-200 MG/5ML                            Antitussives                      180     30
     SAFE TUSSIN LIQ DM          DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                            Antitussives                      180     30
        SAFE-LUV MIS                            CONDOMS LATEX LUBRICATED                                     Contraceptives                             30
        SAFYRAL TAB          DROSPIRENONE-ETHINYL ESTRAD-LEVOMEFOLATE TAB 3-0.03-0.451 MG                    Contraceptives                             30
    SALFLEX TAB 500MG                              SALSALATE TAB 500 MG                                        Salicylates                              30
    SALFLEX TAB 750MG                              SALSALATE TAB 750 MG                                        Salicylates                              30
   SALSALATE TAB 500MG                             SALSALATE TAB 500 MG                                        Salicylates                              30
   SALSALATE TAB 750MG                             SALSALATE TAB 750 MG                                        Salicylates                              30
     SARNOL-HC LOT 1%                           HYDROCORTISONE LOTION 1%                               Anti-inflammatory Agents                         30
                                                                                                                                           Max Qty
                                                                                                                                             Limit   Max Max Age
                                                                                                                                           (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                                 Generic Name                                         Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
     SB ALCOHOL PAD PREP                               *ALCOHOL SWABS***                                        Devices                              30
     SB ALLERGY CAP 25MG                       DIPHENHYDRAMINE HCL CAP 25 MG                          Ethanolamine Derivatives                       30
   SB ALLERGY LIQ 12.5/5ML                DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                      Ethanolamine Derivatives                       30
     SB ALLERGY TAB 10MG                            CETIRIZINE HCL TAB 10 MG                      Second Generation Antihistamines                   30
 SB ALLERGY TAB 25MG MED                       DIPHENHYDRAMINE HCL TAB 25 MG                          Ethanolamine Derivatives                       30
  SB ANTACID SUS ANTI-GAS      ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML                 Antacids and Adsorbents              480      30
   SB ASA LOW TAB 81MG EC                     ASPIRIN TAB DELAYED RELEASE 81 MG                                Salicylates                   31      30
     SB ASPIRIN TAB 325MG                               ASPIRIN TAB 325 MG                      Nonsteroidal Anti-inflammatory Agents        31      30
  SB BISMUTH SUS 262/15ML                 BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                          Antidiarrhea Agents               1800     30
    SB BISMUTH TAB 262MG                      BISMUTH SUBSALICYLATE TAB 262 MG                            Antidiarrhea Agents               120      30
    SB CETIRIZIN SYP 1MG/ML                CETIRIZINE HCL SYRUP 1 MG/ML (5 MG/5ML)                Second Generation Antihistamines                   30      9
  SB CGH CONTR SYP 100/5ML                      GUAIFENESIN SYRUP 100 MG/5ML                                 Expectorants                            30
    SB CHILD ASA CHW 81MG                            ASPIRIN CHEW TAB 81 MG                                    Salicylates                    31     30
  SB CLOTRIMAZ CRE 1% FOOT                          CLOTRIMAZOLE CREAM 1%                                        Azoles                       30     30
   SB COUGHTAB TAB 200MG                            GUAIFENESIN TAB 200 MG                                   Expectorants                    180     30
      SB HYDROCORT CRE 1%                         HYDROCORTISONE CREAM 1%                             Anti-inflammatory Agents                       30
      SB HYDROCORT OIN 1%                           HYDROCORTISONE OINT 1%                            Anti-inflammatory Agents                       30
  SB IBUPROFEN SUS INFANTS                         IBUPROFEN SUSP 40 MG/ML                    Other Nonsteroidal Anti-inflammtory Agents             30      18
   SB IBUPROFEN TAB 200MG                             IBUPROFEN TAB 200 MG                    Other Nonsteroidal Anti-inflammtory Agents             30
    SB INFANTS DRO CHERRY                     ACETAMINOPHEN SUSP 80 MG/0.8ML                       Analgesics and Antipyretics, Misc          30     30
     SB INFANTS DRO GRAPE                     ACETAMINOPHEN SUSP 80 MG/0.8ML                       Analgesics and Antipyretics, Misc          30     30
   SB NON-ASA CHW 160MG                       ACETAMINOPHEN CHEW TAB 160 MG                        Analgesics and Antipyretics, Misc          60     30
 SB NON-ASA CHW 80MG FRT                       ACETAMINOPHEN CHEW TAB 80 MG                        Analgesics and Antipyretics, Misc          60     30
SB NON-ASA CHW 80MG GRP                        ACETAMINOPHEN CHEW TAB 80 MG                        Analgesics and Antipyretics, Misc          60     30
    SB NON-ASA TAB 500MG                          ACETAMINOPHEN TAB 500 MG                         Analgesics and Antipyretics, Misc         250     30
   SB PAIN REL SUS CHILDREN                   ACETAMINOPHEN SUSP 160 MG/5ML                        Analgesics and Antipyretics, Misc         240     30
    SB PSEUDOPHE TAB 30MG                      PSEUDOEPHEDRINE HCL TAB 30 MG                     alpha- and beta-Adrenergic Agonists         120     30
        SB SEV/CONGE CAP                PSEUDOEPHEDRINE-GUAIFENESIN CAP 30-200 MG                            Expectorants                            30
       SCALACORT LOT 2%                           HYDROCORTISONE LOTION 2%                            Anti-inflammatory Agents                       30
       SCALP RELIEF SOL 1%                         HYDROCORTISONE SOLN 1%                             Anti-inflammatory Agents               120     30
     SCALPICIN SOL MAX ST                          HYDROCORTISONE SOLN 1%                             Anti-inflammatory Agents               120     30
   SCOT-TUSSIN LIQ ALRGY SF               DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                      Ethanolamine Derivatives                       30
         SEASONIQUE TAB        LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST TAB 0.01MG(7)                 Contraceptives                   91      91
          SE-CARE CHW              *PRENATAL W/O A VIT W/ FE FUM-FA TAB CHEW 40-1 MG***               Multivitamin Preparations                      30
    SE-CARE TAB CONCEIVE           *PRENATAL W/O A VIT W/ FE FUMARATE-FA TAB 30-1 MG***               Multivitamin Preparations                      30
       SELEGILINE CAP 5MG                            SELEGILINE HCL CAP 5 MG                        Antidepressants, Miscellaneous                   30
       SELEGILINE TAB 5MG                            SELEGILINE HCL TAB 5 MG                        Antidepressants, Miscellaneous                   30
     SELZENTRY TAB 150MG                             MARAVIROC TAB 150 MG                                HIV Fusion Inhibitors                       30
     SELZENTRY TAB 300MG                             MARAVIROC TAB 300 MG                                HIV Fusion Inhibitors                       30
        SE-NATAL 19 CHW            *PRENATAL VIT W/ FE FUMARATE-FA CHEW TAB 29-1 MG***                Multivitamin Preparations                      30      40
         SE-NATAL 19 TAB            *PRENATAL VIT W/ DSS-FE FUMARATE-FA TAB 29-1 MG***                Multivitamin Preparations                      30
         SE-NATAL 90 TAB           *PRENATAL VIT W/ DSS-FE FUMARATE-FA TAB CR 90-1 MG***              Multivitamin Preparations                      30
        SE-NATAL ONE TAB              *PRENATAL VIT W/ FE FUMARATE-FA TAB 60-1 MG***                  Multivitamin Preparations                      30
  SENEXON-S TAB 8.6-50MG                 SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                       Cathartics and Laxatives             100     30
  SENIOR TOPIX LOT EMOLLIX                            *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
    SENNA       TAB 8.6-50MG             SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                       Cathartics and Laxatives             100     30
  SENNA PLUS TAB 8.6-50MG                SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                       Cathartics and Laxatives             100     30
    SENNA S TAB 8.6-50MG                 SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                       Cathartics and Laxatives             100     30
SENNA SODIUM TAB 8.6-50MG                SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                       Cathartics and Laxatives             100     30
  SENNA/DSS TAB 8.6-50MG                 SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                       Cathartics and Laxatives             100     30
 SENNA-C PLUS TAB 8.6-50MG               SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                       Cathartics and Laxatives             100     30
SENNA-DOCUSA TAB 8.6-50MG                SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                       Cathartics and Laxatives             100     30
  SENNALAX-S TAB 8.6-50MG                SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                       Cathartics and Laxatives             100     30
  SENNA-PLUS TAB 8.6-50MG                SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                       Cathartics and Laxatives             100     30
    SENNA-S TAB 8.6-50MG                 SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                       Cathartics and Laxatives             100     30
 SENNA-TIME S TAB 8.6-50MG               SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                       Cathartics and Laxatives             100     30
         SE-PLETE DHA CAP        *PRENATAL VIT W/ FE FUM-FA-OMEGA 3 CAP 28-1.25-200 MG***             Multivitamin Preparations                      30      40
    SEREVENT DIS AER 50MCG      SALMETEROL XINAFOATE AER POW BA 50 MCG/DOSE (BASE EQUIV)         Selective beta-2-Adrenergic Agonists        60      30                                                   Prior Authorization Req'd
         SE-TAN DHA CAP         *PRENATAL W/FE FUM-FE POLY -FA-OMEGA 3 CAP 15-15-1 MG***              Multivitamin Preparations                      30      40
         SETON ET-EC PAK       *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA CAP DR 430 PK*           Multivitamin Preparations                      30      40
           SETONET PAK         *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA 3 CAP 430 PK**           Multivitamin Preparations                      30      40
          SF     GEL 1.1%                     SODIUM FLUORIDE GEL 1.1% (0.5% F)                   Miscellaneous Therapeutic Agents                   30      18
      SF 5000 PLUS CRE 1.1%                      SODIUM FLUORIDE CREAM 1.1%                       Miscellaneous Therapeutic Agents                   30      18
      SFROWASA ENE 4GM                 MESALAMINE SULFITE-FREE (SF) ENEMA 4 GM/60ML                   Anti-inflammatory Agents                       30
    SG ANTACID/ SUS SIMETH     ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML                 Antacids and Adsorbents               480     30
                                                                                                                                        Max Qty
                                                                                                                                          Limit   Max Max Age
                                                                                                                                        (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                                Generic Name                                       Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
 SG ASA LOW TAB 81MG EC                     ASPIRIN TAB DELAYED RELEASE 81 MG                                Salicylates                  31      30
   SG CHILD ASA CHW 81MG                          ASPIRIN CHEW TAB 81 MG                                     Salicylates                  31      30
   SG DIPHEDRYL CAP 25MG                     DIPHENHYDRAMINE HCL CAP 25 MG                          Ethanolamine Derivatives                      30
   SG DIPHEDRYL TAB 25MG                     DIPHENHYDRAMINE HCL TAB 25 MG                          Ethanolamine Derivatives                      30
 SG EX-PRIN CHW 160MG JR                    ACETAMINOPHEN CHEW TAB 160 MG                       Analgesics and Antipyretics, Misc          60     30
 SG EX-PRIN CHW 80MG FRT                     ACETAMINOPHEN CHEW TAB 80 MG                       Analgesics and Antipyretics, Misc          60     30
SG EX-PRIN CHW 80MG GRP                      ACETAMINOPHEN CHEW TAB 80 MG                       Analgesics and Antipyretics, Misc          60     30
SG EX-PRIN CHW 80MG GUM                      ACETAMINOPHEN CHEW TAB 80 MG                       Analgesics and Antipyretics, Misc          60     30
   SG EX-PRIN DRO INFANT                    ACETAMINOPHEN SUSP 80 MG/0.8ML                      Analgesics and Antipyretics, Misc          30     30
   SG EX-PRIN ELX 160/5ML                   ACETAMINOPHEN ELIXIR 160 MG/5ML                     Analgesics and Antipyretics, Misc         240     30
   SG EX-PRIN SUS 160/5ML                   ACETAMINOPHEN SUSP 160 MG/5ML                       Analgesics and Antipyretics, Misc         240     30
    SG EX-PRIN TAB 325MG                        ACETAMINOPHEN TAB 325 MG                        Analgesics and Antipyretics, Misc         250     30
    SG EX-PRIN TAB 500MG                        ACETAMINOPHEN TAB 500 MG                        Analgesics and Antipyretics, Misc         250     30
     SG HYDROCORT CRE 1%                        HYDROCORTISONE CREAM 1%                             Anti-inflammatory Agents                      30
  SG IBUPROFEN TAB 200MG                           IBUPROFEN TAB 200 MG                    Other Nonsteroidal Anti-inflammtory Agents             30
   SG SU-PHEDRI TAB 30MG                     PSEUDOEPHEDRINE HCL TAB 30 MG                    alpha- and beta-Adrenergic Agonists         120     30
   SG TRI-BUFF TAB ASPIRIN                     ASPIRIN BUFFERED TAB 325 MG                                   Salicylates                   31     30
   SG TUSSIN SYP 100/5ML                      GUAIFENESIN SYRUP 100 MG/5ML                                 Expectorants                           30
 SG TUSSIN DM SYP 100-10/5        DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                          Antitussives                  180     30
   SG TUSSIN DM SYP CLEAR         DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                          Antitussives                  180     30
    SILACE      LIQ 10MG/ML               DOCUSATE SODIUM LIQUID 150 MG/15ML                         Cathartics and Laxatives             480     30
     SILACE      SYP 60/15ML               DOCUSATE SODIUM SYRUP 60 MG/15ML                          Cathartics and Laxatives             480     30
    SILADRYL LIQ ALLERGY                DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                      Ethanolamine Derivatives                      30
    SILDEC      SYP 4-45/5ML    BROMPHENIRAMINE & PSEUDOEPHEDRINE SYRUP 4-45 MG/5ML                  Proplamine Derivatives               178     30
          SILDEC DM SYP             PSEUDOEPHED-BROMPHEN-DM SYRUP 45-4-15 MG/5ML                            Antitussives                  178     30
      SILTUSSIN DM LIQ DAS       DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                          Antitussives                  180     30
  SILTUSSIN SA SYP 100/5ML                    GUAIFENESIN SYRUP 100 MG/5ML                                 Expectorants                           30
 SILTUSSIN-DM LIQ DIABETIC       DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                          Antitussives                  180     30
  SILTUSSIN-DM LIQ MAX ST        DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/5ML                          Antitussives                  180     30
 SILTUSSIN-DM SYP ALC FREE        DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                          Antitussives                  180     30
       SILVER SULFA CRE 1%                    SILVER SULFADIAZINE CREAM 1%                     Local Anti-infectives, Miscellaneous               30
   SIMPLY STUFF TAB 30MG                     PSEUDOEPHEDRINE HCL TAB 30 MG                    alpha- and beta-Adrenergic Agonists         120     30
      SIMULECT INJ 10MG                       BASILIXIMAB FOR IV SOLN 10 MG                        Immunosuppressive Agents                       30                                                   Prior Authorization Req'd
      SIMULECT INJ 20MG                       BASILIXIMAB FOR IV SOLN 20 MG                        Immunosuppressive Agents                       30                                                   Prior Authorization Req'd
   SIMVASTATIN TAB 10MG                            SIMVASTATIN TAB 10 MG                         HMG-CoA Reductase Inhibitors                     30
   SIMVASTATIN TAB 20MG                            SIMVASTATIN TAB 20 MG                         HMG-CoA Reductase Inhibitors                     30
   SIMVASTATIN TAB 40MG                            SIMVASTATIN TAB 40 MG                         HMG-CoA Reductase Inhibitors                     30
    SIMVASTATIN TAB 5MG                             SIMVASTATIN TAB 5 MG                         HMG-CoA Reductase Inhibitors                     30
   SIMVASTATIN TAB 80MG                            SIMVASTATIN TAB 80 MG                         HMG-CoA Reductase Inhibitors                     30
     SINGULAIR CHW 4MG              MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)                     Leukotriene Modifiers                       30                                                   Prior Authorization Req'd
