ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS....................................................................................................18
ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS..........................................................................................................18ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR............................................................................................18AMPHETAMINE MIXTURES.................................................................................................................................................................18AMPHETAMINES................................................................................................................................................................................. 18ANALEPTICS.......................................................................................................................................................................................18ANOREXIANTS NON-AMPHETAMINE..................................................................................................................................................18STIMULANTS - MISC..........................................................................................................................................................................18
ALS AGENTS - MISCELLANEOUS..................................................................................................................................................18
ALS AGENTS - MISCELLANEOUS......................................................................................................................................................18
AMETHYST TABLET 90-20 MCG ORAL.........................................................................................................................................18
CONTRACEPTIVES.......................................................................................................................................................................18
AMINOGLYCOSIDES.........................................................................................................................................................................18
AMINOGLYCOSIDES............................................................................................................................................................................18
ANALGESICS - ANTI-INFLAMMATORY.........................................................................................................................................18
ANTIRHEUMATIC - JANUS KINASE (JAK) INHIBITORS.......................................................................................................................18ANTIRHEUMATIC ANTIMETABOLITES..................................................................................................................................................18ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES................................................................................................................................18ANTI-TNF-ALPHA - MONOCLONOAL ANTIBODIES.............................................................................................................................19CYCLOOXYGENASE 2 (COX-2) INHIBITORS.....................................................................................................................................19GOLD COMPOUNDS...........................................................................................................................................................................19INTERLEUKIN-1 BLOCKERS................................................................................................................................................................19INTERLEUKIN-1BETA BLOCKERS.......................................................................................................................................................19INTERLEUKIN-6 RECEPTOR INHIBITORS............................................................................................................................................19NONSTEROIDAL ANTI-INFLAMMATORY AGENT COMBINATIONS........................................................................................................19NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)..............................................................................................................19PYRIMIDINE SYNTHESIS INHIBITORS.................................................................................................................................................19SELECTIVE COSTIMULATION MODULATORS......................................................................................................................................19SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS.............................................................................................................19
ANALGESICS - NONNARCOTIC.....................................................................................................................................................19
ANALGESICS OTHER..........................................................................................................................................................................19ANALGESICS-SEDATIVES...................................................................................................................................................................19SALICYLATE COMBINATIONS.............................................................................................................................................................19SALICYLATES..................................................................................................................................................................................... 19SELECTIVE N-TYPE NEURONAL CALCIUM CHANNEL BLOCKERS.....................................................................................................19
ANALGESICS - OPIOID.....................................................................................................................................................................19
CODEINE COMBINATIONS..................................................................................................................................................................19DIHYDROCODEINE COMBINATIONS....................................................................................................................................................20HYDROCODONE COMBINATIONS.......................................................................................................................................................20OPIOID AGONISTS............................................................................................................................................................................. 20OPIOID COMBINATIONS.....................................................................................................................................................................20OPIOID PARTIAL AGONISTS...............................................................................................................................................................20TRAMADOL COMBINATIONS...............................................................................................................................................................20
ANDROGENS-ANABOLIC.................................................................................................................................................................20
ANDROGENS......................................................................................................................................................................................20
ANORECTAL AGENTS......................................................................................................................................................................20Updated January 1, 2019 Page
INTRARECTAL STEROIDS...................................................................................................................................................................20NITRATE VASODILATING AGENTS.....................................................................................................................................................20RECTAL ANESTHETIC/STEROIDS.......................................................................................................................................................20
ANTHELMINTICS................................................................................................................................................................................20
ANTHELMINTICS.................................................................................................................................................................................20
ANTIANGINAL AGENTS....................................................................................................................................................................21
ANTIANGINALS-OTHER......................................................................................................................................................................21NITRATES...........................................................................................................................................................................................21
ANTIANXIETY AGENTS....................................................................................................................................................................21
ANTIANXIETY AGENTS - MISC...........................................................................................................................................................21BENZODIAZEPINES.............................................................................................................................................................................21
ANTIARRHYTHMICS......................................................................................................................................................................... 21
ANTIARRHYTHMICS - MISC................................................................................................................................................................21ANTIARRHYTHMICS TYPE I-A............................................................................................................................................................21ANTIARRHYTHMICS TYPE I-B............................................................................................................................................................21ANTIARRHYTHMICS TYPE I-C............................................................................................................................................................21ANTIARRHYTHMICS TYPE III..............................................................................................................................................................21
ANTIASTHMATIC AND BRONCHODILATOR AGENTS...............................................................................................................21
ADRENERGIC COMBINATIONS...........................................................................................................................................................21ANTI-IGE MONOCLONAL ANTIBODIES...............................................................................................................................................21BETA ADRENERGICS......................................................................................................................................................................... 21BRONCHODILATORS - ANTICHOLINERGICS........................................................................................................................................22LEUKOTRIENE RECEPTOR ANTAGONISTS.........................................................................................................................................22SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS...............................................................................................................22STEROID INHALANTS......................................................................................................................................................................... 22XANTHINE-EXPECTORANTS...............................................................................................................................................................22XANTHINES........................................................................................................................................................................................ 22
ANTICOAGULANTS...........................................................................................................................................................................22
COUMARIN ANTICOAGULANTS...........................................................................................................................................................22DIRECT FACTOR XA INHIBITORS.......................................................................................................................................................22HEPARINS AND HEPARINOID-LIKE AGENTS......................................................................................................................................22LOW MOLECULAR WEIGHT HEPARINS..............................................................................................................................................22SYNTHETIC HEPARINOID-LIKE AGENTS............................................................................................................................................22THROMBIN INHIBITORS - HIRUDIN TYPE...........................................................................................................................................22THROMBIN INHIBITORS - SELECTIVE DIRECT & REVERSIBLE...........................................................................................................22
ANTICONVULSANTS.........................................................................................................................................................................22
AMPA GLUTAMATE RECEPTOR ANTAGONISTS................................................................................................................................22ANTICONVULSANTS - BENZODIAZEPINES..........................................................................................................................................23ANTICONVULSANTS - MISC................................................................................................................................................................23CARBAMATES.....................................................................................................................................................................................23GABA MODULATORS........................................................................................................................................................................23HYDANTOINS......................................................................................................................................................................................23SUCCINIMIDES................................................................................................................................................................................... 23VALPROIC ACID................................................................................................................................................................................. 23
ANTIDEPRESSANTS.........................................................................................................................................................................23
ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS).....................................................................................................................23
Updated January 1, 2019 Page
ANTIDEPRESSANTS - MISC................................................................................................................................................................23MODIFIED CYCLICS............................................................................................................................................................................23MONOAMINE OXIDASE INHIBITORS (MAOIS)....................................................................................................................................23SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)................................................................................................................23SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS).....................................................................................................24TRICYCLIC AGENTS...........................................................................................................................................................................24
ANTIDIABETICS................................................................................................................................................................................. 24
ALPHA-GLUCOSIDASE INHIBITORS....................................................................................................................................................24ANTIDIABETIC - AMYLIN ANALOGS....................................................................................................................................................24BIGUANIDES.......................................................................................................................................................................................24DIABETIC OTHER...............................................................................................................................................................................24DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS...............................................................................................................................24DIPEPTIDYL PEPTIDASE-4 INHIBITOR-BIGUANIDE COMBINATIONS...................................................................................................24HUMAN INSULIN.................................................................................................................................................................................24INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)..........................................................................................................24INSULIN-INCRETIN MIMETIC COMBINATIONS.....................................................................................................................................24MEGLITINIDE ANALOGUES.................................................................................................................................................................24MEGLITINIDE-BIGUANIDE COMBINATIONS.........................................................................................................................................25SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS...................................................................................................................25SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS......................................................................................................25SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB..........................................................................................25SULFONYLUREAS...............................................................................................................................................................................25SULFONYLUREA-THIAZOLIDINEDIONE COMBINATIONS......................................................................................................................25THIAZOLIDINEDIONE-BIGUANIDE COMBINATIONS..............................................................................................................................25THIAZOLIDINEDIONES.........................................................................................................................................................................25
ANTIDIARRHEALS.............................................................................................................................................................................25
ANTIPERISTALTIC AGENTS................................................................................................................................................................25
ANTIDOTES.........................................................................................................................................................................................25
ANTIDOTES........................................................................................................................................................................................ 25ANTIDOTES - CHELATING AGENTS....................................................................................................................................................25BENZODIAZEPINE ANTAGONISTS.......................................................................................................................................................25OPIOID ANTAGONISTS.......................................................................................................................................................................25
ANTIDOTES AND SPECIFIC ANTAGONISTS...............................................................................................................................25
ANTIDOTES AND SPECIFIC ANTAGONISTS........................................................................................................................................25
ANTIEMETICS.....................................................................................................................................................................................26
5-HT3 RECEPTOR ANTAGONISTS.....................................................................................................................................................26ANTIEMETIC COMBINATIONS.............................................................................................................................................................26ANTIEMETICS - ANTICHOLINERGIC....................................................................................................................................................26SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS....................................................................................................26
ANTIFUNGALS....................................................................................................................................................................................26
ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)................................................................................................26ANTIFUNGALS.................................................................................................................................................................................... 26IMIDAZOLES........................................................................................................................................................................................26TRIAZOLES.........................................................................................................................................................................................26
ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES..............................................................................................26
ANTIHEMOPHILIC PRODUCTS - MONOCLONAL ANTIBODIES.............................................................................................................26
ANTIHISTAMINES..............................................................................................................................................................................26Updated January 1, 2019 Page
ANTIHISTAMINES - ALKYLAMINES......................................................................................................................................................26ANTIHISTAMINES - ETHANOLAMINES.................................................................................................................................................26ANTIHISTAMINES - NON-SEDATING...................................................................................................................................................27ANTIHISTAMINES - PHENOTHIAZINES................................................................................................................................................27ANTIHISTAMINES - PIPERIDINES........................................................................................................................................................27
ANTIHYPERLIPIDEMICS..................................................................................................................................................................27
ANTIHYPERLIPIDEMICS - MISC..........................................................................................................................................................27BILE ACID SEQUESTRANTS...............................................................................................................................................................27FIBRIC ACID DERIVATIVES.................................................................................................................................................................27HMG COA REDUCTASE INHIBITORS................................................................................................................................................27INTEST CHOLEST ABSORP INHIB-HMG COA REDUCTASE INHIB COMB.........................................................................................27INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS......................................................................................................................27MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN INHIBITORS.......................................................................................................27NICOTINIC ACID DERIVATIVES...........................................................................................................................................................27
ANTIHYPERTENSIVES.....................................................................................................................................................................27
ACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS...................................................................................................27ACE INHIBITORS............................................................................................................................................................................... 27ACE INHIBITORS & THIAZIDE/THIAZIDE-LIKE...................................................................................................................................27ADRENOLYTICS-CENTRAL & THIAZIDE/THIAZIDE-LIKE COMB..........................................................................................................28AGENTS FOR PHEOCHROMOCYTOMA...............................................................................................................................................28ANGIOTENSIN II RECEPTOR ANTAG & CA CHANNEL BLOCKER & DIURETIC COMB.......................................................................28ANGIOTENSIN II RECEPTOR ANTAG & CA CHANNEL BLOCKER COMB............................................................................................28ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDE-LIKE......................................................................................................28ANGIOTENSIN II RECEPTOR ANTAGONISTS......................................................................................................................................28ANGIOTENSIN II RECEPTOR ANT-CA CHANNEL BLOCKER-THIAZIDES.............................................................................................28ANTIADRENERGICS - CENTRALLY ACTING........................................................................................................................................28ANTIADRENERGICS - CENTRALLY ACTING & THIAZIDE/THIAZIDE-LIKE COMB.................................................................................28ANTIADRENERGICS - PERIPHERALLY ACTING...................................................................................................................................28BETA BLOCKER & ANGIOTENSIN II RECEPTOR ANTAGONIST COMB...............................................................................................28BETA BLOCKER & DIURETIC COMBINATIONS...................................................................................................................................28DIRECT RENIN INHIBITORS................................................................................................................................................................28DIRECT RENIN INHIBITORS & THIAZIDE/THIAZIDE-LIKE COMB.........................................................................................................28RESERPINE........................................................................................................................................................................................ 28SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)....................................................................................................28VASODILATORS..................................................................................................................................................................................28
ANTI-INFECTIVE AGENTS - MISC..................................................................................................................................................28
ANTI-INFECTIVE AGENTS - MISC.......................................................................................................................................................28ANTI-INFECTIVE MISC. - COMBINATIONS..........................................................................................................................................29ANTIPROTOZOAL AGENTS.................................................................................................................................................................29CARBAPENEM COMBINATIONS..........................................................................................................................................................29CARBAPENEMS.................................................................................................................................................................................. 29CYCLIC LIPOPEPTIDES.......................................................................................................................................................................29GLYCYLCYCLINES..............................................................................................................................................................................29LEPROSTATICS.................................................................................................................................................................................. 29LINCOSAMIDES...................................................................................................................................................................................29OXAZOLIDINONES.............................................................................................................................................................................. 29POLYMYXINS......................................................................................................................................................................................29STREPTOGRAMIN COMBINATIONS.....................................................................................................................................................29
ANTIMALARIALS................................................................................................................................................................................29
ANTIMALARIAL COMBINATIONS..........................................................................................................................................................29
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ANTIMALARIALS..................................................................................................................................................................................29
ANTIMYASTHENIC AGENTS...........................................................................................................................................................29
ANTIMYASTHENIC AGENTS................................................................................................................................................................29ANTIMYASTHENIC/CHOLINERGIC AGENTS.........................................................................................................................................30
ANTIMYCOBACTERIAL AGENTS...................................................................................................................................................30
ANTIMYCOBACTERIAL AGENTS..........................................................................................................................................................30
ANTINEOPLASTIC - BCL-2 INHIBITORS.......................................................................................................................................30
ANTINEOPLASTIC - BCL-2 INHIBITORS.............................................................................................................................................30
ANTINEOPLASTIC & IMMUNOSUPPRESANT DRUGS..............................................................................................................30
ADJUNCTIVE AGENTS.................................................................................................................................................................30
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES................................................................................................................30