     SINGULAIR CHW 5MG              MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)                     Leukotriene Modifiers                       30                                                   Prior Authorization Req'd
      SINGULAIR GRA 4MG        MONTELUKAST SODIUM ORAL GRANULES PACKET 4 MG (BASE EQUIV)              Leukotriene Modifiers                       30                                                   Prior Authorization Req'd
     SINGULAIR TAB 10MG                MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)                      Leukotriene Modifiers                       30                                                   Prior Authorization Req'd
 SKIN CLEANSR LOT SENSITIV                         *EMOLLIENT - LOTION**                           Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
  SKIN REPAIR LOT SCENTED                          *EMOLLIENT - LOTION**                           Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
 SKIN REPAIR LOT UNSCENTD                          *EMOLLIENT - LOTION**                           Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
 SLO-NIACIN TAB 250MG CR                            NIACIN TAB CR 250 MG                                Vitamin B Complex                 62      30
    SM ALCOHOL PAD PREP                              *ALCOHOL SWABS***                                        Devices                             30
  SM ALL DAY TAB ALLERGY                          CETIRIZINE HCL TAB 10 MG                     Second Generation Antihistamines                   30
 SM ALLERGY TAB 25MG RLF                     DIPHENHYDRAMINE HCL TAB 25 MG                          Ethanolamine Derivatives                      30
 SM ANTACID SUS ANTI-GAS       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML              Antacids and Adsorbents               480     30
    SM ANTACID SUS EX ST       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML              Antacids and Adsorbents               480     30
  SM ANTACID SUS MAX ST        ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 400-400-40 MG/5ML              Antacids and Adsorbents               480     30
 SM ANTACID/ SUS ANTIGAS       ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML              Antacids and Adsorbents               480     30
     SM ANTIBIOTI CRE PLUS            NEOMYCIN-POLYMYXIN W/ PRAMOXINE CREAM 1%                             Antibacterials                  15     30
    SM ANTI-DIAR TAB 2MG                         LOPERAMIDE HCL TAB 2 MG                               Antidiarrhea Agents                 31     30
     SM ANTIFUNGL CRE 1%                          CLOTRIMAZOLE CREAM 1%                                        Azoles                      30     30
  SM ARTHRITIS TAB 650MG                      ACETAMINOPHEN TAB CR 650 MG                       Analgesics and Antipyretics, Misc         120     30
    SM ASPIRIN CHW 81MG                           ASPIRIN CHEW TAB 81 MG                                     Salicylates                   31     30
   SM ASPIRIN TAB 325MG                               ASPIRIN TAB 325 MG                                     Salicylates                   31     30
  SM ASPIRIN TAB 81MG EC                    ASPIRIN TAB DELAYED RELEASE 81 MG                                Salicylates                   31     30
     SM BEDDING AER LICE                         PERMETHRIN AEROSOL 0.5%                          Scabicides and Pediculicides            142     30
  SM CHILD ASA CHW 81MG                           ASPIRIN CHEW TAB 81 MG                                     Salicylates                   31     30
  SM DRY SKIN LOT THERAPY                          *EMOLLIENT - LOTION**                           Basic Lotions and Liniments                    30                                                   Prior Authorization Req'd
    SM FLUORIDE SOL MINT                       SODIUM FLUORIDE RINSE 0.05%                      Miscellaneous Therapeutic Agents                  30      18
                                                                                                                                           Max Qty
                                                                                                                                             Limit   Max Max Age
                                                                                                                                           (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                                 Generic Name                                         Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
     SM HYDROCORT CRE 1%                           HYDROCORTISONE CREAM 1%                            Anti-inflammatory Agents                       30
     SM HYDROCORT OIN 1%                             HYDROCORTISONE OINT 1%                           Anti-inflammatory Agents                       30
   SM IBUPROFEN CAP 200MG                              IBUPROFEN CAP 200 MG                   Other Nonsteroidal Anti-inflammtory Agents     100     30
  SM IBUPROFEN SUS INFANTS                          IBUPROFEN SUSP 40 MG/ML                   Other Nonsteroidal Anti-inflammtory Agents             30      18
 SM IBUPROFEN TAB 100MG JR                             IBUPROFEN TAB 100 MG                   Other Nonsteroidal Anti-inflammtory Agents             30
   SM IBUPROFEN TAB 200MG                              IBUPROFEN TAB 200 MG                   Other Nonsteroidal Anti-inflammtory Agents             30
      SM IRON TAB 325MG                FERROUS SULFATE TAB 325 MG (65 MG ELEMENTAL FE)                     Iron Preparations                         30
    SM LICE LOT TREATMNT                               PERMETHRIN LOTION 1%                          Scabicides and Pediculicides                    30
         SM LICE SOLN KIT      PYRETH-PIPERONYL BUTOX SHAM-PERMETH AERO-NIT REMOVER GEL KIT          Scabicides and Pediculicides                    30
 SM LORATADIN SYP 5MG/5ML                         LORATADINE SYRUP 5 MG/5ML                       Second Generation Antihistamines                   30
    SM LORATADIN TAB 10MG                LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG              Second Generation Antihistamines                   30
 SM LORATADIN TAB ALLG REL               LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG              Second Generation Antihistamines                   30
    SM NASAL DEC TAB 30MG                       PSEUDOEPHEDRINE HCL TAB 30 MG                    alpha- and beta-Adrenergic Agonists         120     30
  SM NICOTINE DIS 14MG/24H                    NICOTINE TD PATCH 24HR 14 MG/24HR                    Autonomic Drugs, Miscellaneous                    30
     SM NICOTINE DIS 21MG                     NICOTINE TD PATCH 24HR 21 MG/24HR                    Autonomic Drugs, Miscellaneous                    30
  SM NICOTINE DIS 7MG/24HR                    NICOTINE TD PATCH 24HR 7 MG/24HR                     Autonomic Drugs, Miscellaneous                    30
     SM NICOTINE GUM 2MG                         NICOTINE POLACRILEX GUM 2 MG                      Autonomic Drugs, Miscellaneous                    30
SM NICOTINE GUM 2MG MINT                         NICOTINE POLACRILEX GUM 2 MG                      Autonomic Drugs, Miscellaneous                    30
     SM NICOTINE GUM 4MG                         NICOTINE POLACRILEX GUM 4 MG                      Autonomic Drugs, Miscellaneous                    30
SM NICOTINE GUM 4MG MINT                         NICOTINE POLACRILEX GUM 4 MG                      Autonomic Drugs, Miscellaneous                    30
   SM NON-ASA ELX 160/5ML                     ACETAMINOPHEN ELIXIR 160 MG/5ML                      Analgesics and Antipyretics, Misc        240      30
    SM PAIN REL CAP 500MG                         ACETAMINOPHEN CAP 500 MG                         Analgesics and Antipyretics, Misc        250      30
  SM PAIN REL TAB 500MG/RR                        ACETAMINOPHEN TAB 500 MG                         Analgesics and Antipyretics, Misc        250      30
    SM PAIN REL TAB 8 HOUR                       ACETAMINOPHEN TAB CR 650 MG                       Analgesics and Antipyretics, Misc        120      30
 SM STOMACH SUS 262/15ML                   BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                        Antidiarrhea Agents                1800     30
 SM STOMACH SUS 527/30ML                   BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                        Antidiarrhea Agents                1800     30
    SM TUSSIN SYP 100/5ML                        GUAIFENESIN SYRUP 100 MG/5ML                                 Expectorants                           30
       SM TUSSIN SYP DM             DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                           Antitussives                  180     30
  SM TUSSIN DM SYP 100-10/5         DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                           Antitussives                  180     30
     SM VIT B-6 TAB 100MG                          PYRIDOXINE HCL TAB 100 MG                              Vitamin B Complex                          30
    SMPLE ALLRGY TAB 25MG                      DIPHENHYDRAMINE HCL TAB 25 MG                          Ethanolamine Derivatives                       30
   SMZ/TMP DS TAB 800-160             SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG                            Sulfonamides                           30
         SMZ-TMP SUS                SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML                          Sulfonamides                           30      18
    SMZ-TMP SUS 200-40/5            SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML                          Sulfonamides                           30      18
   SMZ-TMP TAB 400-80MG                SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 400-80 MG                            Sulfonamides                           30
   SMZ-TMP DS TAB 800-160             SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG                            Sulfonamides                           30
     SOD CHLORIDE NEB 0.9%                     SODIUM CHLORIDE SOLN NEBU 0.9%                              Mucolytic Agents                          30
 SOD FLUORIDE CHW 0.25MG F         SODIUM FLUORIDE CHEW TAB 0.25 MG F (FROM 0.55 MG NAF)          Miscellaneous Therapeutic Agents                   30
   SOD FLUORIDE CHW 0.5MG           SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)           Miscellaneous Therapeutic Agents                   30
  SOD FLUORIDE CHW 0.5MG F          SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)           Miscellaneous Therapeutic Agents                   30
   SOD FLUORIDE CHW 1.1MG           SODIUM FLUORIDE CHEW TAB 0.5 MG F (FROM 1.1 MG NAF)           Miscellaneous Therapeutic Agents                   30
    SOD FLUORIDE CHW 1MG             SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)            Miscellaneous Therapeutic Agents                   30
   SOD FLUORIDE CHW 1MG F            SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)            Miscellaneous Therapeutic Agents                   30
   SOD FLUORIDE CHW 2.2MG            SODIUM FLUORIDE CHEW TAB 1 MG F (FROM 2.2 MG NAF)            Miscellaneous Therapeutic Agents                   30
  SOD FLUORIDE DRO 0.125MG        SODIUM FLUORIDE SOLN 0.125 MG/DROP F (0.275 MG/DROP NAF)        Miscellaneous Therapeutic Agents                   30
SOD FLUORIDE DRO 0.5MG/ML          SODIUM FLUORIDE SOLN 0.5 MG/ML F (FROM 1.1 MG/ML NAF)          Miscellaneous Therapeutic Agents                   30
 SOD FLUORIDE SOL 0.2%MINT                        SODIUM FLUORIDE RINSE 0.2%                      Miscellaneous Therapeutic Agents                   30      18
   SOD SULFACET SOL 10% OP                  SULFACETAMIDE SODIUM OPHTH SOLN 10%                              Antibacterials                          30
 SODIPHLUOR DRO 1.1MG/ML           SODIUM FLUORIDE SOLN 0.5 MG/ML F (FROM 1.1 MG/ML NAF)          Miscellaneous Therapeutic Agents                   30
   SODIUM CHLOR NEB 0.45%                     SODIUM CHLORIDE SOLN NEBU 0.45%                              Mucolytic Agents                          30
     SODIUM CHLOR NEB 10%                      SODIUM CHLORIDE SOLN NEBU 10%                               Mucolytic Agents                          30
      SODIUM CHLOR NEB 3%                       SODIUM CHLORIDE SOLN NEBU 3%                               Mucolytic Agents                          30
      SODIUM CHLOR NEB 7%                       SODIUM CHLORIDE SOLN NEBU 7%                               Mucolytic Agents                          30
      SOF-LAX CAP 100MG                          DOCUSATE SODIUM CAP 100 MG                            Cathartics and Laxatives              100     30
         SOFTDEN LOT                                   *EMOLLIENT - LOTION**                         Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
          SOLIA     TAB              DESOGESTREL & ETHINYL ESTRADIOL TAB 0.15 MG-30 MCG                      Contraceptives                          30
     SOOTHE      CHW 262MG                 BISMUTH SUBSALICYLATE CHEW TAB 262 MG                         Antidiarrhea Agents                120      30
    SOOTHE      SUS 262/15ML               BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                        Antidiarrhea Agents                1800     30
    SOOTHE      SUS 525/15ML               BISMUTH SUBSALICYLATE SUSP 525 MG/15ML                        Antidiarrhea Agents                1800     30
      SOOTHE     TAB 262MG                    BISMUTH SUBSALICYLATE TAB 262 MG                           Antidiarrhea Agents                120      30
SOOTHE&COOL LOT MOISTURE                               *EMOLLIENT - LOTION**                         Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
      SORINE     TAB 120MG                            SOTALOL HCL TAB 120 MG                       Beta-Adrenergic Blocking Agents                   30
      SORINE     TAB 160MG                            SOTALOL HCL TAB 160 MG                       Beta-Adrenergic Blocking Agents                   30
      SORINE     TAB 240MG                            SOTALOL HCL TAB 240 MG                       Beta-Adrenergic Blocking Agents                   30
       SORINE     TAB 80MG                             SOTALOL HCL TAB 80 MG                       Beta-Adrenergic Blocking Agents                   30
                                                                                                                                                   Max Qty
                                                                                                                                                     Limit   Max Max Age
                                                                                                                                                   (Liquids Days    Limit    Step      Step Therapy   Specialty
     Drug/Product Name                                  Generic Name                                            Therapy Class                       in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
    SOTALOL AF TAB 120MG                          SOTALOL HCL (AFIB/AFL) TAB 120 MG                     Beta-Adrenergic Blocking Agents                      30
    SOTALOL AF TAB 160MG                          SOTALOL HCL (AFIB/AFL) TAB 160 MG                     Beta-Adrenergic Blocking Agents                      30
     SOTALOL AF TAB 80MG                           SOTALOL HCL (AFIB/AFL) TAB 80 MG                     Beta-Adrenergic Blocking Agents                      30
    SOTALOL HCL TAB 120MG                               SOTALOL HCL TAB 120 MG                          Beta-Adrenergic Blocking Agents                      30
    SOTALOL HCL TAB 160MG                               SOTALOL HCL TAB 160 MG                          Beta-Adrenergic Blocking Agents                      30
    SOTALOL HCL TAB 240MG                               SOTALOL HCL TAB 240 MG                          Beta-Adrenergic Blocking Agents                      30
     SOTALOL HCL TAB 80MG                                SOTALOL HCL TAB 80 MG                          Beta-Adrenergic Blocking Agents                      30
         SPECIAL CARE LOT                                *EMOLLIENT - LOTION**                             Basic Lotions and Liniments                       30                                                   Prior Authorization Req'd
    SPIRIVA CAP HANDIHLR        TIOTROPIUM BROMIDE MONOHYDRATE INHAL CAP 18 MCG (BASE EQUIV)            Antimuscarinics/Antispasmodics                       30                                                   Prior Authorization Req'd
    SPIRONO/HCTZ TAB 25/25            SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TAB 25-25 MG             Mineralocorticoid (Aldost) Recept Antag                  30
   SPIRONOLACT TAB 100MG                             SPIRONOLACTONE TAB 100 MG                       Mineralocorticoid (Aldost) Recept Antag                 30
    SPIRONOLACT TAB 25MG                              SPIRONOLACTONE TAB 25 MG                       Mineralocorticoid (Aldost) Recept Antag                 30
    SPIRONOLACT TAB 50MG                              SPIRONOLACTONE TAB 50 MG                       Mineralocorticoid (Aldost) Recept Antag                 30
  SPORANOX SOL 10MG/ML                           ITRACONAZOLE ORAL SOLN 10 MG/ML                                       Azoles                                30      18                                           Prior Authorization Req'd
    SPRINTEC 28 TAB 28 DAY            NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG-35 MCG                         Contraceptives                             30
          SRONYX     TAB             LEVONORGESTREL & ETHINYL ESTRADIOL TAB 0.1 MG-20 MCG                         Contraceptives                             30
          SSD     CRE 1%                            SILVER SULFADIAZINE CREAM 1%                       Local Anti-infectives, Miscellaneous                  30
         SSD AF    CRE 1%                           SILVER SULFADIAZINE CREAM 1%                       Local Anti-infectives, Miscellaneous                  30
       SSKI     SOL 1GM/ML                         POTASSIUM IODIDE SOLN 1 GM/ML                               Antithyroid Agents                            30      18
        ST IVES LOT 24 HR                                *EMOLLIENT - LOTION**                             Basic Lotions and Liniments                       30                                                   Prior Authorization Req'd
     ST JOSEPH TAB ASPIRIN                       ASPIRIN TAB DELAYED RELEASE 81 MG                                   Salicylates                      31     30
    ST JOSEPH AS CHW 81MG                               ASPIRIN CHEW TAB 81 MG                                       Salicylates                      31     30
    STAGESIC CAP 500-5MG                   HYDROCODONE-ACETAMINOPHEN CAP 5-500 MG                                Opiate Agonists                     150     30
  STAMOIST E TAB 45-600MG              PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 45-600 MG                           Expectorants                       31     30
     STAVUDINE CAP 15MG                                   STAVUDINE CAP 15 MG                    Nucleoside & Nucleotide Rev Transcriptase Inhib             30
     STAVUDINE CAP 20MG                                   STAVUDINE CAP 20 MG                    Nucleoside & Nucleotide Rev Transcriptase Inhib             30
     STAVUDINE CAP 30MG                                   STAVUDINE CAP 30 MG                    Nucleoside & Nucleotide Rev Transcriptase Inhib             30
     STAVUDINE CAP 40MG                                   STAVUDINE CAP 40 MG                    Nucleoside & Nucleotide Rev Transcriptase Inhib             30
   STAVUDINE SOL 1MG/ML                          STAVUDINE FOR ORAL SOLN 1 MG/ML                 Nucleoside & Nucleotide Rev Transcriptase Inhib             30
  STOMACH RELF CHW 262MG                     BISMUTH SUBSALICYLATE CHEW TAB 262 MG                             Antidiarrhea Agents                  120      30
 STOMACH RELF SUS 262/15ML                   BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                            Antidiarrhea Agents                  1800     30
 STOMACH RELF SUS 524/30ML                   BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                            Antidiarrhea Agents                  1800     30
 STOMACH RELF SUS 525/15ML                   BISMUTH SUBSALICYLATE SUSP 525 MG/15ML                            Antidiarrhea Agents                  1800     30
 STOMACH RELF SUS 527/30ML                   BISMUTH SUBSALICYLATE SUSP 262 MG/15ML                            Antidiarrhea Agents                  1800     30
   STOMACH RELF TAB 262MG                        BISMUTH SUBSALICYLATE TAB 262 MG                              Antidiarrhea Agents                  120      30
     STOMACH RELI SUS PLUS                   BISMUTH SUBSALICYLATE SUSP 525 MG/15ML                            Antidiarrhea Agents                  1800     30
   STOOL SOFTNR CAP 100MG                           DOCUSATE SODIUM CAP 100 MG                               Cathartics and Laxatives               100      30
   STOOL SOFTNR CAP 250MG                           DOCUSATE SODIUM CAP 250 MG                               Cathartics and Laxatives               100      30
 STOOL SOFTNR CAP 250MG XS                          DOCUSATE SODIUM CAP 250 MG                               Cathartics and Laxatives               100      30
  STOOL SOFTNR SYP 60/15ML                      DOCUSATE SODIUM SYRUP 60 MG/15ML                             Cathartics and Laxatives               480      30
   STOOL SOFTNR TAB 100MG                           DOCUSATE SODIUM TAB 100 MG                               Cathartics and Laxatives               100      30
 STOOL SOFTNR TAB 8.6-50MG                 SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                          Cathartics and Laxatives               100      30
 STOOL SOFTNR TAB LAXATIVE                 SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                          Cathartics and Laxatives               100      30
 STOOL SOFTNR TAB STIMULNT                 SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                          Cathartics and Laxatives               100      30
      STOP LICE LIQ MAX ST                  PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.33-4%                     Scabicides and Pediculicides              120      30
STOP SMOKING GUM 2MG MINT                           NICOTINE POLACRILEX GUM 2 MG                        Autonomic Drugs, Miscellaneous                       30
STOP SMOKING GUM 2MG ORIG                           NICOTINE POLACRILEX GUM 2 MG                        Autonomic Drugs, Miscellaneous                       30
   STOP SMOKING GUM 4MG                             NICOTINE POLACRILEX GUM 4 MG                        Autonomic Drugs, Miscellaneous                       30
   SUBOXONE MIS 2-0.5MG           BUPRENORPHINE HCL-NALOXONE HCL SL FILM 2-0.5 MG (BASE EQUIV)                Opiate Partial Agonists                        30                                                   Prior Authorization Req'd
    SUBOXONE MIS 8-2MG             BUPRENORPHINE HCL-NALOXONE HCL SL FILM 8-2 MG (BASE EQUIV)                 Opiate Partial Agonists                        30                                                   Prior Authorization Req'd
   SUBOXONE SUB 2-0.5MG           BUPRENORPHINE HCL-NALOXONE HCL SL TAB 2-0.5 MG (BASE EQUIV)                 Opiate Partial Agonists                        30                                                   Prior Authorization Req'd
    SUBOXONE SUB 8-2MG             BUPRENORPHINE HCL-NALOXONE HCL SL TAB 8-2 MG (BASE EQUIV)                  Opiate Partial Agonists                        30                                                   Prior Authorization Req'd
    SUCLOR       CAP 8-120 CR        CHLORPHENIRAMINE & PSEUDOEPHEDRINE CAP CR 8-120 MG                      Proplamine Derivatives                  31      30
      SUCRALFATE TAB 1GM                                  SUCRALFATE TAB 1 GM                                       Protectants                              30
      SUDANYL TAB 30MG                             PSEUDOEPHEDRINE HCL TAB 30 MG                      alpha- and beta-Adrenergic Agonists            120     30
  SUDATEX-G TAB 60-580MG               PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 60-580 MG                           Expectorants                       31     30
  SUDOGEST LIQ 15MG/5ML                         PSEUDOEPHEDRINE HCL LIQ 15 MG/5ML                     alpha- and beta-Adrenergic Agonists            480     30
     SUDOGEST TAB 30MG                             PSEUDOEPHEDRINE HCL TAB 30 MG                      alpha- and beta-Adrenergic Agonists            120     30
     SUDOGEST TAB 60MG                             PSEUDOEPHEDRINE HCL TAB 60 MG                      alpha- and beta-Adrenergic Agonists             60     30
SUDOGEST CHD SYP 30MG/5ML                     PSEUDOEPHEDRINE HCL SYRUP 30 MG/5ML                     alpha- and beta-Adrenergic Agonists            240     30
     SUDOPHED TAB 30MG                             PSEUDOEPHEDRINE HCL TAB 30 MG                      alpha- and beta-Adrenergic Agonists            120     30
       SULF/PREDNIS SUS OP          SULFACETAMIDE SODIUM-PREDNISOLONE OPHTH SUSP 10-0.2%                         Corticosteroids                             30
      SULF-10 SOL 10% OP                      SULFACETAMIDE SODIUM OPHTH SOLN 10%                                 Antibacterials                             30
   SULFACET SOD OIN 10% OP                    SULFACETAMIDE SODIUM OPHTH OINT 10%                                 Antibacterials                             30
   SULFACET SOD SOL 10% OP                    SULFACETAMIDE SODIUM OPHTH SOLN 10%                                 Antibacterials                             30
                                                                                                                                            Max Qty
                                                                                                                                              Limit   Max Max Age
                                                                                                                                            (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                               Generic Name                                          Therapy Class                      in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
   SULFASALAZIN TAB 500MG                         SULFASALAZINE TAB 500 MG                                 Sulfonamides                              240
SULFASALAZIN TAB 500MG DR               SULFASALAZINE TAB DELAYED RELEASE 500 MG                           Sulfonamides                              240
 SULFASALAZIN TAB 500MG EC              SULFASALAZINE TAB DELAYED RELEASE 500 MG                           Sulfonamides                              240
   SULFATRIM SUS 200-40/5         SULFAMETHOXAZOLE-TRIMETHOPRIM SUSP 200-40 MG/5ML                         Sulfonamides                              30       18
    SULFAZINE TAB 500MG                           SULFASALAZINE TAB 500 MG                                 Sulfonamides                              240
   SULFAZINE EC TAB 500MG               SULFASALAZINE TAB DELAYED RELEASE 500 MG                           Sulfonamides                              240
    SULINDAC TAB 150MG                               SULINDAC TAB 150 MG                    Other Nonsteroidal Anti-inflammtory Agents               30
    SULINDAC TAB 200MG                               SULINDAC TAB 200 MG                    Other Nonsteroidal Anti-inflammtory Agents               30
  SUMATRIPTAN INJ 4MG/0.5                 SUMATRIPTAN SUCCINATE INJ 4 MG/0.5ML                     Selective Serotonin Agonists                2     30
  SUMATRIPTAN INJ 6MG/0.5                 SUMATRIPTAN SUCCINATE INJ 6 MG/0.5ML                     Selective Serotonin Agonists                2     30
  SUMATRIPTAN KIT 4MG/0.5               SUMATRIPTAN SUCCINATE INJ KIT 4 MG/0.5ML                   Selective Serotonin Agonists                2     30
  SUMATRIPTAN KIT 6MG/0.5               SUMATRIPTAN SUCCINATE INJ KIT 6 MG/0.5ML                   Selective Serotonin Agonists                2     30
SUMATRIPTAN SPR 20MG/ACT                   SUMATRIPTAN NASAL SPRAY 20 MG/ACT                       Selective Serotonin Agonists                6     30
 SUMATRIPTAN SPR 5MG/ACT                    SUMATRIPTAN NASAL SPRAY 5 MG/ACT                       Selective Serotonin Agonists                6     30
  SUMATRIPTAN TAB 100MG                     SUMATRIPTAN SUCCINATE TAB 100 MG                       Selective Serotonin Agonists                9     30
   SUMATRIPTAN TAB 25MG                      SUMATRIPTAN SUCCINATE TAB 25 MG                       Selective Serotonin Agonists                9     30
   SUMATRIPTAN TAB 50MG                      SUMATRIPTAN SUCCINATE TAB 50 MG                       Selective Serotonin Agonists                9     30
  SUPER RICH LOT ALOE VER                           *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                       30                                                    Prior Authorization Req'd
      SUPER RICH LOT VIT E                          *EMOLLIENT - LOTION**                          Basic Lotions and Liniments                       30                                                    Prior Authorization Req'd
  SUPER TUSSIN LIQ 100-10/5       DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                         Antitussives                      180    30
       SUPER TUSSIN SYP PE         PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 30-100 MG/5ML                         Expectorants                              30
  SUPERTUSSIN SYP 100/5ML                      GUAIFENESIN SYRUP 100 MG/5ML                                Expectorants                              30
      SUPERTUSSIN SYP DM          DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                         Antitussives                      180    30
 SUPHEDRIN LIQ 15MG/5ML                    PSEUDOEPHEDRINE HCL LIQ 15 MG/5ML                   alpha- and beta-Adrenergic Agonists            480    30
     SUPHEDRIN TAB 30MG                       PSEUDOEPHEDRINE HCL TAB 30 MG                    alpha- and beta-Adrenergic Agonists            120    30
    SU-PHEDRIN TAB 30MG                       PSEUDOEPHEDRINE HCL TAB 30 MG                    alpha- and beta-Adrenergic Agonists            120    30
    SUPHEDRINE TAB 30MG                       PSEUDOEPHEDRINE HCL TAB 30 MG                    alpha- and beta-Adrenergic Agonists            120    30
  SUPHERINE CAP NON-DRY                PSEUDOEPHEDRINE-GUAIFENESIN CAP 30-200 MG                           Expectorants                              30
     SUSTIVA CAP 200MG                              EFAVIRENZ CAP 200 MG                   Nonnucleoside Reverse Transcriptase Inhibitors            30
      SUSTIVA CAP 50MG                               EFAVIRENZ CAP 50 MG                   Nonnucleoside Reverse Transcriptase Inhibitors            30
     SUSTIVA TAB 600MG                              EFAVIRENZ TAB 600 MG                   Nonnucleoside Reverse Transcriptase Inhibitors            30
  SU-TUSS DM ELX 200-20/5         DEXTROMETHORPHAN-GUAIFENESIN ELIXIR 20-200 MG/5ML                         Antitussives                      178    30
         SU-TUSS HD ELX       PSEUDOEPHEDRINE W/ HYDROCODONE-GG ELIXIR 30-2.5-100 MG/5ML                    Antitussives                      178    30
   SW NASAL DEC TAB 30MG                      PSEUDOEPHEDRINE HCL TAB 30 MG                    alpha- and beta-Adrenergic Agonists            120    30
SW NICOTINE GUM 2MG MINT                       NICOTINE POLACRILEX GUM 2 MG                      Autonomic Drugs, Miscellaneous                      30
    SW NICOTINE GUM 4MG                        NICOTINE POLACRILEX GUM 4 MG                      Autonomic Drugs, Miscellaneous                      30
   SYMAX-SL SUB 0.125MG                    HYOSCYAMINE SULFATE TAB SL 0.125 MG                   Antimuscarinics/Antispasmodics               20     30
    SYNAREL SOL 2MG/ML                    NAFARELIN ACETATE NASAL SOLN 2 MG/ML                            Gonadotropins                              30                                                    Prior Authorization Req'd
   SYNTHROID TAB 100MCG                    LEVOTHYROXINE SODIUM TAB 100 MCG                               Thyroid Agents                             30
   SYNTHROID TAB 112MCG                    LEVOTHYROXINE SODIUM TAB 112 MCG                               Thyroid Agents                             30
   SYNTHROID TAB 125MCG                    LEVOTHYROXINE SODIUM TAB 125 MCG                               Thyroid Agents                             30
   SYNTHROID TAB 137MCG                    LEVOTHYROXINE SODIUM TAB 137 MCG                               Thyroid Agents                             30
   SYNTHROID TAB 150MCG                    LEVOTHYROXINE SODIUM TAB 150 MCG                               Thyroid Agents                             30
   SYNTHROID TAB 175MCG                    LEVOTHYROXINE SODIUM TAB 175 MCG                               Thyroid Agents                             30
   SYNTHROID TAB 200MCG                    LEVOTHYROXINE SODIUM TAB 200 MCG                               Thyroid Agents                             30
    SYNTHROID TAB 25MCG                     LEVOTHYROXINE SODIUM TAB 25 MCG                               Thyroid Agents                             30
   SYNTHROID TAB 300MCG                    LEVOTHYROXINE SODIUM TAB 300 MCG                               Thyroid Agents                             30
    SYNTHROID TAB 50MCG                     LEVOTHYROXINE SODIUM TAB 50 MCG                               Thyroid Agents                             30
    SYNTHROID TAB 75MCG                     LEVOTHYROXINE SODIUM TAB 75 MCG                               Thyroid Agents                             30
    SYNTHROID TAB 88MCG                     LEVOTHYROXINE SODIUM TAB 88 MCG                               Thyroid Agents                             30
      TABLOID TAB 40MG                             THIOGUANINE TAB 40 MG                              Antineoplastic Agents                          30
   TACROLIMUS CAP 0.5MG                            TACROLIMUS CAP 0.5 MG                           Immunosuppressive Agents                          30
     TACROLIMUS CAP 1MG                             TACROLIMUS CAP 1 MG                            Immunosuppressive Agents                          30
     TACROLIMUS CAP 5MG                             TACROLIMUS CAP 5 MG                            Immunosuppressive Agents                          30
  TACTINAL CHW CHILDREN                       ACETAMINOPHEN CHEW TAB 80 MG                       Analgesics and Antipyretics, Misc             60    30
     TACTINAL TAB 325MG                         ACETAMINOPHEN TAB 325 MG                         Analgesics and Antipyretics, Misc            250    30
     TACTINAL TAB 500MG                         ACETAMINOPHEN TAB 500 MG                         Analgesics and Antipyretics, Misc            250    30
      TAMIFLU CAP 30MG                OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV)                  Neuraminidase Inhibitors                         10
      TAMIFLU CAP 45MG                OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV)                  Neuraminidase Inhibitors                         10
      TAMIFLU CAP 75MG                OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV)                  Neuraminidase Inhibitors                         10
   TAMIFLU SUS 12MG/ML            OSELTAMIVIR PHOSPHATE FOR SUSP 12 MG/ML (BASE EQUIV)              Neuraminidase Inhibitors                         10
    TAMOXIFEN TAB 10MG                TAMOXIFEN CITRATE TAB 10 MG (BASE EQUIVALENT)                   Antineoplastic Agents                   60     30
    TAMOXIFEN TAB 20MG                TAMOXIFEN CITRATE TAB 20 MG (BASE EQUIVALENT)                   Antineoplastic Agents                   30     30
   TAMSULOSIN CAP 0.4MG                          TAMSULOSIN HCL CAP 0.4 MG                   Sympatholytic (Adrenergic Block) Agents                 30                                                    Prior Authorization Req'd
     TARGRETIN CAP 75MG                            BEXAROTENE CAP 75 MG                               Antineoplastic Agents                          30
                                                                                                                                       Max Qty
                                                                                                                                         Limit   Max Max Age
                                                                                                                                       (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                               Generic Name                                       Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