ALKYLATING AGENTS........................................................................................................................................................................ 30ANDROGEN BIOSYNTHESIS INHIBITORS............................................................................................................................................30ANTIADRENALS.................................................................................................................................................................................. 30ANTIANDROGENS...............................................................................................................................................................................30ANTIESTROGENS............................................................................................................................................................................... 30ANTIMETABOLITES.............................................................................................................................................................................30ANTINEOPLASTIC - AUTOLOGOUS CELLULAR IMMUNOTHERAPY......................................................................................................30ANTINEOPLASTIC - BISPECIFIC T-CELL ENGAGERS..........................................................................................................................31ANTINEOPLASTIC - BRAF KINASE INHIBITORS.................................................................................................................................31ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS.....................................................................................................................31ANTINEOPLASTIC - HISTONE DEACETYLASE INHIBITORS..................................................................................................................31ANTINEOPLASTIC - IMMUNOMODULATORS........................................................................................................................................31ANTINEOPLASTIC - MEK INHIBITORS................................................................................................................................................31ANTINEOPLASTIC - MONOCLONAL ANTIBODIES................................................................................................................................31ANTINEOPLASTIC - MTOR KINASE INHIBITORS.................................................................................................................................31ANTINEOPLASTIC - MULTIKINASE INHIBITORS...................................................................................................................................31ANTINEOPLASTIC - PROTEASOME INHIBITORS..................................................................................................................................31ANTINEOPLASTIC - TYROSINE KINASE INHIBITORS...........................................................................................................................31ANTINEOPLASTIC ANTIBIOTICS..........................................................................................................................................................31ANTINEOPLASTIC -ANTIBODY FOR RADIOPHARMACEUTICAL THERAPY............................................................................................31ANTINEOPLASTIC ANTIBODY-DRUG COMPLEXES.............................................................................................................................31ANTINEOPLASTIC COMBINATIONS.....................................................................................................................................................32ANTINEOPLASTIC ENZYMES..............................................................................................................................................................32ANTINEOPLASTIC RADIOPHARMACEUTICALS.....................................................................................................................................32ANTINEOPLASTICS - INTERLEUKINS...................................................................................................................................................32ANTINEOPLASTICS - PHOTOACTIVATED AGENTS..............................................................................................................................32ANTINEOPLASTICS MISC................................................................................................................................................................... 32AROMATASE INHIBITORS...................................................................................................................................................................32CARBOXYPEPTIDASE ENZYME AGENTS............................................................................................................................................32CARDIAC PROTECTIVE AGENTS........................................................................................................................................................32CHEMOTHERAPY ADJUNCTS - HYPERURICEMIA AGENTS.................................................................................................................32CHEMOTHERAPY ADJUNCTS - KERATINOCYTE GROWTH FACTORS................................................................................................32CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS...........................................................................................................................32ESTROGEN RECEPTOR ANTAGONIST................................................................................................................................................32ESTROGENS-ANTINEOPLASTIC..........................................................................................................................................................32FOLIC ACID ANTAGONISTS RESCUE AGENTS...................................................................................................................................32GONADOTROPIN RELEASING HORMONE (GNRH) ANTAGONISTS....................................................................................................32IMIDAZOTETRAZINES..........................................................................................................................................................................32
Updated January 1, 2019 Page
ISOCITRATE DEHYDROGENASE-2 (IDH2) INHIBITORS......................................................................................................................32JANUS ASSOCIATED KINASE (JAK) INHIBITORS...............................................................................................................................32LHRH ANALOGS............................................................................................................................................................................... 32MITOTIC INHIBITORS..........................................................................................................................................................................33NITROGEN MUSTARDS......................................................................................................................................................................33NITROSOUREAS.................................................................................................................................................................................33PROGESTINS-ANTINEOPLASTIC.........................................................................................................................................................33RETINOIDS......................................................................................................................................................................................... 33SELECTIVE RETINOID X RECEPTOR AGONISTS................................................................................................................................33TOPOISOMERASE I INHIBITORS.........................................................................................................................................................33URINARY TRACT PROTECTIVE AGENTS............................................................................................................................................33VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) INHIBITORS..................................................................................................33
ANTIPARKINSON AGENTS..............................................................................................................................................................33
ANTIPARKINSON ANTICHOLINERGICS................................................................................................................................................33ANTIPARKINSON DOPAMINERGICS....................................................................................................................................................33ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS........................................................................................................................33LEVODOPA COMBINATIONS...............................................................................................................................................................33NONERGOLINE DOPAMINE RECEPTOR AGONISTS............................................................................................................................33PERIPHERAL COMT INHIBITORS.......................................................................................................................................................34
ANTIPSYCHOTICS/ANTIMANIC AGENTS.....................................................................................................................................34
ANTIMANIC AGENTS...........................................................................................................................................................................34ANTIPSYCHOTICS - MISC...................................................................................................................................................................34BENZISOXAZOLES..............................................................................................................................................................................34BUTYROPHENONES............................................................................................................................................................................34DIBENZODIAZEPINES..........................................................................................................................................................................34DIBENZOTHIAZEPINES........................................................................................................................................................................34DIBENZOXAZEPINES...........................................................................................................................................................................34PHENOTHIAZINES...............................................................................................................................................................................34QUINOLINONE DERIVATIVES..............................................................................................................................................................34THIENBENZODIAZEPINES................................................................................................................................................................... 34THIOXANTHENES................................................................................................................................................................................34
ANTIRETROVIRALS - CD4-DIRECTED POST-ATTACHMENT INHIBITOR.............................................................................34
ANTIRETROVIRALS - CD4-DIRECTED POST-ATTACHMENT INHIBITOR.............................................................................................34
ANTISEPTICS & DISINFECTANTS.................................................................................................................................................34
CHLORINE ANTISEPTICS....................................................................................................................................................................34
ANTIVIRALS........................................................................................................................................................................................ 34
ANTIRETROVIRAL COMBINATIONS.....................................................................................................................................................34ANTIRETROVIRALS - CCR5 ANTAGONISTS (ENTRY INHIBITOR).......................................................................................................35ANTIRETROVIRALS - FUSION INHIBITORS..........................................................................................................................................35ANTIRETROVIRALS - INTEGRASE INHIBITORS....................................................................................................................................35ANTIRETROVIRALS - PROTEASE INHIBITORS.....................................................................................................................................35ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE ANALOGUES...............................................................................................................35ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PURINES........................................................................................................35ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-PYRIMIDINES..................................................................................................35ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES-THYMIDINES...................................................................................................35ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES........................................................................................................................35CMV AGENTS....................................................................................................................................................................................35HEPATITIS B AGENTS........................................................................................................................................................................35HEPATITIS C AGENTS........................................................................................................................................................................36
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HERPES AGENTS - PURINE ANALOGUES..........................................................................................................................................36HERPES AGENTS - THYMIDINE ANALOGUES....................................................................................................................................36INFLUENZA AGENTS...........................................................................................................................................................................36NEURAMINIDASE INHIBITORS.............................................................................................................................................................36
ASSORTED CLASSES......................................................................................................................................................................36
ANTILEPROTICS................................................................................................................................................................................. 36B-LYMPHOCYTE STIMULATOR (BLYS)-SPECIFIC INHIBITORS..........................................................................................................36CHELATING AGENTS..........................................................................................................................................................................36CYCLOSPORINE ANALOGS................................................................................................................................................................36ENZYMES........................................................................................................................................................................................... 36IMMUNE GLOBULIN IMMUNOSUPPRESSANTS....................................................................................................................................36INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS.............................................................................................................36IRRIGATION SOLUTIONS.....................................................................................................................................................................36MACROLIDE IMMUNOSUPPRESSANTS................................................................................................................................................36MONOCLONAL ANTIBODIES...............................................................................................................................................................36PERITONIAL DIALYSIS SOLUTIONS....................................................................................................................................................37POTASSIUM REMOVING RESINS........................................................................................................................................................37PROSTAGLANDINS............................................................................................................................................................................. 37PURINE ANALOGS..............................................................................................................................................................................37SCLEROSING AGENTS.......................................................................................................................................................................37SELECTIVE T-CELL COSTIMULATION BLOCKERS..............................................................................................................................37
BETA BLOCKERS.............................................................................................................................................................................. 37
ALPHA-BETA BLOCKERS...................................................................................................................................................................37BETA BLOCKERS CARDIO-SELECTIVE..............................................................................................................................................37BETA BLOCKERS NON-SELECTIVE....................................................................................................................................................37