        TARON FORTE CAP           *FE BISGLYCINATE-FE POLYSACCH-VIT C-VIT B12-FA CAP***                Iron Preparations                         30
  TARON-EC CAL TAB 28-1MG      *PRENATAL W/O A VIT W/ FE FUMARATE-FA TAB DR 30-1 MG***            Multivitamin Preparations                      30      40
     TASMAR      TAB 100MG                          TOLCAPONE TAB 100 MG                        Central Nervous System Agents                    30
     TASMAR      TAB 200MG                          TOLCAPONE TAB 200 MG                        Central Nervous System Agents                    30
      TAVIST ND TAB 10MG                             LORATADINE TAB 10 MG                     Second Generation Antihistamines                   30
   TAZTIA XT CAP 120MG/24       DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 120 MG     Calcium-Channel Blocking Agents, Misc                30
   TAZTIA XT CAP 180MG/24       DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 180 MG     Calcium-Channel Blocking Agents, Misc                30
   TAZTIA XT CAP 240MG/24       DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 240 MG     Calcium-Channel Blocking Agents, Misc                30
   TAZTIA XT CAP 300MG/24       DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 300 MG     Calcium-Channel Blocking Agents, Misc                30
   TAZTIA XT CAP 360MG/24       DILTIAZEM HCL EXTENDED RELEASE BEADS CAP SR 24HR 360 MG     Calcium-Channel Blocking Agents, Misc                30
    TEBAMIDE SUP 100MG             TRIMETHOBENZAMIDE-BENZOCAINE SUPPOS 100 MG-2%                         Antihistamines                  30      30
    TEBAMIDE SUP 200MG             TRIMETHOBENZAMIDE-BENZOCAINE SUPPOS 200 MG-2%                         Antihistamines                  30      30
    TEGRETOL CHW 100MG                      CARBAMAZEPINE CHEW TAB 100 MG                       Anticonvulsants, Miscellaneous                   30
   TEGRETOL SUS 100/5ML                      CARBAMAZEPINE SUSP 100 MG/5ML                      Anticonvulsants, Miscellaneous                   30      12
     TEGRETOL TAB 200MG                          CARBAMAZEPINE TAB 200 MG                       Anticonvulsants, Miscellaneous                   30
    TEGRETOL XR TAB 100MG                  CARBAMAZEPINE TAB SR 12HR 100 MG                     Anticonvulsants, Miscellaneous                   30                                                   Prior Authorization Req'd
    TEMAZEPAM CAP 15MG                               TEMAZEPAM CAP 15 MG                                Benzodiazepines                  7       30
  TEMAZEPAM CAP 22.5MG                             TEMAZEPAM CAP 22.5 MG                                Benzodiazepines                  7       30
    TEMAZEPAM CAP 30MG                               TEMAZEPAM CAP 30 MG                                Benzodiazepines                  7       30
          TENCET    CAP          BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-325-40 MG            Analgesics and Antipyretics, Misc         20      30
     TERAZOSIN CAP 10MG                            TERAZOSIN HCL CAP 10 MG                     Alpha-Adrenergic Blocking Agents                  30
      TERAZOSIN CAP 1MG                             TERAZOSIN HCL CAP 1 MG                     Alpha-Adrenergic Blocking Agents                  30
      TERAZOSIN CAP 2MG                             TERAZOSIN HCL CAP 2 MG                     Alpha-Adrenergic Blocking Agents                  30
      TERAZOSIN CAP 5MG                             TERAZOSIN HCL CAP 5 MG                     Alpha-Adrenergic Blocking Agents                  30
       TERBINAFINE CRE 1%                         TERBINAFINE HCL CREAM 1%                                 Allylamines                   30      30
    TERBINAFINE TAB 250MG                        TERBINAFINE HCL TAB 250 MG                                Allylamines                           30                                                   Prior Authorization Req'd
    TERBUTALINE TAB 2.5MG                     TERBUTALINE SULFATE TAB 2.5 MG                 Selective beta-2-Adrenergic Agonists                30
     TERBUTALINE TAB 5MG                       TERBUTALINE SULFATE TAB 5 MG                  Selective beta-2-Adrenergic Agonists                30
     TERCONAZOLE CRE 0.4%                   TERCONAZOLE VAGINAL CREAM 0.4%                                    Azoles                     45      30
     TERCONAZOLE CRE 0.8%                   TERCONAZOLE VAGINAL CREAM 0.8%                                    Azoles                     45      30
   TERCONAZOLE SUP 80MG                    TERCONAZOLE VAGINAL SUPPOS 80 MG                                Antifungals                           30
       TESLAC    TAB 50MG                          TESTOLACTONE TAB 50 MG                            Antineoplastic Agents                       30
 TESTOST CYP INJ 100MG/ML              TESTOSTERONE CYPIONATE IM IN OIL 100 MG/ML                          Androgens                             30                                                   Prior Authorization Req'd
 TESTOST CYP INJ 200MG/ML              TESTOSTERONE CYPIONATE IM IN OIL 200 MG/ML                          Androgens                             30                                                   Prior Authorization Req'd
TESTOST ENAN INJ 200MG/ML             TESTOSTERONE ENANTHATE IM IN OIL 200 MG/ML                           Androgens                             30                                                   Prior Authorization Req'd
      TESTRED CAP 10MG                       METHYLTESTOSTERONE CAP 10 MG                                  Androgens                             30                                                   Prior Authorization Req'd
   TETRACYCLINE CAP 250MG                       TETRACYCLINE HCL CAP 250 MG                               Tetracyclines                          30
   TETRACYCLINE CAP 500MG                       TETRACYCLINE HCL CAP 500 MG                               Tetracyclines                          30
       TEXACORT SOL 1%                            HYDROCORTISONE SOLN 1%                           Anti-inflammatory Agents              120     30
TGQ 30/PSE/3 SYP BRM/15DM          PSEUDOEPHED-BROMPHEN-DM SYRUP 30-3-15 MG/5ML                           Antitussives                   178     30
 TGQ 50PSE/3 SYP BRM/30DM          PSEUDOEPHED-BROMPHEN-DM SYRUP 50-3-30 MG/5ML                           Antitussives                   178     30
    TGT ACETAMIN SUS CHILD                  ACETAMINOPHEN SUSP 160 MG/5ML                      Analgesics and Antipyretics, Misc         240     30
   TGT ACETAMIN TAB 500MG                       ACETAMINOPHEN TAB 500 MG                       Analgesics and Antipyretics, Misc         250     30
TGT ACETAMIN TAB 500MG/RR                       ACETAMINOPHEN TAB 500 MG                       Analgesics and Antipyretics, Misc         250     30
     TGT ALLERGY CAP 25MG                    DIPHENHYDRAMINE HCL CAP 25 MG                         Ethanolamine Derivatives                      30
  TGT ALLERGY LIQ CHILDREN              DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                     Ethanolamine Derivatives                      30
    TGT ALLERGY TAB RELIEF                           LORATADINE TAB 10 MG                     Second Generation Antihistamines                   30
  TGT ALLERGY TAB RLF 10MG            LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG             Second Generation Antihistamines                   30
  TGT ANTACID SUS ANTI-GAS    ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML              Antacids and Adsorbents               480     30
    TGT APAP DRO INFANTS                    ACETAMINOPHEN SUSP 80 MG/0.8ML                     Analgesics and Antipyretics, Misc          30     30
    TGT ASPIRIN CHW CHILD                          ASPIRIN CHEW TAB 81 MG                                  Salicylates                    31     30
    TGT ASPIRIN TAB 325MG                              ASPIRIN TAB 325 MG                                  Salicylates                    31     30
     TGT ASPIRIN TAB 81MG                   ASPIRIN TAB DELAYED RELEASE 81 MG                              Salicylates                    31     30
   TGT ASPIRIN TAB 81MG EC                  ASPIRIN TAB DELAYED RELEASE 81 MG                              Salicylates                    31     30
     TGT ATHLETES CRE FOOT                        TERBINAFINE HCL CREAM 1%                                 Allylamines                    30     30
  TGT COUGH LIQ FORM DM          DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                        Antitussives                   180     30
 TGT INFANTS SUS IBUPROFN                         IBUPROFEN SUSP 40 MG/ML                 Other Nonsteroidal Anti-inflammtory Agents             30      18
    TGT NICOTINE DIS STEP 1                NICOTINE TD PATCH 24HR 21 MG/24HR                   Autonomic Drugs, Miscellaneous                    30
    TGT NICOTINE DIS STEP 2                NICOTINE TD PATCH 24HR 14 MG/24HR                   Autonomic Drugs, Miscellaneous                    30
    TGT NICOTINE DIS STEP 3                 NICOTINE TD PATCH 24HR 7 MG/24HR                   Autonomic Drugs, Miscellaneous                    30
TGT NICOTINE GUM 2MG MINT                     NICOTINE POLACRILEX GUM 2 MG                     Autonomic Drugs, Miscellaneous                    30
TGT NICOTINE GUM 2MG ORIG                     NICOTINE POLACRILEX GUM 2 MG                     Autonomic Drugs, Miscellaneous                    30
    TGT NICOTINE GUM 4MG                      NICOTINE POLACRILEX GUM 4 MG                     Autonomic Drugs, Miscellaneous                    30
   TGT SENNA TAB LAXATIVE              SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG                     Cathartics and Laxatives             100     30
 THEOCHRON TAB 100MG CR                     THEOPHYLLINE TAB SR 12HR 100 MG                  Respiratory Smooth Muscle Relaxants                 30
                                                                                                                                    Max Qty
                                                                                                                                      Limit   Max Max Age
                                                                                                                                    (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                               Generic Name                                       Therapy Class                 in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
THEOCHRON TAB 200MG CR                      THEOPHYLLINE TAB SR 12HR 200 MG                 Respiratory Smooth Muscle Relaxants               30
THEOCHRON TAB 300MG CR                      THEOPHYLLINE TAB SR 12HR 300 MG                 Respiratory Smooth Muscle Relaxants               30
  THEOCHRON TAB 450MG                       THEOPHYLLINE TAB SR 12HR 450 MG                 Respiratory Smooth Muscle Relaxants               30
THEOPHYLLINE CAP 125MG ER                   THEOPHYLLINE CAP SR 12HR 125 MG                 Respiratory Smooth Muscle Relaxants               30
THEOPHYLLINE CAP 200MG ER                   THEOPHYLLINE CAP SR 12HR 200 MG                 Respiratory Smooth Muscle Relaxants               30
THEOPHYLLINE TAB 100MG CR                   THEOPHYLLINE TAB SR 12HR 100 MG                 Respiratory Smooth Muscle Relaxants               30
THEOPHYLLINE TAB 100MG ER                   THEOPHYLLINE TAB SR 12HR 100 MG                 Respiratory Smooth Muscle Relaxants               30
THEOPHYLLINE TAB 100MG TD                   THEOPHYLLINE TAB SR 12HR 100 MG                 Respiratory Smooth Muscle Relaxants               30
THEOPHYLLINE TAB 200MG CR                   THEOPHYLLINE TAB SR 12HR 200 MG                 Respiratory Smooth Muscle Relaxants               30
THEOPHYLLINE TAB 200MG ER                   THEOPHYLLINE TAB SR 12HR 200 MG                 Respiratory Smooth Muscle Relaxants               30
THEOPHYLLINE TAB 200MG SR                   THEOPHYLLINE TAB SR 12HR 200 MG                 Respiratory Smooth Muscle Relaxants               30
THEOPHYLLINE TAB 200MG TD                   THEOPHYLLINE TAB SR 12HR 200 MG                 Respiratory Smooth Muscle Relaxants               30
THEOPHYLLINE TAB 300MG CR                   THEOPHYLLINE TAB SR 12HR 300 MG                 Respiratory Smooth Muscle Relaxants               30
THEOPHYLLINE TAB 300MG ER                   THEOPHYLLINE TAB SR 12HR 300 MG                 Respiratory Smooth Muscle Relaxants               30
THEOPHYLLINE TAB 300MG SR                   THEOPHYLLINE TAB SR 12HR 300 MG                 Respiratory Smooth Muscle Relaxants               30
THEOPHYLLINE TAB 300MG TD                   THEOPHYLLINE TAB SR 12HR 300 MG                 Respiratory Smooth Muscle Relaxants               30
THEOPHYLLINE TAB 300MGSR                    THEOPHYLLINE TAB SR 12HR 300 MG                 Respiratory Smooth Muscle Relaxants               30
THEOPHYLLINE TAB 400MG ER                   THEOPHYLLINE TAB SR 24HR 400 MG                 Respiratory Smooth Muscle Relaxants               30
THEOPHYLLINE TAB 450MG CR                   THEOPHYLLINE TAB SR 12HR 450 MG                 Respiratory Smooth Muscle Relaxants               30
THEOPHYLLINE TAB 450MG ER                   THEOPHYLLINE TAB SR 12HR 450 MG                 Respiratory Smooth Muscle Relaxants               30
THEOPHYLLINE TAB 600MG ER                   THEOPHYLLINE TAB SR 24HR 600 MG                 Respiratory Smooth Muscle Relaxants               30
     THERABETIC LOT SKIN                           *EMOLLIENT - LOTION**                         Basic Lotions and Liniments                  30                                                   Prior Authorization Req'd
      THERACORT LOT 1%                         HYDROCORTISONE LOTION 1%                           Anti-inflammatory Agents                    30
       THERA-DERM LOT                              *EMOLLIENT - LOTION**                         Basic Lotions and Liniments                  30                                                   Prior Authorization Req'd
 THERA-P HAND LOT & BODY                           *EMOLLIENT - LOTION**                         Basic Lotions and Liniments                  30                                                   Prior Authorization Req'd
    THERAPEUTIC LOT BATH                           *EMOLLIENT - LOTION**                         Basic Lotions and Liniments                  30                                                   Prior Authorization Req'd
 THERAPEUTIC LOT DRY SKIN                          *EMOLLIENT - LOTION**                         Basic Lotions and Liniments                  30                                                   Prior Authorization Req'd
    THERAPLEX LOT CLEAR                            *EMOLLIENT - LOTION**                         Basic Lotions and Liniments                  30                                                   Prior Authorization Req'd
   THERAPLEX LOT HYDRO                             *EMOLLIENT - LOTION**                         Basic Lotions and Liniments                  30                                                   Prior Authorization Req'd
     THERMAZENE CRE 1%                        SILVER SULFADIAZINE CREAM 1%                   Local Anti-infectives, Miscellaneous             30
 THRIVE       GUM 2MG MINT                   NICOTINE POLACRILEX GUM 2 MG                     Autonomic Drugs, Miscellaneous                  30
 THRIVE       GUM 4MG MINT                   NICOTINE POLACRILEX GUM 4 MG                     Autonomic Drugs, Miscellaneous                  30
 THROMBAT III INJ 1000UNIT             ANTITHROMBIN III (HUMAN) FOR INJ 1000 UNIT               Miscellaneous Anticoagulants                  30                                                   Prior Authorization Req'd
  THROMBAT III INJ 500UNIT              ANTITHROMBIN III (HUMAN) FOR INJ 500 UNIT               Miscellaneous Anticoagulants                  30                                                   Prior Authorization Req'd
    THYROID TAB 120MG                         THYROID TAB 120 MG (2 GRAIN)                              Thyroid Agents                        30
    THYROID TAB 130MG                               THYROID TAB 130 MG                                  Thyroid Agents                        30
     THYROID TAB 15MG                         THYROID TAB 15 MG (1/4 GRAIN)                             Thyroid Agents                        30
    THYROID TAB 180MG                         THYROID TAB 180 MG (3 GRAIN)                              Thyroid Agents                        30
    THYROID TAB 195MG                               THYROID TAB 195 MG                                  Thyroid Agents                        30
      THYROID TAB 2GR                               THYROID TAB 130 MG                                  Thyroid Agents                        30
     THYROID TAB 30MG                         THYROID TAB 30 MG (1/2 GRAIN)                             Thyroid Agents                        30
    THYROID TAB 32.5MG                              THYROID TAB 32.5 MG                                 Thyroid Agents                        30
     THYROID TAB 60MG                          THYROID TAB 60 MG (1 GRAIN)                              Thyroid Agents                        30
     THYROID TAB 65MG                                THYROID TAB 65 MG                                  Thyroid Agents                        30
     THYROID TAB 90MG                        THYROID TAB 90 MG (1 1/2 GRAIN)                            Thyroid Agents                        30
   TICLOPIDINE TAB 250MG                        TICLOPIDINE HCL TAB 250 MG                     Platelet-Aggregation Inhibitors                30
 TIDAFEN LA TAB 45-800MG          PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 45-800 MG                      Expectorants                 31      30
   TIKOSYN CAP 125MCG                       DOFETILIDE CAP 125 MCG (0.125 MG)                      Class III Antiarrhythmics                  30                                       Specialty   Prior Authorization Req'd
   TIKOSYN CAP 250MCG                       DOFETILIDE CAP 250 MCG (0.25 MG)                       Class III Antiarrhythmics                  30                                       Specialty   Prior Authorization Req'd
   TIKOSYN CAP 500MCG                        DOFETILIDE CAP 500 MCG (0.5 MG)                       Class III Antiarrhythmics                  30                                       Specialty   Prior Authorization Req'd