BILE ACID SYNTHESIS DISORDER AGENTS..............................................................................................................................37
BILE ACID SYNTHESIS DISORDER AGENTS......................................................................................................................................37
BIOLOGICALS MISC..........................................................................................................................................................................37
ALLERGENIC EXTRACTS....................................................................................................................................................................37BIOLOGICALS MISC............................................................................................................................................................................37
CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG.................................................................................37
CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG...............................................................................................37
CALCIUM CHANNEL BLOCKERS...................................................................................................................................................37
CALCIUM CHANNEL BLOCKERS.........................................................................................................................................................37
CARDIOTONICS.................................................................................................................................................................................38
CARDIAC GLYCOSIDES......................................................................................................................................................................38PHOSPHODIESTERASE INHIBITORS...................................................................................................................................................38
CARDIOVASCULAR AGENTS - MISC............................................................................................................................................38
CALCIUM CHANNEL BLOCKER & HMG COA REDUCTASE INHIBIT COMB.......................................................................................38PERIPHERAL VASODILATORS............................................................................................................................................................38PROSTAGLANDIN - IMPOTENCE AGENTS...........................................................................................................................................38PROSTAGLANDIN VASODILATORS.....................................................................................................................................................38PULM HYPERTEN-SOLUBLE GUANYLATE CYCLASE STIMULATOR (SGC)........................................................................................38PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS.........................................................................................38PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS.................................................................................................38SELECTIVE CGMP PHOSPHODIESTERASE TYPE 5 INHIBITORS.......................................................................................................38
Updated January 1, 2019 Page
VASOACTIVE NATRIURETIC PEPTIDES..............................................................................................................................................38
CARDIOVASCULAR, HYPERTENSION & LIPIDS........................................................................................................................38
ANTICOAGULANTS.......................................................................................................................................................................38MISC. CARDIOVASCULAR AGENTS.........................................................................................................................................38MISC. COAGULATION AGENTS.................................................................................................................................................38
CEPHALOSPORIN COMBINATIONS..............................................................................................................................................38
CEPHALOSPORIN COMBINATIONS.....................................................................................................................................................38
CEPHALOSPORINS...........................................................................................................................................................................38
CEPHALOSPORINS - 1ST GENERATION.............................................................................................................................................38CEPHALOSPORINS - 2ND GENERATION............................................................................................................................................39CEPHALOSPORINS - 3RD GENERATION............................................................................................................................................39CEPHALOSPORINS - 4TH GENERATION.............................................................................................................................................39CEPHALOSPORINS - 5TH GENERATION.............................................................................................................................................39
CONTRACEPTIVES...........................................................................................................................................................................39
BIPHASIC CONTRACEPTIVES - ORAL.................................................................................................................................................39COMBINATION CONTRACEPTIVES - ORAL.........................................................................................................................................39COMBINATION CONTRACEPTIVES - VAGINAL....................................................................................................................................39EMERGENCY CONTRACEPTIVES........................................................................................................................................................40EXTENDED-CYCLE CONTRACEPTIVES - ORAL..................................................................................................................................40FOUR PHASE CONTRACEPTIVES - ORAL..........................................................................................................................................40PROGESTIN CONTRACEPTIVES - IMPLANTS......................................................................................................................................40PROGESTIN CONTRACEPTIVES - INJECTABLE...................................................................................................................................40PROGESTIN CONTRACEPTIVES - IUD...............................................................................................................................................40PROGESTIN CONTRACEPTIVES - ORAL.............................................................................................................................................40TRIPHASIC CONTRACEPTIVES - ORAL...............................................................................................................................................40
CORTICOSTEROIDS.........................................................................................................................................................................40
GLUCOCORTICOSTEROIDS.................................................................................................................................................................40
COUGH/COLD/ALLERGY.................................................................................................................................................................40
ANTITUSSIVE - NONNARCOTIC..........................................................................................................................................................40ANTITUSSIVE - OPIOID.......................................................................................................................................................................40DECONGESTANT................................................................................................................................................................................40DECONGESTANT-ANTIHISTAMINE......................................................................................................................................................40DECONGESTANT-ANTIHISTAMINE W/ EXPECTORANT........................................................................................................................40MUCOLYTICS......................................................................................................................................................................................40NON-NARC ANTITUSSIVE-ANTIHISTAMINE.......................................................................................................................................40NON-NARC ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE............................................................................................................41OPIOID ANTITUSSIVE-ANTIHISTAMINE...............................................................................................................................................41OPIOID ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE...................................................................................................................41OPIOID ANTITUSSIVE-EXPECTORANT................................................................................................................................................41
CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS..................................................................................................................41
CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS...........................................................................................................................41
DERMATOLOGICALS........................................................................................................................................................................41
ACNE ANTIBIOTICS............................................................................................................................................................................41ACNE COMBINATIONS........................................................................................................................................................................41ACNE PRODUCTS.............................................................................................................................................................................. 41ANTIBIOTICS - TOPICAL.....................................................................................................................................................................41
Updated January 1, 2019 Page
ANTIFUNGALS - TOPICAL...................................................................................................................................................................41ANTIFUNGALS - TOPICAL COMBINATIONS.........................................................................................................................................41ANTI-INFLAMMATORY AGENTS - TOPICAL.........................................................................................................................................41ANTINEOPLASTIC ALKYLATING AGENTS - TOPICAL..........................................................................................................................41ANTINEOPLASTIC ANTIMETABOLITES - TOPICAL...............................................................................................................................41ANTINEOPLASTIC OR PREMALIGNANT LESIONS - TOPICAL MISC.....................................................................................................41ANTIPERSPIRANTS......................................................................................................................................................................42ANTIPSORIATICS................................................................................................................................................................................42ANTIPSORIATICS - SYSTEMIC............................................................................................................................................................42ANTISEBORRHEIC PRODUCTS...........................................................................................................................................................42ANTIVIRALS - TOPICAL.......................................................................................................................................................................42BURN PRODUCTS..............................................................................................................................................................................42CORTICOSTEROIDS - TOPICAL..........................................................................................................................................................42DEPIGMENTING AGENTS................................................................................................................................................................... 42EMOLLIENT/KERATOLYTIC AGENTS...................................................................................................................................................42EMOLLIENTS...................................................................................................................................................................................... 42ENZYMES - TOPICAL..........................................................................................................................................................................42IMIDAZOLE-RELATED ANTIFUNGALS - TOPICAL................................................................................................................................42IMMUNOMODULATORS IMIDAZOQUINOLINAMINES - TOPICAL............................................................................................................42KERATOLYTIC/ANTIMITOTIC AGENTS................................................................................................................................................43LOCAL ANESTHETICS - TOPICAL.......................................................................................................................................................43MACROLIDE IMMUNOSUPPRESSANTS - TOPICAL..............................................................................................................................43MISC. DERMATOLOGICAL PRODUCTS...............................................................................................................................................43PIGMENTING AGENTS........................................................................................................................................................................43ROSACEA AGENTS............................................................................................................................................................................ 43SCABICIDES & PEDICULICIDES..........................................................................................................................................................43TOPICAL ANESTHETIC COMBINATIONS..............................................................................................................................................43TOPICAL ANESTHETIC GASSES.........................................................................................................................................................43TOPICAL SELECTIVE RETINOID X RECEPTOR AGONISTS.................................................................................................................43TOPICAL STEROID COMBINATIONS...................................................................................................................................................43WOUND CARE - GROWTH FACTOR AGENTS....................................................................................................................................43WOUND DRESSINGS..........................................................................................................................................................................43
DIAGNOSTIC PRODUCTS................................................................................................................................................................43
DIAGNOSTIC BIOLOGICALS................................................................................................................................................................43DIAGNOSTIC DRUGS..........................................................................................................................................................................43DIAGNOSTIC RADIOPHARMACEUTICALS - CARDIAC..........................................................................................................................44MISCELLANEOUS CONTRAST MEDIA.................................................................................................................................................44RADIOGRAPHIC CONTRAST MEDIA - IODINATED...............................................................................................................................44
DIAGNOSTICS & MISCELLANEOUS AGENTS.............................................................................................................................44
IRRIGATING SOLUTIONS............................................................................................................................................................44MISCELLANEOUS AGENTS........................................................................................................................................................44NEUTRACEUTICALS.....................................................................................................................................................................44
DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS.................................................................................................44
DIETARY MANAGEMENT PRODUCT COMBINATIONS.........................................................................................................................44DIETARY MANAGEMENT PRODUCTS.................................................................................................................................................44
DIGESTIVE AIDS................................................................................................................................................................................44
DIGESTIVE ENZYMES.........................................................................................................................................................................44
DILUENT.............................................................................................................................................................................................. 44
DILUENT.............................................................................................................................................................................................44
Updated January 1, 2019 Page
DIURETICS..........................................................................................................................................................................................44
CARBONIC ANHYDRASE INHIBITORS.................................................................................................................................................44DIURETIC COMBINATIONS..................................................................................................................................................................44LOOP DIURETICS...............................................................................................................................................................................44OSMOTIC DIURETICS.........................................................................................................................................................................45POTASSIUM SPARING DIURETICS.....................................................................................................................................................45THIAZIDES AND THIAZIDE-LIKE DIURETICS.......................................................................................................................................45
ENDOCRINE AND METABOLIC AGENTS - MISC........................................................................................................................45
BISPHOSPHONATES...........................................................................................................................................................................45CALCIMIMETIC AGENTS.....................................................................................................................................................................45CALCITONINS..................................................................................................................................................................................... 45CARNITINE REPLENISHER - AGENTS.................................................................................................................................................45DOPAMINE RECEPTOR AGONISTS.....................................................................................................................................................45FABRY DISEASE - AGENTS................................................................................................................................................................45GAA DEFICIENCY TREATMENT - AGENTS........................................................................................................................................45GROWTH HORMONE RECEPTOR ANTAGONISTS...............................................................................................................................45GROWTH HORMONE RELEASING HORMONES (GHRH)...................................................................................................................45GROWTH HORMONES........................................................................................................................................................................45HEREDITARY OROTIC ACIDURIA TREATMENT - AGENTS..................................................................................................................45HEREDITARY TYROSINEMIA TYPE 1 (HT-1) TREATMENT - AGENTS................................................................................................45HOMOCYSTINURIA TREATMENT - AGENTS........................................................................................................................................45HYPERAMMONEMIA TREATMENT - AGENTS......................................................................................................................................45HYPERPARATHYROID TREATMENT - VITAMIN D ANALOGS...............................................................................................................45HYPOPHOSPHATASIA (HPP) AGENTS...............................................................................................................................................46INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS).......................................................................................................................46LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS.........................................................................................................46LYSOSOMAL ACID LIPASE (LAL) DEFICIENCY - AGENTS.................................................................................................................46LYSOSOMAL STORAGE DISEASE TREATMENT - AGENTS.................................................................................................................46MUCOPOLYSACCHARIDOSIS I (MPS I) - AGENTS.............................................................................................................................46MUCOPOLYSACCHARIDOSIS II (MPS II) - AGENTS...........................................................................................................................46MUCOPOLYSACCHARIDOSIS VI (MPS VI) - AGENTS........................................................................................................................46OVULATION STIMULANTS-GONADOTROPINS.....................................................................................................................................46OVULATION STIMULANTS-SYNTHETIC...............................................................................................................................................46PARATHYROID HORMONE AND DERIVATIVES...................................................................................................................................46PHENYLKETONURIA TREATMENT - AGENTS......................................................................................................................................46RANK LIGAND (RANKL) INHIBITORS...............................................................................................................................................46SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)..........................................................................................................46SELECTIVE VASOPRESSIN V2-RECEPTOR ANTAGONISTS................................................................................................................46SOMATOSTATIC AGENTS...................................................................................................................................................................46UREA CYCLE DISORDER - AGENTS..................................................................................................................................................46VASOPRESSIN....................................................................................................................................................................................46
ENDOCRINE/DIABETES...................................................................................................................................................................46
INSULIN SYRINGES/MISCELLANEOUS DME..........................................................................................................................46
ESTROGENS...................................................................................................................................................................................... 47
ESTROGEN & ANDROGEN.................................................................................................................................................................47ESTROGEN & PROGESTIN.................................................................................................................................................................47ESTROGENS.......................................................................................................................................................................................47
ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB.............................................................................47
ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR COMB..............................................................................................47
Updated January 1, 2019 Page
FENTANYL COMBINATIONS...........................................................................................................................................................47
FENTANYL COMBINATIONS................................................................................................................................................................47
FLUOROQUINOLONES.....................................................................................................................................................................47
FLUOROQUINOLONES........................................................................................................................................................................47
GASTROENTEROLOGY...................................................................................................................................................................47
ANTIVERTIGO & ANTIEMETIC AGENTS..................................................................................................................................47MISC. GASTROINTESTINAL AGENTS......................................................................................................................................47
GASTROINTESTINAL AGENTS - MISC.........................................................................................................................................47
FARNESOID X RECEPTOR (FXR) AGONISTS....................................................................................................................................47GALLSTONE SOLUBILIZING AGENTS..................................................................................................................................................47GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS...................................................................................................................47GASTROINTESTINAL STIMULANTS.....................................................................................................................................................47IBS AGENT - GUANYLATE CYCLASE-C (GC-C) AGONISTS.............................................................................................................47IBS AGENT - MU-OPIOID RECEPTOR AGONISTS.............................................................................................................................47IBS AGENT - SELECTIVE 5-HT3 RECEPTOR ANTAGONISTS............................................................................................................48INFLAMMATORY BOWEL AGENTS......................................................................................................................................................48PERIPHERAL OPIOID RECEPTOR ANTAGONISTS...............................................................................................................................48PHOSPHATE BINDER AGENTS...........................................................................................................................................................48TUMOR NECROSIS FACTOR ALPHA BLOCKERS................................................................................................................................48
GENERAL ANESTHETICS................................................................................................................................................................48
ANESTHETICS - MISC........................................................................................................................................................................48BARBITURATE ANESTHETICS.............................................................................................................................................................48
GENITOURINARY AGENTS - MISCELLANEOUS........................................................................................................................48
5-ALPHA REDUCTASE INHIBITORS....................................................................................................................................................48ALPHA 1-ADRENOCEPTOR ANTAGONISTS........................................................................................................................................48CITRATES...........................................................................................................................................................................................48CYSTINOSIS AGENTS.........................................................................................................................................................................48GENITOURINARY IRRIGANTS..............................................................................................................................................................48INTERSTITIAL CYSTITIS AGENTS.......................................................................................................................................................48PHOSPHATES.....................................................................................................................................................................................48URINARY ANALGESICS...................................................................................................................................................................... 48
GOUT AGENTS...................................................................................................................................................................................48
GOUT AGENTS...................................................................................................................................................................................48URICOSURICS.................................................................................................................................................................................... 49
HEMATOLOGICAL AGENTS - MISC...............................................................................................................................................49
ANTIHEMOPHILIC PRODUCTS............................................................................................................................................................49BRADYKININ B2 RECEPTOR ANTAGONISTS......................................................................................................................................49C1 INHIBITORS...................................................................................................................................................................................49COMPLEMENT INHIBITORS.................................................................................................................................................................49CYCLOPENTYLTRIAZOLOPYRIMIDINE (CPTP) DERIVATIVES.............................................................................................................49GLYCOPROTEIN IIB/IIIA RECEPTOR INHIBITORS...............................................................................................................................49HEMATORHEOLOGIC AGENTS...........................................................................................................................................................49HEMIN................................................................................................................................................................................................ 49HUMAN PROTEIN C...........................................................................................................................................................................49PHOSPHODIESTERASE III INHIBITORS...............................................................................................................................................49PLASMA EXPANDERS.........................................................................................................................................................................49PLASMA KALLIKREIN INHIBITORS.......................................................................................................................................................49