         TILIA FE TAB        NORETHINDRONE AC-ETHINYL ESTRAD-FE TAB 1-20/1-30/1-35 MG-MCG               Contraceptives                        30
 TIMOLOL GEL SOL 0.25% OP           TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.25%            BETA ADRENERGIC BLOCKING AGENTS                   30
 TIMOLOL GEL SOL 0.5% OP             TIMOLOL MALEATE OPHTH GEL FORMING SOLN 0.5%            BETA ADRENERGIC BLOCKING AGENTS                   30
TIMOLOL MAL SOL 0.25% OP                  TIMOLOL MALEATE OPHTH SOLN 0.25%                  BETA ADRENERGIC BLOCKING AGENTS                   30
 TIMOLOL MAL SOL 0.5% OP                   TIMOLOL MALEATE OPHTH SOLN 0.5%                  BETA ADRENERGIC BLOCKING AGENTS                   30
   TIMOLOL MAL TAB 10MG                        TIMOLOL MALEATE TAB 10 MG                      Beta-Adrenergic Blocking Agents                 30
   TIMOLOL MAL TAB 20MG                        TIMOLOL MALEATE TAB 20 MG                      Beta-Adrenergic Blocking Agents                 30
    TIMOLOL MAL TAB 5MG                         TIMOLOL MALEATE TAB 5 MG                      Beta-Adrenergic Blocking Agents                 30
TIMOPTIC OCU SOL 0.25% OP                 TIMOLOL MALEATE OPHTH SOLN 0.25%                  BETA ADRENERGIC BLOCKING AGENTS                   30
 TIMOPTIC OCU SOL 0.5% OP                  TIMOLOL MALEATE OPHTH SOLN 0.5%                  BETA ADRENERGIC BLOCKING AGENTS                   30
          TISIT    LIQ                 PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.17-2%                Scabicides and Pediculicides          120     30
  TMP/SMZ DS TAB 160-800           SULFAMETHOXAZOLE-TRIMETHOPRIM TAB 800-160 MG                          Sulfonamides                         30
       T-NAF     GEL 1.1%                   SODIUM FLUORIDE GEL 1.1% (0.5% F)                 Miscellaneous Therapeutic Agents                30      18
      TOBRADEX OIN OP               TOBRAMYCIN-DEXAMETHASONE OPHTH OINT 0.3-0.1%                        Corticosteroids                       30
     TOBRADEX ST SUS OP            TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.05%                        Corticosteroids                       30
                                                                                                                                 Max Qty
                                                                                                                                   Limit   Max Max Age
                                                                                                                                 (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                           Generic Name                                     Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
 TOBRAMYCIN SOL 0.3% OP                 TOBRAMYCIN SULFATE OPHTH SOLN 0.3%                         Antibacterials                          30
TOBRAMYCIN/ SUS DEXAMETH         TOBRAMYCIN-DEXAMETHASONE OPHTH SUSP 0.3-0.1%                     Corticosteroids                          30
   TOBRASOL SOL 0.3% OP                 TOBRAMYCIN SULFATE OPHTH SOLN 0.3%                         Antibacterials                          30
  TOLMETIN SOD CAP 400MG                     TOLMETIN SODIUM CAP 400 MG             Other Nonsteroidal Anti-inflammtory Agents             30
  TOLMETIN SOD TAB 200MG                     TOLMETIN SODIUM TAB 200 MG             Other Nonsteroidal Anti-inflammtory Agents             30
  TOLMETIN SOD TAB 600MG                     TOLMETIN SODIUM TAB 600 MG             Other Nonsteroidal Anti-inflammtory Agents             30
 TOLU-SED DM LIQ 100-10/5    DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                      Antitussives                   180     30
   TOPIRAGEN TAB 100MG                          TOPIRAMATE TAB 100 MG                     Anticonvulsants, Miscellaneous                   30                                                   Prior Authorization Req'd
   TOPIRAGEN TAB 200MG                          TOPIRAMATE TAB 200 MG                     Anticonvulsants, Miscellaneous                   30                                                   Prior Authorization Req'd
    TOPIRAGEN TAB 25MG                          TOPIRAMATE TAB 25 MG                      Anticonvulsants, Miscellaneous                   30                                                   Prior Authorization Req'd
    TOPIRAGEN TAB 50MG                          TOPIRAMATE TAB 50 MG                      Anticonvulsants, Miscellaneous                   30                                                   Prior Authorization Req'd
   TOPIRAMATE CAP 15MG                     TOPIRAMATE SPRINKLE CAP 15 MG                  Anticonvulsants, Miscellaneous                   30                                                   Prior Authorization Req'd
   TOPIRAMATE CAP 25MG                     TOPIRAMATE SPRINKLE CAP 25 MG                  Anticonvulsants, Miscellaneous                   30                                                   Prior Authorization Req'd
  TOPIRAMATE TAB 100MG                          TOPIRAMATE TAB 100 MG                     Anticonvulsants, Miscellaneous                   30                                                   Prior Authorization Req'd
  TOPIRAMATE TAB 200MG                          TOPIRAMATE TAB 200 MG                     Anticonvulsants, Miscellaneous                   30                                                   Prior Authorization Req'd
   TOPIRAMATE TAB 25MG                          TOPIRAMATE TAB 25 MG                      Anticonvulsants, Miscellaneous                   30                                                   Prior Authorization Req'd
   TOPIRAMATE TAB 50MG                          TOPIRAMATE TAB 50 MG                      Anticonvulsants, Miscellaneous                   30                                                   Prior Authorization Req'd
   TORSEMIDE TAB 100MG                           TORSEMIDE TAB 100 MG                             Loop Diuretics                           30
    TORSEMIDE TAB 10MG                           TORSEMIDE TAB 10 MG                              Loop Diuretics                           30
    TORSEMIDE TAB 20MG                           TORSEMIDE TAB 20 MG                              Loop Diuretics                           30
     TORSEMIDE TAB 5MG                            TORSEMIDE TAB 5 MG                              Loop Diuretics                           30
 TOTAL ALLERG LIQ 12.5/5ML           DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                 Ethanolamine Derivatives                       30
   TOTAL ALLERG TAB 25MG                   DIPHENHYDRAMINE HCL TAB 25 MG                    Ethanolamine Derivatives                       30
 TOURO DM TAB 30-575MG       DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 30-575 MG                     Antitussives                    31     30
  TRAMADOL HCL TAB 50MG                        TRAMADOL HCL TAB 50 MG                            Opiate Agonists                   120     30
   TRAVATAN DRO 0.004%                     TRAVOPROST OPHTH SOLN 0.004%                    PROSTAGLANDIN ANALOGS                           30
  TRAVATAN Z DRO 0.004%                    TRAVOPROST OPHTH SOLN 0.004%                    PROSTAGLANDIN ANALOGS                           30
   TRELSTAR MIX INJ 22.5MG            TRIPTORELIN PAMOATE FOR IM SUSP 22.5 MG                  Antineoplastic Agents                       30                                                   Prior Authorization Req'd
  TRENTAL TAB 400MG CR                       PENTOXIFYLLINE TAB CR 400 MG                    Hemorrheologic Agents                         30
     TRETINOIN CAP 10MG                           TRETINOIN CAP 10 MG                          Antineoplastic Agents                       30
      TREXALL TAB 10MG             METHOTREXATE SODIUM TAB 10 MG (BASE EQUIV)                  Antineoplastic Agents                       30
      TREXALL TAB 15MG             METHOTREXATE SODIUM TAB 15 MG (BASE EQUIV)                  Antineoplastic Agents                       30
       TREXALL TAB 5MG              METHOTREXATE SODIUM TAB 5 MG (BASE EQUIV)                  Antineoplastic Agents                       30
     TREXALL TAB 7.5MG            METHOTREXATE SODIUM TAB 7.5 MG (BASE EQUIV)                  Antineoplastic Agents                       30
  TRI ACTING SYP CHST CON       PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 15-50 MG/5ML                     Expectorants                            30
    TRIAC EXPECT SYP 15/50      PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 15-50 MG/5ML                     Expectorants                            30
   TRIACTIN SYP 15-50MG         PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 15-50 MG/5ML                     Expectorants                            30
          TRIAD     CAP       BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP 50-325-40 MG         Analgesics and Antipyretics, Misc         20      30
        TRIADVANCE TAB       *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***           Multivitamin Preparations                      30
   TRIAM/HCTZ CAP 37.5-25      TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 37.5-25 MG            Potassium-sparing Diuretics                     30
        TRIAM/NYSTAT CRE      NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 UNIT/GM-%             Anti-inflammatory Agents                       30
        TRIAM/NYSTAT OIN       NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 UNIT/GM-%             Anti-inflammatory Agents                       30
    TRIAMCIN/ORA PST 0.1%           TRIAMCINOLONE ACETONIDE DENTAL PASTE 0.1%               Anti-inflammatory Agents                       30                                                   Prior Authorization Req'd
 TRIAMCINOLON CRE 0.025%              TRIAMCINOLONE ACETONIDE CREAM 0.025%                  Anti-inflammatory Agents                       30
   TRIAMCINOLON CRE 0.1%               TRIAMCINOLONE ACETONIDE CREAM 0.1%                   Anti-inflammatory Agents                       30
   TRIAMCINOLON CRE 0.5%               TRIAMCINOLONE ACETONIDE CREAM 0.5%                   Anti-inflammatory Agents                       30
 TRIAMCINOLON LOT 0.025%              TRIAMCINOLONE ACETONIDE LOTION 0.025%                 Anti-inflammatory Agents                       30
   TRIAMCINOLON LOT 0.1%               TRIAMCINOLONE ACETONIDE LOTION 0.1%                  Anti-inflammatory Agents                       30
 TRIAMCINOLON OIN 0.025%               TRIAMCINOLONE ACETONIDE OINT 0.025%                  Anti-inflammatory Agents                       30
  TRIAMCINOLON OIN 0.05%                TRIAMCINOLONE ACETONIDE OINT 0.05%                  Anti-inflammatory Agents                       30
   TRIAMCINOLON OIN 0.1%                 TRIAMCINOLONE ACETONIDE OINT 0.1%                  Anti-inflammatory Agents                       30
   TRIAMCINOLON OIN 0.5%                 TRIAMCINOLONE ACETONIDE OINT 0.5%                  Anti-inflammatory Agents                       30
   TRIAMCINOLON PST 0.1%            TRIAMCINOLONE ACETONIDE DENTAL PASTE 0.1%               Anti-inflammatory Agents                       30                                                   Prior Authorization Req'd
  TRIAMINIC DRO INFANTS                   ACETAMINOPHEN SUSP 80 MG/0.8ML                 Analgesics and Antipyretics, Misc         30      30
         TRIAMINIC TAB             LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG          Second Generation Antihistamines                   30
 TRIAMT/HCTZ CAP 50-25MG        TRIAMTERENE & HYDROCHLOROTHIAZIDE CAP 50-25 MG             Potassium-sparing Diuretics                     30
  TRIAMT/HCTZ TAB 37.5-25      TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 37.5-25 MG            Potassium-sparing Diuretics                     30
 TRIAMT/HCTZ TAB 75-50MG        TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50 MG             Potassium-sparing Diuretics                     30
 TRI-A-VITE CHW W/FL 1MG     *PEDIATRIC VITAMINS ACD W/ FLUORIDE CHEW TAB 1 MG***           Multivitamin Preparations                      30
  TRIAZOLAM TAB 0.125MG                        TRIAZOLAM TAB 0.125 MG                            Benzodiazepines                   7       30
   TRIAZOLAM TAB 0.25MG                         TRIAZOLAM TAB 0.25 MG                            Benzodiazepines                   7       30
         TRI-BIOZENE OIN       NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%                     Antibacterials                  15      30
   TRI-BUFF ASA TAB 325MG     ASPIRIN BUFFERED (CA CARB-MG CARB-MG OX) TAB 325 MG                    Salicylates                   31      30
   TRICARE TAB PRENATAL          *PRENATAL VIT W/ FE FUMARATE-FA TAB 27-1 MG***             Multivitamin Preparations                      30      40
   TRICOSAL TAB 1000MG            CHOLINE & MAGNESIUM SALICYLATES TAB 1000 MG                        Salicylates                           30
                                                                                                                                                    Max Qty
                                                                                                                                                      Limit   Max Max Age
                                                                                                                                                    (Liquids Days    Limit    Step      Step Therapy   Specialty
     Drug/Product Name                                   Generic Name                                            Therapy Class                       in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
     TRICOSAL TAB 500MG                     CHOLINE & MAGNESIUM SALICYLATES TAB 500 MG                              Salicylates                               30
     TRICOSAL TAB 750MG                     CHOLINE & MAGNESIUM SALICYLATES TAB 750 MG                              Salicylates                               30
       TRIDERM CRE 0.1%                        TRIAMCINOLONE ACETONIDE CREAM 0.1%                           Anti-inflammatory Agents                          30
       TRIDERM OIN 0.1%                          TRIAMCINOLONE ACETONIDE OINT 0.1%                          Anti-inflammatory Agents                          30
    TRIFLURIDINE SOL 1% OP                           TRIFLURIDINE OPHTH SOLN 1%                                      Antivirals                               30
      TRIGELS-F CAP FORTE            FE FUMARATE-VIT C-VIT B12-FA CAP 460 (151 FE)-60-0.01-1 MG                 Iron Preparations                             30
 TRIHEXYPHEN ELX 0.4MG/ML                       TRIHEXYPHENIDYL HCL ELIXIR 0.4 MG/ML                      Central Nervous System Agents                       30      18
     TRIHEXYPHEN TAB 2MG                            TRIHEXYPHENIDYL HCL TAB 2 MG                          Central Nervous System Agents                       30
     TRIHEXYPHEN TAB 5MG                            TRIHEXYPHENIDYL HCL TAB 5 MG                          Central Nervous System Agents                       30
        TRI-LEGEST TAB FE        NORETHINDRONE AC-ETHINYL ESTRAD-FE TAB 1-20/1-30/1-35 MG-MCG                     Contraceptives                              30
     TRI-LO- TAB SPRINTEC         NORGESTIMATE-ETH ESTRAD TAB 0.18-25/0.215-25/0.25-25 MG-MCG                     Contraceptives                              30
         TRIMESIS RX TAB             *PRENATAL W/ CALCIUM CARBONATE-B6-B12-FA TAB 1 MG***                   Multivitamin Preparations                         30      40
  TRIMETHOBENZ SUP 100MG                 TRIMETHOBENZAMIDE-BENZOCAINE SUPPOS 100 MG-2%                            Antihistamines                      30      30
  TRIMETHOBENZ SUP 200MG                 TRIMETHOBENZAMIDE-BENZOCAINE SUPPOS 200 MG-2%                            Antihistamines                      30      30
TRIMETHOPRIM SOL POLYMYXN           POLYMYXIN B-TRIMETHOPRIM OPHTH SOLN 10000 UNIT/ML-0.1%                         Antibacterials                             30
     TRIMOX        CAP 500MG                    AMOXICILLIN (TRIHYDRATE) CAP 500 MG                              Aminopenicillins                             30
    TRIMOX        SUS 250/5ML              AMOXICILLIN (TRIHYDRATE) FOR SUSP 250 MG/5ML                          Aminopenicillins                             30      18
        TRINATAL RX TAB 1                 *PRENATAL VIT W/ FE FUMARATE-FA TAB 60-1 MG***                    Multivitamin Preparations                         30
          TRINESSA TAB            NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG                     Contraceptives                              30
    TRIP BUF ASA TAB 325MG             ASPIRIN BUFFERED (CA CARB-MG CARB-MG OX) TAB 325 MG                          Salicylates                       31      30
   TRIPLE ANTIB OIN 0.1% OP           NEOMYCIN-POLYMYXIN-DEXAMETHASONE OPHTH OINT 0.1%                            Corticosteroids                             30
    TRIPLE ANTIB OIN MAX ST             NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%                            Antibacterials                     15      30
       TRIPLE ANTIB OIN OP      NEOMYCIN-BACITRAC ZN-POLYMYX 5(3.5)MG-400UNT-10000UNT OP OIN                       Antibacterials                             30
      TRIPLE ANTIB OIN PLUS             NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%                            Antibacterials                     15      30
  TRIPLE ANTIB OIN PLUS MAX             NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%                            Antibacterials                     15      30
  TRIPLE ANTIB OIN XTRA MAX             NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINT 1%                            Antibacterials                     15      30
       TRIPLE ANTIB SOL OP                 NEOMYCIN-POLYMYXIN B-GRAMICIDIN OPHTH SOLN                              Antibacterials                             30
         TRI-PREVIFEM TAB         NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG                     Contraceptives                              30
  TRISENOX SOL 10MG/10M                      ARSENIC TRIOXIDE INJ 10 MG/10ML (1 MG/ML)                        Antineoplastic Agents                           30                                                   Prior Authorization Req'd
         TRI-SPRINTEC TAB         NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.215-35/0.25-35 MG-MCG                     Contraceptives                              30