Updated January 1, 2019 Page
PLASMA PROTEINS............................................................................................................................................................................49PLATELET AGGREGATION INHIBITOR COMBINATIONS.......................................................................................................................49PLATELET AGGREGATION INHIBITORS..............................................................................................................................................50PROTAMINE........................................................................................................................................................................................50QUINAZOLINE AGENTS...................................................................................................................................................................... 50THIENOPYRIDINE DERIVATIVES.........................................................................................................................................................50TISSUE PLASMINOGEN ACTIVATORS.................................................................................................................................................50
HEMATOPOIETIC AGENTS.............................................................................................................................................................50
AGENTS FOR GAUCHER DISEASE.....................................................................................................................................................50COBALAMINS......................................................................................................................................................................................50CXCR4 RECEPTOR ANTAGONIST....................................................................................................................................................50CYTOTOXIC AGENTS......................................................................................................................................................................... 50ERYTHROPOIESIS-STIMULATING AGENTS (ESAS)...........................................................................................................................50FOLIC ACID/FOLATES........................................................................................................................................................................50GRANULOCYTE COLONY-STIMULATING FACTORS (G-CSF)............................................................................................................50GRANULOCYTE/MACROPHAGE COLONY-STIMULATING FACTOR(GM-CSF)....................................................................................50IRON...................................................................................................................................................................................................50IRON COMBINATIONS.........................................................................................................................................................................50IRON W/ FOLIC ACID..........................................................................................................................................................................50THROMBOPOIETIN (TPO) RECEPTOR AGONISTS.............................................................................................................................50
HEMOSTATICS...................................................................................................................................................................................50
HEMOSTATICS - SYSTEMIC................................................................................................................................................................50
HEPATITIS C AGENT - COMBINATIONS.......................................................................................................................................51
HEPATITIS C AGENT - COMBINATIONS.............................................................................................................................................51
HYPNOTICS........................................................................................................................................................................................ 51
BARBITURATE HYPNOTICS................................................................................................................................................................51BENZODIAZEPINE HYPNOTICS...........................................................................................................................................................51NON-BENZODIAZEPINE - GABA-RECEPTOR MODULATORS............................................................................................................51SELECTIVE MELATONIN RECEPTOR AGONISTS................................................................................................................................51
IMMUNOLOGY, VACCINES & BIOTECHNOLOGY.......................................................................................................................51
VACCINES & MISCELLANEOUS IMMUNOLOGICALS............................................................................................................51
IMPLANON IMPLANT 68 MG SUBCUTANEOUS..........................................................................................................................51
CONTRACEPTIVES.......................................................................................................................................................................51
INTEGRIN RECEPTOR ANTAGONISTS........................................................................................................................................51
INTEGRIN RECEPTOR ANTAGONISTS................................................................................................................................................51
INTERLEUKIN-6 (IL-6) ANTAGONISTS..........................................................................................................................................51
INTERLEUKIN-6 (IL-6) ANTAGONISTS................................................................................................................................................51
LAXATIVES..........................................................................................................................................................................................51
BOWEL EVACUANT COMBINATIONS..................................................................................................................................................51LAXATIVES - MISCELLANEOUS..........................................................................................................................................................51
LEPTIN ANALOGUES........................................................................................................................................................................51
LEPTIN ANALOGUES..........................................................................................................................................................................51
LOCAL ANESTHETICS-PARENTERAL..........................................................................................................................................51
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LOCAL ANESTHETIC & SYMPATHOMIMETIC......................................................................................................................................51LOCAL ANESTHETICS - AMIDES........................................................................................................................................................52LOCAL ANESTHETICS - ESTERS........................................................................................................................................................52
MACROLIDES..................................................................................................................................................................................... 52
AZITHROMYCIN.................................................................................................................................................................................. 52CLARITHROMYCIN..............................................................................................................................................................................52ERYTHROMYCINS...............................................................................................................................................................................52
MEDICAL DEVICES........................................................................................................................................................................... 52
CERVICAL CAPS................................................................................................................................................................................ 52DIAPHRAGMS..................................................................................................................................................................................... 52GLUCOSE MONITORING TEST SUPPLIES..........................................................................................................................................52NEEDLES & SYRINGES......................................................................................................................................................................52
MIGRAINE PRODUCTS.....................................................................................................................................................................52
ERGOT COMBINATIONS.....................................................................................................................................................................52MIGRAINE PRODUCTS................................................................................................................................................................53SELECTIVE SEROTONIN AGONIST-NSAID COMBINATIONS..............................................................................................................53SELECTIVE SEROTONIN AGONISTS 5-HT(1)....................................................................................................................................53
MINERALS & ELECTROLYTES.......................................................................................................................................................53
BICARBONATES..................................................................................................................................................................................53CALCIUM............................................................................................................................................................................................ 53CHLORIDE.......................................................................................................................................................................................... 53CITRATE.............................................................................................................................................................................................53ELECTROLYTES & DEXTROSE...........................................................................................................................................................53ELECTROLYTES PARENTERAL...........................................................................................................................................................53IODINE PRODUCTS.............................................................................................................................................................................53MAGNESIUM.......................................................................................................................................................................................53MANGANESE...................................................................................................................................................................................... 53PHOSPHATE.......................................................................................................................................................................................53POTASSIUM........................................................................................................................................................................................53TRACE MINERAL COMBINATIONS......................................................................................................................................................54TRACE MINERALS..............................................................................................................................................................................54ZINC................................................................................................................................................................................................... 54
MIXED ALLERGENIC EXTRACTS...................................................................................................................................................54
MIXED ALLERGENIC EXTRACTS........................................................................................................................................................54
MONOBACTAMS................................................................................................................................................................................54
MONOBACTAMS................................................................................................................................................................................. 54
MOUTH/THROAT/DENTAL AGENTS..............................................................................................................................................54
ANTI-INFECTIVE COMBINATIONS - THROAT.......................................................................................................................................54FLUORIDE DENTAL PRODUCTS.........................................................................................................................................................54SALIVA STIMULANTS..........................................................................................................................................................................54TRIPEPTIDYL PEPTIDASE 1 DEFICIENCY TREATMENT - AGENTS.....................................................................................................54
MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS...............................................................................................................54
MUCOPOLYSACCHARIDOSIS IV (MPS IV) - AGENTS........................................................................................................................54
MUCOPOLYSACCHARIDOSIS VII (MPS VII) - AGENTS.............................................................................................................54
MUCOPOLYSACCHARIDOSIS VII (MPS VII) - AGENTS.....................................................................................................................54
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MULTIVITAMINS.................................................................................................................................................................................54
B-COMPLEX VITAMINS.......................................................................................................................................................................54B-COMPLEX W/ C & FOLIC ACID......................................................................................................................................................54B-COMPLEX W/ C-BIOTIN-E-MINERALS & FOLIC ACID....................................................................................................................54B-COMPLEX W/ C-ZN & FOLIC ACID................................................................................................................................................54MULTIPLE VITAMINS W/ CALCIUM.....................................................................................................................................................54MULTIPLE VITAMINS W/ MINERALS...................................................................................................................................................55MULTIPLE VITAMINS W/ MINERALS & CALCIUM-FOLIC ACID............................................................................................................55MULTIPLE VITAMINS W/ MINERALS & FOLIC ACID............................................................................................................................55MULTIVITAMINS..................................................................................................................................................................................55PRENATAL MV & MIN W/FE-FA.......................................................................................................................................................55PRENATAL MV & MIN W/FE-FA-CA-OMEGA 3 FISH OIL................................................................................................................55PRENATAL MV & MIN W/FE-FA-DHA.............................................................................................................................................55PRENATAL VITAMINS.........................................................................................................................................................................56