    TRI-VIT/FE DRO /FL 0.25       *PEDIATRIC VITAMINS ACD FLUORIDE & FE DROPS 0.25-10 MG/ML***              Multivitamin Preparations                         30      18
          TRI-VIT/FL CHW              *PEDIATRIC VITAMINS ACD W/ FLUORIDE CHEW TAB 1 MG***                  Multivitamin Preparations                         30
     TRI-VIT/FL DRO 0.25MG           *PEDIATRIC VITAMINS ACD W/ FLUORIDE SOLN 0.25 MG/ML***                 Multivitamin Preparations                         30      18
     TRI-VIT/FL DRO 0.5MG             *PEDIATRIC VITAMINS ACD W/ FLUORIDE SOLN 0.5 MG/ML***                 Multivitamin Preparations                         30      18
   TRI-VIT/FLUO DRO 0.25MG           *PEDIATRIC VITAMINS ACD W/ FLUORIDE SOLN 0.25 MG/ML***                 Multivitamin Preparations                         30      18
    TRI-VIT/FLUO DRO 0.5MG            *PEDIATRIC VITAMINS ACD W/ FLUORIDE SOLN 0.5 MG/ML***                 Multivitamin Preparations                         30      18
  TRI-VITA BET CHW /FLUORID           *PEDIATRIC VITAMINS ACD W/ FLUORIDE CHEW TAB 1 MG***                  Multivitamin Preparations                         30
         TRI-VITAMIN DRO         *PEDIATRIC VITAMINS ADC DROPS 1500 UNIT-400 UNIT-35 MG/ML***               Multivitamin Preparations                         30      1
        TRI-VITAMINS DRO         *PEDIATRIC VITAMINS ADC DROPS 1500 UNIT-400 UNIT-35 MG/ML***               Multivitamin Preparations                         30      1
         TRIVORA-28 TAB          LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG                     Contraceptives                              30
           TRIZIVIR TAB            ABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE TAB 300-150-300 MG      Nucleoside & Nucleotide Rev Transcriptase Inhib             30
           TROJAN     MIS                          CONDOMS LATEX NON-LUBRICATED                                   Contraceptives                              30
     TROJAN       MIS ENZ-LUB                        CONDOMS LATEX LUBRICATED                                     Contraceptives                              30
   TROJAN        MIS NAT LAMB                            *CONDOMS - MALE***                                       Contraceptives                              30
   TROJAN       MIS NATULAMB                    CONDOMS NON-LATEX NON-LUBRICATED                                  Contraceptives                              30
    TROJAN       MIS REGULAR                       CONDOMS LATEX NON-LUBRICATED                                   Contraceptives                              30
      TROJAN       MIS RIBBED                      CONDOMS LATEX NON-LUBRICATED                                   Contraceptives                              30
    TROJAN       MIS VERY SEN                        CONDOMS LATEX LUBRICATED                                     Contraceptives                              30
    TROJAN       MIS VERY THN                        CONDOMS LATEX LUBRICATED                                     Contraceptives                              30
 TROJAN EXTEN MIS LUBRICAT                           CONDOMS LATEX LUBRICATED                                     Contraceptives                              30
        TROJAN MAGN MIS                              CONDOMS LATEX LUBRICATED                                     Contraceptives                              30
TROJAN MAGN MIS WARM SEN                             CONDOMS LATEX LUBRICATED                                     Contraceptives                              30
  TROJAN MAGN MIS XL/LUBE                            CONDOMS LATEX LUBRICATED                                     Contraceptives                              30
  TROJAN PLEAS MIS SPERMICI                          CONDOMS LATEX LUBRICATED                                     Contraceptives                              30
         TROJAN PLUS MIS                           CONDOMS LATEX NON-LUBRICATED                                   Contraceptives                              30
          TROJAN RIB MIS                             CONDOMS LATEX LUBRICATED                                     Contraceptives                              30
 TROJAN SHARE MIS LUBRICAT                           CONDOMS LATEX LUBRICATED                                     Contraceptives                              30
 TROJAN SUPRA MIS SPERMICI                           CONDOMS LATEX LUBRICATED                                     Contraceptives                              30
 TROJAN TWIST MIS PLEASURE                           CONDOMS LATEX LUBRICATED                                     Contraceptives                              30
 TROJAN ULTRA MIS LUBRICAT                           CONDOMS LATEX LUBRICATED                                     Contraceptives                              30
 TROJAN/SPERM MIS VERY SEN                           CONDOMS LATEX LUBRICATED                                     Contraceptives                              30
 TROJAN/SPERM MIS VERY THN                           CONDOMS LATEX LUBRICATED                                     Contraceptives                              30
    TROJAN-ASSRT MIS PACK                          CONDOMS LATEX NON-LUBRICATED                                   Contraceptives                              30
    TROJAN-ENZ MIS LARGE                             CONDOMS LATEX LUBRICATED                                     Contraceptives                              30
  TROJAN-ENZ MIS LUBRICAT                            CONDOMS LATEX LUBRICATED                                     Contraceptives                              30
                                                                                                                                               Max Qty
                                                                                                                                                 Limit   Max Max Age
                                                                                                                                               (Liquids Days    Limit    Step      Step Therapy   Specialty
   Drug/Product Name                                 Generic Name                                           Therapy Class                       in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
TROJAN-ENZ MIS W/SPERMI                        CONDOMS LATEX LUBRICATED                                       Contraceptives                             30
       TROPAZONE LOT                              *EMOLLIENT - LOTION**                                Basic Lotions and Liniments                       30                                                   Prior Authorization Req'd
    TRUST NATAL PAK DHA       *PRENAT-FE BIS-FE PROT SUCC-FA-CA TAB & OMEGA 3 CAP 250 PK**             Multivitamin Preparations                         30      40
   TRUSTEX MIS BANANA                        CONDOMS LATEX NON-LUBRICATED                                     Contraceptives                             30
 TRUSTEX MIS CHOCOLAT                        CONDOMS LATEX NON-LUBRICATED                                     Contraceptives                             30
   TRUSTEX MIS FLAVORS                       CONDOMS LATEX NON-LUBRICATED                                     Contraceptives                             30
     TRUSTEX MIS MINT                        CONDOMS LATEX NON-LUBRICATED                                     Contraceptives                             30
  TRUSTEX MIS STRWBRY                        CONDOMS LATEX NON-LUBRICATED                                     Contraceptives                             30
   TRUSTEX MIS VANILLA                       CONDOMS LATEX NON-LUBRICATED                                     Contraceptives                             30
TRUSTEX LUBR MIS ASSORTED                      CONDOMS LATEX LUBRICATED                                       Contraceptives                             30
 TRUSTEX LUBR MIS BANANA                       CONDOMS LATEX LUBRICATED                                       Contraceptives                             30
   TRUSTEX LUBR MIS CHOC                       CONDOMS LATEX LUBRICATED                                       Contraceptives                             30
   TRUSTEX LUBR MIS COLA                       CONDOMS LATEX LUBRICATED                                       Contraceptives                             30
 TRUSTEX LUBR MIS COLORS                       CONDOMS LATEX LUBRICATED                                       Contraceptives                             30
TRUSTEX LUBR MIS EX LARGE                      CONDOMS LATEX LUBRICATED                                       Contraceptives                             30
  TRUSTEX LUBR MIS EX STR                      CONDOMS LATEX LUBRICATED                                       Contraceptives                             30
  TRUSTEX LUBR MIS GRAPE                       CONDOMS LATEX LUBRICATED                                       Contraceptives                             30
   TRUSTEX LUBR MIS MINT                       CONDOMS LATEX LUBRICATED                                       Contraceptives                             30
TRUSTEX LUBR MIS RIB/STUD                      CONDOMS LATEX LUBRICATED                                       Contraceptives                             30
TRUSTEX LUBR MIS SPERMICI                      CONDOMS LATEX LUBRICATED                                       Contraceptives                             30
TRUSTEX LUBR MIS STRWBRY                       CONDOMS LATEX LUBRICATED                                       Contraceptives                             30
 TRUSTEX LUBR MIS VANILLA                      CONDOMS LATEX LUBRICATED                                       Contraceptives                             30
 TRUSTEX/RIA MIS LUBRICAT                      CONDOMS LATEX LUBRICATED                                       Contraceptives                             30
 TRUSTEX/RIA MIS NON-LUB                     CONDOMS LATEX NON-LUBRICATED                                     Contraceptives                             30
 TRUSTEX/RIA MIS SPERMICI                      CONDOMS LATEX LUBRICATED                                       Contraceptives                             30
TRUSTX NON-9 MIS RIB/STUD                      CONDOMS LATEX LUBRICATED                                       Contraceptives                             30
        TRUVADA TAB          EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TAB 200-300 MG      Nucleoside & Nucleotide Rev Transcriptase Inhib             30
 TUSNEL DIABT LIQ 10-100/5       DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                             Antitussives                      180     30
        TUSSI-BID TAB           DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 60-1200 MG                            Antitussives                       31     30
   TUSSICLR DH SYP 3.5-100          HYDROCODONE-GUAIFENESIN SYRUP 3.5-100 MG/5ML                               Antitussives                      178     30
TUSSIDEN DM LIQ 10-300MG         DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-300 MG/5ML                             Antitussives                      180     30
     TUSSIGON TAB 5MG                 HYDROCODONE W/ HOMATROPINE TAB 5-1.5 MG                                  Antitussives                       31     30
    TUSSIN     SYP 100/5ML                    GUAIFENESIN SYRUP 100 MG/5ML                                     Expectorants                              30
 TUSSIN CHEST SYP 100/5ML                     GUAIFENESIN SYRUP 100 MG/5ML                                     Expectorants                              30
TUSSIN COUGH LIQ 10-100/5        DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                             Antitussives                      180     30
TUSSIN COUGH LIQ CONGESTI        DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                             Antitussives                      180     30
TUSSIN COUGH SYP 100/5ML                      GUAIFENESIN SYRUP 100 MG/5ML                                     Expectorants                              30
        TUSSIN DM LIQ            DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                             Antitussives                      180     30
  TUSSIN DM LIQ 100-10/5         DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                             Antitussives                      180     30
    TUSSIN DM LIQ CLEAR          DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                             Antitussives                      180     30
     TUSSIN DM LIQ MAX           DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/5ML                             Antitussives                      180     30
  TUSSIN DM SYP 100-10/5         DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                              Antitussives                      180     30
    TUSSIN DM SYP CLEAR          DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                              Antitussives                      180     30
  TUSSIN EXP SYP 100/5ML                      GUAIFENESIN SYRUP 100 MG/5ML                                     Expectorants                              30
   TUSSIN PE SYP 30-100/5         PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 30-100 MG/5ML                              Expectorants                              30
  TUSSIN-DM SYP 100-15/5         DEXTROMETHORPHAN-GUAIFENESIN SYRUP 15-100 MG/5ML                              Antitussives                      180     30
  TUSSITAB TAB 1200-60M         DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 60-1200 MG                            Antitussives                       31     30
        TUSSPLEX SYP          PHENYLEPH-PYRILAMINE W/ HYDROCODONE SYRUP 5-12-6 MG/5ML                          Antitussives                      178     30
    TWINJECT INJ 0.3MG                 EPINEPHRINE INJ DEVICE 0.3 MG/0.3ML (1:1000)               alpha- and beta-Adrenergic Agonists                    30
   TYCOLENE TAB 325MG                          ACETAMINOPHEN TAB 325 MG                             Analgesics and Antipyretics, Misc            250     30
   TYCOLENE TAB 500MG                          ACETAMINOPHEN TAB 500 MG                             Analgesics and Antipyretics, Misc            250     30
TYLENOL GO CHW EXTRA ST                     ACETAMINOPHEN CHEW TAB 500 MG                           Analgesics and Antipyretics, Misc             60     30
   TYLOPHEN CAP 500MG                          ACETAMINOPHEN CAP 500 MG                             Analgesics and Antipyretics, Misc            250     30
   TYLOPHEN TAB 325MG                          ACETAMINOPHEN TAB 325 MG                             Analgesics and Antipyretics, Misc            250     30
   ULTILET ALCH PAD SWAB                           *ALCOHOL SWABS***                                             Devices                                 30
      ULTIMATE FEE MIS                         CONDOMS LATEX LUBRICATED                                       Contraceptives                             30
   ULTIMATECARE CAP ONE      *PRENATAL VIT W/ FE CBN-FE ASP GLYC-FA-OMEGA 3 CAP 27-1MG***              Multivitamin Preparations                         30      40
 ULTIMATECARE CAP ONE NF     *PRENATAL W/FE CBNYL-FE ASP GLYC-FA-DSS-OMEGA CAP 20-7-1 MG*              Multivitamin Preparations                         30      40
      ULTRA NATAL TAB            *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***                  Multivitamin Preparations                         30
    ULTRA NATAL TAB CARE         *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***                  Multivitamin Preparations                         30
       ULTRA TABS TAB            *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***                  Multivitamin Preparations                         30
      ULTRA-NATAL TAB            *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***                  Multivitamin Preparations                         30
   UN-ASPIRIN TAB 500MG                        ACETAMINOPHEN TAB 500 MG                             Analgesics and Antipyretics, Misc            250     30
    UNI-EASE CAP 100MG                        DOCUSATE SODIUM CAP 100 MG                                Cathartics and Laxatives                 100     30
  UNIFED      LIQ 30MG/5ML                 PSEUDOEPHEDRINE HCL LIQ 30 MG/5ML                      alpha- and beta-Adrenergic Agonists            240     30
                                                                                                                                    Max Qty
                                                                                                                                      Limit   Max Max Age
                                                                                                                                    (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                              Generic Name                                        Therapy Class                 in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
       UNI-LAN SUS           ALUM & MAG HYDROXIDE-SIMETHICONE SUSP 200-200-20 MG/5ML               Antacids and Adsorbents            480     30
  UNIPHYL TAB 400MG CR                     THEOPHYLLINE TAB SR 24HR 400 MG                  Respiratory Smooth Muscle Relaxants               30
  UNIPHYL TAB 600MG CR                     THEOPHYLLINE TAB SR 24HR 600 MG                  Respiratory Smooth Muscle Relaxants               30
     UNI-SED TAB 30MG                      PSEUDOEPHEDRINE HCL TAB 30 MG                     alpha- and beta-Adrenergic Agonists      120     30
 UNITH DIRECT TAB 100MCG                 LEVOTHYROXINE SODIUM TAB 100 MCG                                Thyroid Agents                       30
 UNITH DIRECT TAB 112MCG                 LEVOTHYROXINE SODIUM TAB 112 MCG                                Thyroid Agents                       30
 UNITH DIRECT TAB 125MCG                 LEVOTHYROXINE SODIUM TAB 125 MCG                                Thyroid Agents                       30
 UNITH DIRECT TAB 150MCG                 LEVOTHYROXINE SODIUM TAB 150 MCG                                Thyroid Agents                       30
 UNITH DIRECT TAB 175MCG                 LEVOTHYROXINE SODIUM TAB 175 MCG                                Thyroid Agents                       30
 UNITH DIRECT TAB 200MCG                 LEVOTHYROXINE SODIUM TAB 200 MCG                                Thyroid Agents                       30
  UNITH DIRECT TAB 25MCG                  LEVOTHYROXINE SODIUM TAB 25 MCG                                Thyroid Agents                       30
 UNITH DIRECT TAB 300MCG                 LEVOTHYROXINE SODIUM TAB 300 MCG                                Thyroid Agents                       30
  UNITH DIRECT TAB 50MCG                  LEVOTHYROXINE SODIUM TAB 50 MCG                                Thyroid Agents                       30
  UNITH DIRECT TAB 75MCG                  LEVOTHYROXINE SODIUM TAB 75 MCG                                Thyroid Agents                       30
  UNITH DIRECT TAB 88MCG                  LEVOTHYROXINE SODIUM TAB 88 MCG                                Thyroid Agents                       30
  UNITHROID TAB 100MCG                   LEVOTHYROXINE SODIUM TAB 100 MCG                                Thyroid Agents                       30
  UNITHROID TAB 112MCG                   LEVOTHYROXINE SODIUM TAB 112 MCG                                Thyroid Agents                       30
  UNITHROID TAB 125MCG                   LEVOTHYROXINE SODIUM TAB 125 MCG                                Thyroid Agents                       30
  UNITHROID TAB 137MCG                   LEVOTHYROXINE SODIUM TAB 137 MCG                                Thyroid Agents                       30
  UNITHROID TAB 150MCG                   LEVOTHYROXINE SODIUM TAB 150 MCG                                Thyroid Agents                       30
  UNITHROID TAB 175MCG                   LEVOTHYROXINE SODIUM TAB 175 MCG                                Thyroid Agents                       30
  UNITHROID TAB 200MCG                   LEVOTHYROXINE SODIUM TAB 200 MCG                                Thyroid Agents                       30
  UNITHROID TAB 25MCG                     LEVOTHYROXINE SODIUM TAB 25 MCG                                Thyroid Agents                       30
  UNITHROID TAB 300MCG                   LEVOTHYROXINE SODIUM TAB 300 MCG                                Thyroid Agents                       30
  UNITHROID TAB 50MCG                     LEVOTHYROXINE SODIUM TAB 50 MCG                                Thyroid Agents                       30
  UNITHROID TAB 75MCG                     LEVOTHYROXINE SODIUM TAB 75 MCG                                Thyroid Agents                       30
  UNITHROID TAB 88MCG                     LEVOTHYROXINE SODIUM TAB 88 MCG                                Thyroid Agents                       30
    UNIVERT TAB 32MG                           MECLIZINE HCL TAB 32 MG                                   Antihistamines                       30
      URELIEF PLUS TAB      PHENAZOPYRIDINE-BUTABARBITAL-HYOSCYAMINE TAB 150-15-0.3 MG        Antipruritics and Local Anesthetics             30
    VALCYTE TAB 450MG                       VALGANCICLOVIR HCL TAB 450 MG                        Nucleosides and Nucleotides                  30
  VANACET TAB 5-500MG               HYDROCODONE-ACETAMINOPHEN TAB 5-500 MG                              Opiate Agonists               150     30
 VANCOCIN HCL CAP 125MG                      VANCOMYCIN HCL CAP 125 MG                                   Glycopeptides                        30                                                   Prior Authorization Req'd
 VANCOCIN HCL CAP 250MG                      VANCOMYCIN HCL CAP 250 MG                                   Glycopeptides                        30                                                   Prior Authorization Req'd
     VANCOMYCIN POW                            VANCOMYCIN HCL POWDER                                 Pharmaceutical Aids                      30                                                   Prior Authorization Req'd
   VANCOMYCIN POW USP                          VANCOMYCIN HCL POWDER                                 Pharmaceutical Aids                      30                                                   Prior Authorization Req'd
   VANDAZOLE GEL 0.75%                    METRONIDAZOLE VAGINAL GEL 0.75%                                Antibacterials               70      30
    VANICREAM LOT LITE                          *EMOLLIENT - LOTION**                             Basic Lotions and Liniments                 30                                                   Prior Authorization Req'd
     VANOS     CRE 0.1%                       FLUOCINONIDE CREAM 0.1%                              Anti-inflammatory Agents            30     30
VCKS DAYQUIL LIQ MUCUS DM      DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/15ML                         Antitussives                180     30
   VEETIDS SOL 125/5ML              PENICILLIN V POTASSIUM FOR SOLN 125 MG/5ML                         Natural Penicillins                    14      18
   VEETIDS SOL 250/5ML              PENICILLIN V POTASSIUM FOR SOLN 250 MG/5ML                         Natural Penicillins                    14      18
    VEETIDS TAB 250MG                     PENICILLIN V POTASSIUM TAB 250 MG                            Natural Penicillins                    14
    VEETIDS TAB 500MG                     PENICILLIN V POTASSIUM TAB 500 MG                            Natural Penicillins                    14
     VELETRI INJ 1.5MG                  EPOPROSTENOL SODIUM FOR INJ 1.5 MG                    Vasodilating Agents, Miscellaneous              30                                                   Prior Authorization Req'd
       VELIVET PAK           DESOGEST-ETHIN EST TAB 0.1-0.025/0.125-0.025/0.15-0.025MG-MG                Contraceptives                       30
  VENOFER INJ 20MG/ML                   IRON SUCROSE INJ 20 MG/ML (FE EQUIV)                           Iron Preparations                      30                                                   Prior Authorization Req'd
 VERAPAMIL CAP 100MG ER                   VERAPAMIL HCL CAP SR 24HR 100 MG                  Calcium-Channel Blocking Agents, Misc             30
 VERAPAMIL CAP 120MG ER                   VERAPAMIL HCL CAP SR 24HR 120 MG                  Calcium-Channel Blocking Agents, Misc             30
 VERAPAMIL CAP 120MG SR                   VERAPAMIL HCL CAP SR 24HR 120 MG                  Calcium-Channel Blocking Agents, Misc             30
 VERAPAMIL CAP 180MG ER                   VERAPAMIL HCL CAP SR 24HR 180 MG                  Calcium-Channel Blocking Agents, Misc             30
 VERAPAMIL CAP 180MG SR                   VERAPAMIL HCL CAP SR 24HR 180 MG                  Calcium-Channel Blocking Agents, Misc             30
 VERAPAMIL CAP 200MG ER                   VERAPAMIL HCL CAP SR 24HR 200 MG                  Calcium-Channel Blocking Agents, Misc             30
 VERAPAMIL CAP 240MG ER                   VERAPAMIL HCL CAP SR 24HR 240 MG                  Calcium-Channel Blocking Agents, Misc             30
 VERAPAMIL CAP 240MG SR                   VERAPAMIL HCL CAP SR 24HR 240 MG                  Calcium-Channel Blocking Agents, Misc             30
 VERAPAMIL CAP 300MG ER                   VERAPAMIL HCL CAP SR 24HR 300 MG                  Calcium-Channel Blocking Agents, Misc             30
 VERAPAMIL CAP 360MG SR                   VERAPAMIL HCL CAP SR 24HR 360 MG                  Calcium-Channel Blocking Agents, Misc             30
  VERAPAMIL TAB 120MG                         VERAPAMIL HCL TAB 120 MG                      Calcium-Channel Blocking Agents, Misc             30
 VERAPAMIL TAB 120MG ER                      VERAPAMIL HCL TAB CR 120 MG                    Calcium-Channel Blocking Agents, Misc             30
 VERAPAMIL TAB 120MG SR                      VERAPAMIL HCL TAB CR 120 MG                    Calcium-Channel Blocking Agents, Misc             30
 VERAPAMIL TAB 180MG CR                      VERAPAMIL HCL TAB CR 180 MG                    Calcium-Channel Blocking Agents, Misc             30
 VERAPAMIL TAB 180MG ER                      VERAPAMIL HCL TAB CR 180 MG                    Calcium-Channel Blocking Agents, Misc             30
 VERAPAMIL TAB 180MG SA                      VERAPAMIL HCL TAB CR 180 MG                    Calcium-Channel Blocking Agents, Misc             30
 VERAPAMIL TAB 180MG SR                      VERAPAMIL HCL TAB CR 180 MG                    Calcium-Channel Blocking Agents, Misc             30
 VERAPAMIL TAB 240MG CR                      VERAPAMIL HCL TAB CR 240 MG                    Calcium-Channel Blocking Agents, Misc             30
 VERAPAMIL TAB 240MG ER                      VERAPAMIL HCL TAB CR 240 MG                    Calcium-Channel Blocking Agents, Misc             30
                                                                                                                                              Max Qty
                                                                                                                                                Limit   Max Max Age
                                                                                                                                              (Liquids Days    Limit    Step      Step Therapy   Specialty
   Drug/Product Name                                Generic Name                                           Therapy Class                       in mLs) Supply (Years) Required?   Requirement      Drug      Coverage Status
 VERAPAMIL TAB 240MG SA                       VERAPAMIL HCL TAB CR 240 MG                       Calcium-Channel Blocking Agents, Misc                   30
 VERAPAMIL TAB 240MG SR                       VERAPAMIL HCL TAB CR 240 MG                       Calcium-Channel Blocking Agents, Misc                   30
   VERAPAMIL TAB 40MG                            VERAPAMIL HCL TAB 40 MG                        Calcium-Channel Blocking Agents, Misc                   30
   VERAPAMIL TAB 80MG                            VERAPAMIL HCL TAB 80 MG                        Calcium-Channel Blocking Agents, Misc                   30
        VEROTIN-BY TAB              *PRENATAL VIT W/ FE FUMARATE-FA TAB 65-1 MG***                    Multivitamin Preparations                         30      40
        VEROTIN-GR TAB              *PRENATAL VIT W/ FE FUMARATE-FA TAB 65-1 MG***                    Multivitamin Preparations                         30      40
VIBRAMYCIN SUS 25MG/5ML             DOXYCYCLINE MONOHYDRATE FOR SUSP 25 MG/5ML                               Tetracyclines                              14      18
VIBRAMYCIN SYP 50MG/5ML                  DOXYCYCLINE CALCIUM SYRUP 50 MG/5ML                                 Tetracyclines                              14      18
   VICOCLEAR SYP 5-100/5            HYDROCODONE-GUAIFENESIN SYRUP 5-100 MG/5ML                                Antitussives                      178     30
 VICODIN HP TAB 10-660MG             HYDROCODONE-ACETAMINOPHEN TAB 10-660 MG                               Opiate Agonists                      150     30
       VIDEX     SOL 2GM                        DIDANOSINE FOR SOLN 2 GM                    Nucleoside & Nucleotide Rev Transcriptase Inhib             30
       VIDEX     SOL 4GM                        DIDANOSINE FOR SOLN 4 GM                    Nucleoside & Nucleotide Rev Transcriptase Inhib             30
    VINATAL TAB FORTE          *PRENATAL VIT W/ IRON CARBONYL-FE SULF-FA TAB 60-1 MG***               Multivitamin Preparations                         30      40
         VINATE C TAB            *PRENATAL W/O A VIT W/ FE FUMARATE-FA TAB 30-1 MG***                 Multivitamin Preparations                         30
       VINATE CARE CHW           *PRENATAL W/O A VIT W/ FE FUM-FA TAB CHEW 40-1 MG***                 Multivitamin Preparations                         30
        VINATE GT TAB            *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***                 Multivitamin Preparations                         30
         VINATE IC CAP        *PRENATAL W/O A W/FE FUM-FE POLY-FA CAP 162.115.2-1 MG***               Multivitamin Preparations                         30      40
         VINATE II TAB        *PRENATAL VIT W/ FE BISGLYCINATE CHELATE-FA TAB 29-1 MG***              Multivitamin Preparations                         30      40
         VINATE III TAB        *PRENATAL VIT W/ FE BISGLYC-FE PROT SUCC-FA TAB 29-1 MG***             Multivitamin Preparations                         30      40
        VINATE ONE TAB              *PRENATAL VIT W/ FE FUMARATE-FA TAB 60-1 MG***                    Multivitamin Preparations                         30
     VINATE PN TAB CARE      *PRENATAL WITHOUT A W/ FE ASPARTO GLY-DOC-FA TAB 30-1MG***               Multivitamin Preparations                         30      40
       VINATE ULTRA TAB          *PRENATAL VIT W/ DSS-IRON CARBONYL-FA TAB 90-1 MG***                 Multivitamin Preparations                         30
   VI-Q-TUSS SYP 5-100/5            HYDROCODONE-GUAIFENESIN SYRUP 5-100 MG/5ML                                Antitussives                      178     30
 VIRACEPT POW 50MG/GM                 NELFINAVIR MESYLATE ORAL POWDER 50 MG/GM                          HIV Protease Inhibitors                         30
    VIRACEPT TAB 250MG                      NELFINAVIR MESYLATE TAB 250 MG                              HIV Protease Inhibitors                         30
    VIRACEPT TAB 625MG                      NELFINAVIR MESYLATE TAB 625 MG                              HIV Protease Inhibitors                         30
VIRAMUNE SUS 50MG/5ML                          NEVIRAPINE SUSP 50 MG/5ML                    Nonnucleoside Reverse Transcriptase Inhibitors              30
   VIRAMUNE TAB 200MG                             NEVIRAPINE TAB 200 MG                     Nonnucleoside Reverse Transcriptase Inhibitors              30
    VIREAD      TAB 300MG             TENOFOVIR DISOPROXIL FUMARATE TAB 300 MG              Nucleoside & Nucleotide Rev Transcriptase Inhib             30
  VITAFOL-OB TAB 65-1MG             *PRENATAL VIT W/ FE FUMARATE-FA TAB 65-1 MG***                    Multivitamin Preparations                         30      40
   VITAMIN B 6 TAB 100MG                        PYRIDOXINE HCL TAB 100 MG                                 Vitamin B Complex                             30
    VITAMIN B 6 TAB 50MG                        PYRIDOXINE HCL TAB 50 MG                                  Vitamin B Complex                             30
   VITAMIN B6 TAB 250MG                         PYRIDOXINE HCL TAB 250 MG                                 Vitamin B Complex                             30
   VITAMIN B-6 TAB 100MG                        PYRIDOXINE HCL TAB 100 MG                                 Vitamin B Complex                             30
   VITAMIN B-6 TAB 250MG                        PYRIDOXINE HCL TAB 250 MG                                 Vitamin B Complex                             30
   VITAMIN B-6 TAB 500MG                        PYRIDOXINE HCL TAB 500 MG                                 Vitamin B Complex                             30
   VITAMIN B-6 TAB 50MG                         PYRIDOXINE HCL TAB 50 MG                                  Vitamin B Complex                             30
 VITAMIN D CAP 50000UNT                      ERGOCALCIFEROL CAP 50000 UNIT                                     Vitamin D                                30
  VITAMIN D DRO INFANTS                 CHOLECALCIFEROL ORAL LIQUID 400 UNIT/ML                                Vitamin D                        50      30
 VITAMIN D TAB 1000UNIT                      CHOLECALCIFEROL TAB 1000 UNIT                                     Vitamin D                        30      30
 VITAMIN D TAB 2000UNIT                      CHOLECALCIFEROL TAB 2000 UNIT                                     Vitamin D                        30      30
     VITAMIN D TAB -400                       CHOLECALCIFEROL TAB 400 UNIT                                     Vitamin D                        30      30
  VITAMIN D TAB 400UNIT                       CHOLECALCIFEROL TAB 400 UNIT                                     Vitamin D                        30      30
       VITAMIN D3 DRO                   CHOLECALCIFEROL ORAL LIQUID 400 UNIT/ML                                Vitamin D                        50      30
 VITAMIN D3 TAB 1000UNIT                     CHOLECALCIFEROL TAB 1000 UNIT                                     Vitamin D                        30      30
 VITAMIN D3 TAB 2000UNIT                     CHOLECALCIFEROL TAB 2000 UNIT                                     Vitamin D                        30      30
  VITAMIN D3 TAB 400UNIT                      CHOLECALCIFEROL TAB 400 UNIT                                     Vitamin D                        30      30
 VITAMIN D-3 TAB 1000UNIT                    CHOLECALCIFEROL TAB 1000 UNIT                                     Vitamin D                        30      30
 VITAMIN D-3 TAB 2000UNIT                    CHOLECALCIFEROL TAB 2000 UNIT                                     Vitamin D                        30      30
  VITAMIN D-3 TAB 400UNIT                     CHOLECALCIFEROL TAB 400 UNIT                                     Vitamin D                        30      30
   VITAMIN K INJ 2MG/ML                        PHYTONADIONE INJ 2 MG/ML                                   Vitamin K Activity                            30
  VITAMIN K1 INJ 10MG/ML                       PHYTONADIONE INJ 10 MG/ML                                  Vitamin K Activity                            30
  VITAMIN K1 INJ 1MG/0.5                       PHYTONADIONE INJ 2 MG/ML                                   Vitamin K Activity                            30
        VITA-NATAL CAP      *PRENATAL MULTIVITAMINS & MINERALS W/ IRON & FA CAP 1 MG***               Multivitamin Preparations                         30      40
VITANATAL OB MIS PLUS DHA   *PRENATAL MV W/FE FUM-FA TAB 65-1 MG & DHA CAP 250 MG PACK *              Multivitamin Preparations                         30      40
      VITAPHIL TAB AIDE       *PRENATAL VIT W/ FE BISGLYCINATE CHELATE-FA TAB 28-1 MG***              Multivitamin Preparations                         30      40
         VITASPIRE TAB           *PRENATAL W/O A VIT W/ FE CARBONYL-FA TAB 29-1 MG***                 Multivitamin Preparations                         30      40
    VITUSSIN SYP 5-100/5            HYDROCODONE-GUAIFENESIN SYRUP 5-100 MG/5ML                                Antitussives                      178     30
    VIVELLE DIS 0.05MG                 ESTRADIOL TD PATCH BIWEEKLY 0.05 MG/24HR                                Estrogens                                30
     VIVELLE DIS 0.1MG                  ESTRADIOL TD PATCH BIWEEKLY 0.1 MG/24HR                                Estrogens                                30
  VIVELLE-DOT DIS 0.025MG              ESTRADIOL TD PATCH BIWEEKLY 0.025 MG/24HR                               Estrogens                                30
 VIVELLE-DOT DIS 0.0375MG             ESTRADIOL TD PATCH BIWEEKLY 0.0375 MG/24HR                               Estrogens                                30
   VIVELLE-DOT DIS 0.05MG              ESTRADIOL TD PATCH BIWEEKLY 0.05 MG/24HR                                Estrogens                                30
  VIVELLE-DOT DIS 0.075MG              ESTRADIOL TD PATCH BIWEEKLY 0.075 MG/24HR                               Estrogens                                30
   VIVELLE-DOT DIS 0.1MG                ESTRADIOL TD PATCH BIWEEKLY 0.1 MG/24HR                                Estrogens                                30
                                                                                                                             Max Qty
                                                                                                                               Limit   Max Max Age
                                                                                                                             (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                         Generic Name                                   Therapy Class                    in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
 V-R CLOTRIMA TAB INSERTS              CLOTRIMAZOLE VAGINAL TAB 100 MG                            Azoles                        7      30                                                   Prior Authorization Req'd
   V-R LICE LIQ CRM RNSE          PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.33-4%            Scabicides and Pediculicides            120     30
     V-R LICE RIN LIQ 1%                   PERMETHRIN CREME RINSE 1%                   Scabicides and Pediculicides            120     30
V-R NON-ASA DRO 100MG/ML                ACETAMINOPHEN SOLN 100 MG/ML                 Analgesics and Antipyretics, Misc          30     30
 V-R NON-ASA ELX 160/5ML               ACETAMINOPHEN ELIXIR 160 MG/5ML               Analgesics and Antipyretics, Misc         240     30
  V-R TUSSIN SYP 100/5ML                 GUAIFENESIN SYRUP 100 MG/5ML                          Expectorants                            30
   V-R VIT B-6 TAB 100MG                    PYRIDOXINE HCL TAB 100 MG                       Vitamin B Complex                          30
    V-R VIT B-6 TAB 50MG                    PYRIDOXINE HCL TAB 50 MG                        Vitamin B Complex                          30
  VYTORIN TAB 10-10MG                 EZETIMIBE-SIMVASTATIN TAB 10-10 MG              HMG-CoA Reductase Inhibitors                     30                                                   Prior Authorization Req'd
  VYTORIN TAB 10-20MG                 EZETIMIBE-SIMVASTATIN TAB 10-20 MG              HMG-CoA Reductase Inhibitors                     30                                                   Prior Authorization Req'd
  VYTORIN TAB 10-40MG                 EZETIMIBE-SIMVASTATIN TAB 10-40 MG              HMG-CoA Reductase Inhibitors                     30                                                   Prior Authorization Req'd
  VYTORIN TAB 10-80MG                 EZETIMIBE-SIMVASTATIN TAB 10-80 MG              HMG-CoA Reductase Inhibitors                     30                                                   Prior Authorization Req'd
    VYVANSE CAP 20MG               LISDEXAMFETAMINE DIMESYLATE CAP 20 MG                      Amphetamines                     30      30      20
    VYVANSE CAP 30MG               LISDEXAMFETAMINE DIMESYLATE CAP 30 MG                      Amphetamines                     30      30      20
    VYVANSE CAP 40MG               LISDEXAMFETAMINE DIMESYLATE CAP 40 MG                      Amphetamines                     30      30      20
    VYVANSE CAP 50MG               LISDEXAMFETAMINE DIMESYLATE CAP 50 MG                      Amphetamines                     30      30      20
    VYVANSE CAP 60MG               LISDEXAMFETAMINE DIMESYLATE CAP 60 MG                      Amphetamines                     30      30      20
    VYVANSE CAP 70MG               LISDEXAMFETAMINE DIMESYLATE CAP 70 MG                      Amphetamines                     30      30      20
    WAL-DRYL CAP 25MG                   DIPHENHYDRAMINE HCL CAP 25 MG                   Ethanolamine Derivatives                       30
  WAL-DRYL LIQ 12.5/5ML           DIPHENHYDRAMINE HCL LIQUID 12.5 MG/5ML                Ethanolamine Derivatives                       30
    WAL-DRYL TAB 25MG                   DIPHENHYDRAMINE HCL TAB 25 MG                   Ethanolamine Derivatives                       30
  WAL-ITIN SYP 5MG/5ML                    LORATADINE SYRUP 5 MG/5ML                 Second Generation Antihistamines                   30
    WAL-ITIN TAB 10MG                         LORATADINE TAB 10 MG                  Second Generation Antihistamines                   30
  WAL-ITIN TAB ALLER-ML         LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG         Second Generation Antihistamines                   30
   WAL-PHED TAB 30MG                    PSEUDOEPHEDRINE HCL TAB 30 MG              alpha- and beta-Adrenergic Agonists         120     30
  WAL-PROFEN CAP 200MG                        IBUPROFEN CAP 200 MG              Other Nonsteroidal Anti-inflammtory Agents     100     30
  WAL-PROFEN TAB 200MG                        IBUPROFEN TAB 200 MG              Other Nonsteroidal Anti-inflammtory Agents             30
      WAL-SPORIN OIN                   *BACITRACIN-POLYMYXIN B OINT***                         Antibacterials                          30
   WAL-TUSSIN CAP COLD          PSEUDOEPHEDRINE-GUAIFENESIN CAP 30-200 MG                      Expectorants                            30
     WAL-TUSSIN LIQ DM      DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-100 MG/5ML                   Antitussives                   180     30
  WAL-TUSSIN LIQ DM MAX     DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-200 MG/5ML                   Antitussives                   180     30
  WAL-TUSSIN SYP 100/5ML                 GUAIFENESIN SYRUP 100 MG/5ML                          Expectorants                            30
    WAL-TUSSIN SYP DM       DEXTROMETHORPHAN-GUAIFENESIN SYRUP 10-100 MG/5ML                    Antitussives                   180     30
    WAL-VERT TAB 10MG           LORATADINE RAPIDLY-DISINTEGRATING TAB 10 MG         Second Generation Antihistamines                   30
      WAL-ZAN 75 TAB                         RANITIDINE HCL TAB 75 MG                   Histamine H2-Antagonists               60      30
  WAL-ZYR SOL 1MG/ML               CETIRIZINE HCL SYRUP 1 MG/ML (5 MG/5ML)          Second Generation Antihistamines                   30      9
    WAL-ZYR TAB 10MG                         CETIRIZINE HCL TAB 10 MG               Second Generation Antihistamines                   30
   WARFARIN TAB 10MG                      WARFARIN SODIUM TAB 10 MG                        Coumarin Derivatives                        30
    WARFARIN TAB 1MG                       WARFARIN SODIUM TAB 1 MG                        Coumarin Derivatives                        30
   WARFARIN TAB 2.5MG                     WARFARIN SODIUM TAB 2.5 MG                       Coumarin Derivatives                        30
    WARFARIN TAB 2MG                       WARFARIN SODIUM TAB 2 MG                        Coumarin Derivatives                        30
    WARFARIN TAB 3MG                       WARFARIN SODIUM TAB 3 MG                        Coumarin Derivatives                        30
    WARFARIN TAB 4MG                       WARFARIN SODIUM TAB 4 MG                        Coumarin Derivatives                        30
    WARFARIN TAB 5MG                       WARFARIN SODIUM TAB 5 MG                        Coumarin Derivatives                        30
    WARFARIN TAB 6MG                       WARFARIN SODIUM TAB 6 MG                        Coumarin Derivatives                        30
   WARFARIN TAB 7.5MG                     WARFARIN SODIUM TAB 7.5 MG                       Coumarin Derivatives                        30
  WEBCOL PREP PAD LARGE                         *ALCOHOL SWABS***                                 Devices                              30
 WEBCOL PREP PAD MEDIUM                         *ALCOHOL SWABS***                                 Devices                              30
   WELCHOL TAB 625MG                      COLESEVELAM HCL TAB 625 MG                      Bile Acid Sequestrants                       30                                                   Prior Authorization Req'd
  WESTHROID TAB 130MG                           THYROID TAB 130 MG                            Thyroid Agents                           30
 WESTHROID TAB 16.25MG                         THYROID TAB 16.25 MG                           Thyroid Agents                           30
  WESTHROID TAB 195MG                           THYROID TAB 195 MG                            Thyroid Agents                           30
  WESTHROID TAB 260MG                           THYROID TAB 260 MG                            Thyroid Agents                           30
  WESTHROID TAB 32.5MG                         THYROID TAB 32.5 MG                            Thyroid Agents                           30
  WESTHROID TAB 325MG                     THYROID TAB 325 MG (5 GRAIN)                        Thyroid Agents                           30
   WESTHROID TAB 65MG                            THYROID TAB 65 MG                            Thyroid Agents                           30
  WESTHROID TAB 97.5MG                         THYROID TAB 97.5 MG                            Thyroid Agents                           30
         WIBI     LOT                         *EMOLLIENT - LOTION**                    Basic Lotions and Liniments                     30                                                   Prior Authorization Req'd
   WIDE-SEAL DPR KIT 60                   DIAPHRAGM WIDE SEAL 60 MM                           Contraceptives                           30
   WIDE-SEAL DPR KIT 65                   DIAPHRAGM WIDE SEAL 65 MM                           Contraceptives                           30
   WIDE-SEAL DPR KIT 70                   DIAPHRAGM WIDE SEAL 70 MM                           Contraceptives                           30
   WIDE-SEAL DPR KIT 75                   DIAPHRAGM WIDE SEAL 75 MM                           Contraceptives                           30
   WIDE-SEAL DPR KIT 80                   DIAPHRAGM WIDE SEAL 80 MM                           Contraceptives                           30
   WIDE-SEAL DPR KIT 85                   DIAPHRAGM WIDE SEAL 85 MM                           Contraceptives                           30
   WIDE-SEAL DPR KIT 90                   DIAPHRAGM WIDE SEAL 90 MM                           Contraceptives                           30
                                                                                                                                               Max Qty
                                                                                                                                                 Limit   Max Max Age
                                                                                                                                               (Liquids Days    Limit    Step      Step Therapy   Specialty
    Drug/Product Name                                Generic Name                                           Therapy Class                       in mLs) Supply (Years) Required?   Requirement      Drug         Coverage Status
    WIDE-SEAL DPR KIT 95                         DIAPHRAGM WIDE SEAL 95 MM                                    Contraceptives                             30
    YL VIT B-6 TAB 100MG                           PYRIDOXINE HCL TAB 100 MG                                Vitamin B Complex                            30
   YODOXIN TAB 210MG                                 IODOQUINOL TAB 210 MG                                      Amebicides                               30
   YODOXIN TAB 650MG                                 IODOQUINOL TAB 650 MG                                      Amebicides                               30
   ZAFIRLUKAST TAB 10MG                               ZAFIRLUKAST TAB 10 MG                               Leukotriene Modifiers                          30                                                   Prior Authorization Req'd
   ZAFIRLUKAST TAB 20MG                               ZAFIRLUKAST TAB 20 MG                               Leukotriene Modifiers                          30                                                   Prior Authorization Req'd
 ZAMICET SOL 10-325MG              HYDROCODONE-ACETAMINOPHEN SOLN 10-325 MG/15ML                              Opiate Agonists                    480     30
  ZANTAC       TAB 150MG EF                    RANITIDINE HCL EFFER TAB 150 MG                          Histamine H2-Antagonists                         30
   ZANTAC       TAB 25MG EF                     RANITIDINE HCL EFFER TAB 25 MG                          Histamine H2-Antagonists                         30
        ZARAH        TAB               DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG                           Contraceptives                             30
      ZAZOLE       CRE 0.4%                   TERCONAZOLE VAGINAL CREAM 0.4%                                       Azoles                        45      30
      ZAZOLE       CRE 0.8%                   TERCONAZOLE VAGINAL CREAM 0.8%                                       Azoles                        45      30
     ZAZOLE       SUP 80MG                   TERCONAZOLE VAGINAL SUPPOS 80 MG                                      Azoles                                30
   ZEMA-PAK PAK 10 DAY                      DEXAMETHASONE TAB 1.5 MG TAPER PACK                                   Adrenals                               30
   ZEMA-PAK PAK 13 DAY                      DEXAMETHASONE TAB 1.5 MG TAPER PACK                                   Adrenals                               30
    ZEMA-PAK PAK 6 DAY                      DEXAMETHASONE TAB 1.5 MG TAPER PACK                                   Adrenals                               30
       ZENCHENT TAB               NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4 MG-35 MCG                         Contraceptives                             30
  ZENPEP      CAP 10000UNT      PANCRELIPASE (LIP-PROT-AMYL) DR CAP 10000-34000-55000 UNIT                       Digestants                              30
  ZENPEP      CAP 15000UNT      PANCRELIPASE (LIP-PROT-AMYL) DR CAP 15000-51000-82000 UNIT                       Digestants                              30
  ZENPEP      CAP 20000UNT     PANCRELIPASE (LIP-PROT-AMYL) DR CAP 20000-68000-109000 UNIT                       Digestants                              30
  ZENPEP       CAP 5000UNIT      PANCRELIPASE (LIP-PROT-AMYL) DR CAP 5000-17000-27000 UNIT                       Digestants                              30
        ZEOSA       CHW       NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEW TAB 0.4 MG-35 MCG                     Contraceptives                             30
      ZETIA      TAB 10MG                               EZETIMIBE TAB 10 MG                         Cholesterol Absorption Inhibitors                    30                                                   Prior Authorization Req'd
  ZIAGEN      SOL 20MG/ML               ABACAVIR SULFATE SOLN 20 MG/ML (BASE EQUIV)          Nucleoside & Nucleotide Rev Transcriptase Inhib             30
    ZIAGEN       TAB 300MG                ABACAVIR SULFATE TAB 300 MG (BASE EQUIV)           Nucleoside & Nucleotide Rev Transcriptase Inhib             30
  ZIDOVUDINE CAP 100MG                                ZIDOVUDINE CAP 100 MG                  Nucleoside & Nucleotide Rev Transcriptase Inhib             30
ZIDOVUDINE SYP 50MG/5ML                           ZIDOVUDINE SYRUP 10 MG/ML                  Nucleoside & Nucleotide Rev Transcriptase Inhib             30
  ZIDOVUDINE TAB 300MG                                ZIDOVUDINE TAB 300 MG                  Nucleoside & Nucleotide Rev Transcriptase Inhib             30
   ZITHRANOL-RR CRE 1.2%                              ANTHRALIN CREAM 1.2%                     Skin and Mucous Membrane Agents, Misc                     30
ZITHROMAX POW 1GM PAK                      AZITHROMYCIN POWD PACK FOR SUSP 1 GM                              Other Macrolides                            14                                                   Prior Authorization Req'd
      ZMAX        SUS 2GM           AZITHROMYCIN EXTENDED RELEASE FOR ORAL SUSP 2 GM                         Other Macrolides                            30
   ZMAX PEDIATR SUS 2GM             AZITHROMYCIN EXTENDED RELEASE FOR ORAL SUSP 2 GM                         Other Macrolides                            30
    ZOLPIDEM TAB 10MG                            ZOLPIDEM TARTRATE TAB 10 MG                     Anxiolytics, Sedatives, & Hypnotics Misc         7      30
     ZOLPIDEM TAB 5MG                             ZOLPIDEM TARTRATE TAB 5 MG                     Anxiolytics, Sedatives, & Hypnotics Misc         7      30
  ZOLVIT      SOL 10-300MG         HYDROCODONE-ACETAMINOPHEN SOLN 10-300 MG/15ML                              Opiate Agonists                    480     30
  ZOMETA        INJ 4MG/5ML         ZOLEDRONIC ACID INJ CONC FOR IV INFUSION 4 MG/5ML                  Bone Resorption Inhibitors                        30                                                   Prior Authorization Req'd
  ZONATUSS CAP 150MG                                BENZONATATE CAP 150 MG                                      Antitussives                     31      30
  ZONISAMIDE CAP 100MG                               ZONISAMIDE CAP 100 MG                           Anticonvulsants, Miscellaneous                      30                                                   Prior Authorization Req'd
   ZONISAMIDE CAP 25MG                                ZONISAMIDE CAP 25 MG                           Anticonvulsants, Miscellaneous                      30                                                   Prior Authorization Req'd
   ZONISAMIDE CAP 50MG                                ZONISAMIDE CAP 50 MG                           Anticonvulsants, Miscellaneous                      30                                                   Prior Authorization Req'd
       ZOTEX-DMX TAB             DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 57.5-775 MG                           Antitussives                     31      30
       ZOVIA 1/35E TAB          ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-35 MCG                      Contraceptives                             30
       ZOVIA 1/50E TAB          ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB 1 MG-50 MCG                      Contraceptives                             30
    ZOVIRAX TAB 400MG                                  ACYCLOVIR TAB 400 MG                           Nucleosides and Nucleotides                        30
     ZYCLARA CRE 3.75%                              IMIQUIMOD CREAM 3.75%                      Skin and Mucous Membrane Agents, Misc                     30                                                   Prior Authorization Req'd

								
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