MUSCULOSKELETAL THERAPY AGENTS...................................................................................................................................56
CENTRAL MUSCLE RELAXANTS........................................................................................................................................................56DIRECT MUSCLE RELAXANTS...........................................................................................................................................................56VISCOSUPPLEMENTS.........................................................................................................................................................................56
NASAL AGENTS - SYSTEMIC AND TOPICAL..............................................................................................................................56
ANTIHISTAMINE-STEROID..................................................................................................................................................................56NASAL ANTICHOLINERGICS...............................................................................................................................................................56NASAL ANTIHISTAMINES....................................................................................................................................................................56NASAL STEROIDS.............................................................................................................................................................................. 56TOPICAL DECONGESTANTS...............................................................................................................................................................56
NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB...................................................................................56
NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB................................................................................................56
NEUROMUSCULAR AGENTS..........................................................................................................................................................56
BENZATHIAZOLES.............................................................................................................................................................................. 56DEPOLARIZING MUSCLE RELAXANTS................................................................................................................................................56NEUROMUSCULAR BLOCKING AGENT - NEUROTOXINS....................................................................................................................56
NUTRIENTS.........................................................................................................................................................................................56
AMINO ACID MIXTURES.....................................................................................................................................................................56CARBOHYDRATES..............................................................................................................................................................................57LIPIDS................................................................................................................................................................................................ 57
OBSTETRICS & GYNECOLOGY.....................................................................................................................................................57
DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES.............................................................................................57
OPHTHALMIC AGENTS....................................................................................................................................................................57
ARTIFICIAL TEARS............................................................................................................................................................................. 57BETA-BLOCKERS - OPHTHALMIC.......................................................................................................................................................57BETA-BLOCKERS - OPHTHALMIC COMBINATIONS.............................................................................................................................57CYCLOPLEGIC MYDRIATICS...............................................................................................................................................................57LYMPHOCYTE FUNCTION-ASSOCIATED ANTIGEN-1 (LFA-1) ANTAG...............................................................................................57MIOTICS - CHOLINESTERASE INHIBITORS.........................................................................................................................................57MIOTICS - DIRECT ACTING................................................................................................................................................................57OPHTHALMIC ANTIALLERGIC.............................................................................................................................................................57OPHTHALMIC ANTIBIOTICS................................................................................................................................................................57OPHTHALMIC ANTIFUNGAL................................................................................................................................................................57
Updated January 1, 2019 Page
OPHTHALMIC ANTI-INFECTIVE COMBINATIONS.................................................................................................................................58OPHTHALMIC ANTIVIRALS..................................................................................................................................................................58OPHTHALMIC CARBONIC ANHYDRASE INHIBITORS...........................................................................................................................58OPHTHALMIC DECONGESTANTS........................................................................................................................................................58OPHTHALMIC DIAGNOSTIC PRODUCTS.............................................................................................................................................58OPHTHALMIC ENZYMES.....................................................................................................................................................................58OPHTHALMIC IMMUNOMODULATORS.................................................................................................................................................58OPHTHALMIC IRRIGATION SOLUTIONS..............................................................................................................................................58OPHTHALMIC LOCAL ANESTHETICS..................................................................................................................................................58OPHTHALMIC NONSTEROIDAL ANTI-INFLAMMATORY AGENTS..........................................................................................................58OPHTHALMIC PHOTODYNAMIC THERAPY AGENTS...........................................................................................................................58OPHTHALMIC RHO KINASE INHIBITORS.............................................................................................................................................58OPHTHALMIC SELECTIVE ALPHA ADRENERGIC AGONISTS..............................................................................................................58OPHTHALMIC STEROID COMBINATIONS............................................................................................................................................58OPHTHALMIC STEROIDS....................................................................................................................................................................58OPHTHALMIC SULFONAMIDES...........................................................................................................................................................58OPHTHALMICS - CYSTINOSIS AGENTS..............................................................................................................................................58PROSTAGLANDINS - OPHTHALMIC.....................................................................................................................................................58VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) ANTAGONISTS.............................................................................................59
OPHTHALMIC GENE THERAPY......................................................................................................................................................59
OPHTHALMIC GENE THERAPY...........................................................................................................................................................59
OPHTHALMOLOGY........................................................................................................................................................................... 59
MACULAR DEGENERATION.................................................................................................................................................................59
OTIC AGENTS.....................................................................................................................................................................................59
OTIC AGENTS - MISCELLANEOUS.....................................................................................................................................................59OTIC ANALGESIC COMBINATIONS.....................................................................................................................................................59OTIC ANTI-INFECTIVES......................................................................................................................................................................59OTIC STEROID-ANTI-INFECTIVE COMBINATIONS...............................................................................................................................59OTIC STEROIDS.................................................................................................................................................................................59
OXYTOCICS........................................................................................................................................................................................59
ABORTIFACIENTS/CERVICAL RIPENING - PROSTAGLANDINS............................................................................................................59OXYTOCICS........................................................................................................................................................................................59
PASSIVE IMMUNIZING AGENTS....................................................................................................................................................59
ANTIVIRAL MONOCLONAL ANTIBODIES.............................................................................................................................................59IMMUNE SERUMS...............................................................................................................................................................................59
PCSK9 INHIBITORS...........................................................................................................................................................................59
PCSK9 INHIBITORS...........................................................................................................................................................................59
PENICILLINS....................................................................................................................................................................................... 60
AMINOPENICILLINS.............................................................................................................................................................................60NATURAL PENICILLINS.......................................................................................................................................................................60PENICILLIN COMBINATIONS...............................................................................................................................................................60PENICILLINASE-RESISTANT PENICILLINS...........................................................................................................................................60
PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS........................................................................................................60
PHOSPHATIDYLINOSITOL 3-KINASE (PI3K) INHIBITORS...................................................................................................................60
POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS......................................................................................................60
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POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS...............................................................................................................60
POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS.......................................................................................................60
POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS................................................................................................................60
POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS....................................................................................60
POSTHERPETIC NEURALGIA (PHN)/NEUROPATHIC PAIN AGENTS..................................................................................................60
PROGESTINS..................................................................................................................................................................................... 60
PROGESTINS......................................................................................................................................................................................60
PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS............................................................................................60
PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS........................................................................................................60
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC...........................................................................................60
AGENTS FOR NARCOTIC WITHDRAWAL............................................................................................................................................60ALCOHOL DETERRENTS....................................................................................................................................................................60ANTI-CATAPLECTIC AGENTS.............................................................................................................................................................60ANTIDEMENTIA AGENT COMBINATIONS.............................................................................................................................................60BENZODIAZEPINES & TRICYCLIC AGENTS........................................................................................................................................60CHOLINOMIMETICS - ACHE INHIBITORS...........................................................................................................................................61FIBROMYALGIA AGENT - SNRIS.......................................................................................................................................................61MOVEMENT DISORDER DRUG THERAPY..........................................................................................................................................61MULTIPLE SCLEROSIS AGENTS.........................................................................................................................................................61MULTIPLE SCLEROSIS AGENTS - INTERFERONS...............................................................................................................................61MULTIPLE SCLEROSIS AGENTS - MONOCLONAL ANTIBODIES..........................................................................................................61MULTIPLE SCLEROSIS AGENTS - NRF2 PATHWAY ACTIVATORS.....................................................................................................61MULTIPLE SCLEROSIS AGENTS - POTASSIUM CHANNEL BLOCKERS...............................................................................................61N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONISTS......................................................................................................61PHENOTHIAZINES & TRICYCLIC AGENTS..........................................................................................................................................61PSEUDOBULBAR AFFECT AGENT COMBINATIONS............................................................................................................................61SMOKING DETERRENTS.....................................................................................................................................................................61SPHINGOSINE 1-PHOSPHATE (S1P) RECEPTOR MODULATORS......................................................................................................61THIENBENZODIAZEPINES & SSRIS...................................................................................................................................................61VASOMOTOR SYMPTOM AGENTS - SSRIS.......................................................................................................................................61
PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST...........................................................................61
PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST.............................................................................................61
RESPIRATORY AGENTS - MISC....................................................................................................................................................61
ALPHA-PROTEINASE INHIBITOR (HUMAN).........................................................................................................................................61CFTR POTENTIATORS......................................................................................................................................................................61CYSTIC FIBROSIS AGENT - COMBINATIONS......................................................................................................................................61HYDROLYTIC ENZYMES.....................................................................................................................................................................61INTERLEUKIN-5 ANTAGONISTS (IGG1 KAPPA)..................................................................................................................................62PULMONARY FIBROSIS AGENTS........................................................................................................................................................62
SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS..........................................................................................................62
SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS...................................................................................................................62
SINUS NODE INHIBITORS...............................................................................................................................................................62
SINUS NODE INHIBITORS...................................................................................................................................................................62
SPINAL MUSCULAR ATROPHY AGENTS (SMA).........................................................................................................................62
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SPINAL MUSCULAR ATROPHY AGENTS (SMA)................................................................................................................................62
TAZAROTENE CREAM 0.1 % EXTERNAL.....................................................................................................................................62
DERMATOLOGICALS....................................................................................................................................................................62
TETRACYCLINES...............................................................................................................................................................................62
TETRACYCLINES................................................................................................................................................................................ 62
TETRAHYDROISOQUINOLINES.....................................................................................................................................................62
TETRAHYDROISOQUINOLINES............................................................................................................................................................62
THYROID AGENTS............................................................................................................................................................................62
ANTITHYROID AGENTS...................................................................................................................................................................... 62THYROID HORMONES........................................................................................................................................................................62
TOXOIDS............................................................................................................................................................................................. 62
TOXOID COMBINATIONS....................................................................................................................................................................62
TRYPTOPHAN HYDROXYLASE INHIBITORS..............................................................................................................................62
TRYPTOPHAN HYDROXYLASE INHIBITORS........................................................................................................................................62
ULCER DRUGS...................................................................................................................................................................................62
ANTISPASMODICS..............................................................................................................................................................................62BELLADONNA ALKALOIDS..................................................................................................................................................................62H-2 ANTAGONISTS............................................................................................................................................................................ 63MISC. ANTI-ULCER............................................................................................................................................................................63PROTON PUMP INHIBITOR-ANTACID COMBINATIONS........................................................................................................................63PROTON PUMP INHIBITORS...............................................................................................................................................................63QUATERNARY ANTICHOLINERGICS....................................................................................................................................................63ULCER ANTI-INFECTIVE W/ PROTON PUMP INHIBITORS...................................................................................................................63ULCER DRUGS - PROSTAGLANDINS..................................................................................................................................................63
URINARY ANTI-INFECTIVES...........................................................................................................................................................63
URINARY ANTI-INFECTIVES................................................................................................................................................................63URINARY ANTISEPTIC-ANTISPASMODIC &/OR ANALGESICS.............................................................................................................63
URINARY ANTISPASMODICS.........................................................................................................................................................63
BETA-3 ADRENERGIC AGONISTS......................................................................................................................................................63URINARY ANTISPASMODIC - ANTIMUSCARINIC (ANTICHOLINERGIC)................................................................................................63URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOL)(NEW).................................................................................................63URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS (NEW)........................................................................................................63URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS............................................................................................................63
VACCINES........................................................................................................................................................................................... 64
BACTERIAL VACCINES.......................................................................................................................................................................64VIRAL VACCINE COMBINATIONS........................................................................................................................................................64VIRAL VACCINES................................................................................................................................................................................64
VAGINAL PRODUCTS.......................................................................................................................................................................64
IMIDAZOLE-RELATED ANTIFUNGALS..................................................................................................................................................64VAGINAL ANTI-INFECTIVES................................................................................................................................................................64VAGINAL ESTROGENS.......................................................................................................................................................................64VAGINAL PROGESTINS...................................................................................................................................................................... 64
VASOPRESSORS.............................................................................................................................................................................. 64Updated January 1, 2019 Page
ANAPHYLAXIS THERAPY AGENTS......................................................................................................................................................64VASOPRESSORS................................................................................................................................................................................64
VITAMINS.............................................................................................................................................................................................64
VITAMIN A..........................................................................................................................................................................................64VITAMIN B-6...................................................................................................................................................................................... 65VITAMIN C..........................................................................................................................................................................................65VITAMIN K..........................................................................................................................................................................................65
VITAMINS, HEMATINICS & ELECTROLYTES..............................................................................................................................65
VITAMINS & HEMATINICS...........................................................................................................................................................65
X-LINKED HYPOPHOSPHATEMIA (XLH) TREATMENT - AGENTS..........................................................................................65
X-LINKED HYPOPHOSPHATEMIA (XLH) TREATMENT - AGENTS.......................................................................................................65
Updated January 1, 2019 Page
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS
ADHD Agent - Selective Alpha Adrenergic AgonistsGENERIC clonidine hcl er guanfacine er
ADHD Agent - Selective Norepinephrine Reuptake Inhibitor
GENERIC atomoxetine hcl
NON PREFERRED STRATTERA
Amphetamine MixturesGENERIC amphetamine salt combo er
PREFERRED MYDAYIS
AmphetaminesGENERIC dexmethylphenidate er dextroamphetamine sulfate dextroamphetamine sulfate er methamphetamine hcl
PREFERRED EVEKEO VYVANSE
AnalepticsGENERIC caffeine citrated caffeine/sodium benzoate
Anorexiants Non-AmphetamineGENERIC benzphetamine hcl diethylpropion hcl phendimetrazine tartrate phendimetrazine tartrate er phentermine hcl
Stimulants - Misc.GENERIC armodafinil methylphenidate cd methylphenidate er methylphenidate hcl methylphenidate la modafinil
PREFERRED DAYTRANA QUILLICHEW ER
QUILLIVANT XR
NON PREFERRED FOCALIN XR
ALS Agents - Miscellaneous
ALS Agents - MiscellaneousNON PREFERRED RADICAVA
Amethyst TABLET 90-20 MCG Oral
CONTRACEPTIVESGENERIC amethyst
AMINOGLYCOSIDES
AminoglycosidesGENERIC gentamicin sulfate gentamicin sulfate gentamicin sulfate in ns kanamycin sulfate neomycin sulfate paromomycin sulfate tobramycin sulfate tobramycin sulfate in ns
PREFERRED AMIKACIN GENTAMICIN SULFATE IN NS 100MG/50ML KANAMYCIN SULFATE POWDER
NON PREFERRED BETHKIS CAYSTON GENTAMICIN SULFATE 60MG/ML VIAL GENTAMICIN SULFATE IN NS 120MG/0.1L KITABIS PAK TOBI PODHALER TOBRAMYCIN SULFATE 300MG/5ML AMPUL
ANALGESICS - ANTI-INFLAMMATORY
Antirheumatic - Janus Kinase (JAK) InhibitorsNON PREFERRED XELJANZ XELJANZ XR
Antirheumatic AntimetabolitesPREFERRED OTREXUP
Anti-TNF-alpha - Monoclonal AntibodiesPREFERRED
Updated January 1, 2019 Page
HUMIRA SIMPONI ARIA
Anti-TNF-alpha - Monoclonoal AntibodiesPREFERRED SIMPONI 100MG/ML
NON PREFERRED SIMPONI 50MG/0.5ML
Cyclooxygenase 2 (COX-2) InhibitorsGENERIC celecoxib
NON PREFERRED CELEBREX
Gold CompoundsPREFERRED RIDAURA
Interleukin-1 BlockersNON PREFERRED ARCALYST
Interleukin-1beta BlockersNON PREFERRED ILARIS
Interleukin-6 Receptor InhibitorsNON PREFERRED ACTEMRA
Nonsteroidal Anti-inflammatory Agent CombinationsGENERIC diclofenac sodium/misoprostol del rel
Nonsteroidal Anti-inflammatory Agents (NSAIDs)GENERIC diclofenac potassium diclofenac sodium etodolac etodolac er fenoprofen calcium ibuprofen ibuprofen lysine indomethacin indomethacin er ketoprofen er meclofenamate sodium mefenamic acid meloxicam nabumetone naproxen naproxen sodium oxaprozin piroxicam sulindac tolmetin sodium
PREFERRED
CALDOLOR DICLOFENAC SODIUM POWDER
NON PREFERRED FENOPROFEN CALCIUM NEOPROFEN ZORVOLEX
Pyrimidine Synthesis InhibitorsGENERIC leflunomide
Selective Costimulation ModulatorsNON PREFERRED ORENCIA ORENCIA CLICKJECT
Soluble Tumor Necrosis Factor Receptor AgentsPREFERRED ENBREL
ANALGESICS - NonNarcotic
Analgesics OtherGENERIC acetaminophen-diphenhydramine clonidine
PREFERRED OFIRMEV
Analgesics-SedativesGENERIC butalbital compound butalbital/apap/caffeine butalbital/aspirin/caffeine
Salicylate CombinationsGENERIC choline mag trisalicylate
SalicylatesGENERIC diflunisal salicylamide salsalate
NON PREFERRED DISALCID
Selective N-Type Neuronal Calcium Channel BlockersNON PREFERRED PRIALT
Updated January 1, 2019 Page
ANALGESICS - OPIOID
Codeine CombinationsGENERIC acetaminophen/codeine butalbital compound/codeine butalbital/caff/apap/codeine
Dihydrocodeine CombinationsGENERIC dihydrocodeine/aspirin/caffeine
Hydrocodone CombinationsGENERIC hydrocodone/acetaminophen hydrocodone/ibuprofen
Opioid AgonistsGENERIC alfentanil hcl codeine sulfate fentanyl citrate hydromorphone hcl levorphanol tartrate meperidine hcl methadone hcl morphine sulfate morphine sulfate cr morphine sulfate er oxycodone hcl oxycodone hcl/ibuprofen oxymorphone hcl oxymorphone hcl er remifentanil hcl sufentil 50mcg/ml ampul tramadol hcl tramadol hcl er
PREFERRED INFUMORPH OXYCONTIN ER ULTIVA
NON PREFERRED CODEINE SULFATE SOLUTION DILAUDID-HP FENTANYL CITRATE 100MCG/2ML FENTORA HYDROMORPHONE HCL 0.5MG/0.5ML SYRINGE MORPHINE SULFATE NUCYNTA NUCYNTA ER ROXYBOND SUFENTIL 50MCG/ML VIAL TRAMADOL HCL ER
Opioid CombinationsGENERIC oxycodone w/aspirin oxycodone/acetaminophen
Opioid Partial AgonistsGENERIC buprenorphine buprenorphine/naloxone butorphanol
nalbuphine hcl pentazocine lactate
PREFERRED BUTRANS SUBOXONE ZUBSOLV
NON PREFERRED BELBUCA SUBLOCADE SUBOXONE TABLET TALWIN
Tramadol CombinationsGENERIC tramadol/acetaminophen
ANDROGENS-ANABOLIC
AndrogensGENERIC danazol oxandrolone testosterone cypionate testosterone enanthate testosterone gel
PREFERRED ANDRODERM FLUOXYMESTERONE METHITEST
NON PREFERRED AXIRON TESTOSTERONE GEL
ANORECTAL AGENTS
Intrarectal SteroidsPREFERRED CORTIFOAM
NON PREFERRED UCERIS FOAM
Nitrate Vasodilating AgentsPREFERRED RECTIV
Rectal Anesthetic/SteroidsGENERIC hydrocortisone/pramoxine lidocaine-hc pramcort
NON PREFERRED LIDOCAINE-HC PROCTOFOAM-HC
Updated January 1, 2019 Page
ANTHELMINTICS
AnthelminticsGENERIC ivermectin praziquantel
PREFERRED ALBENZA BENZNIDAZOLE EMVERM
NON PREFERRED BILTRICIDE STROMECTOL
ANTIANGINAL AGENTS
Antianginals-OtherPREFERRED RANEXA
NitratesGENERIC isosorbide dinitrate isosorbide mononitrate isosorbide mononitrate er minitran nitroglycerin nitroglycerin er nitroglycerin in d5w nitroglycerin spray nitroglycerin tablets
PREFERRED DILATRATE-SR
NON PREFERRED NITRO-DUR NITROSTAT
ANTIANXIETY AGENTS
Antianxiety Agents - Misc.GENERIC buspirone hcl hydroxyzine hcl hydroxyzine pamoate
NON PREFERRED VISTARIL
BenzodiazepinesGENERIC alprazolam alprazolam er alprazolam odt chlordiazepoxide hcl clorazepate dipotassium lorazepam oxazepam
NON PREFERRED
XANAX XANAX XR
ANTIARRHYTHMICS
Antiarrhythmics - Misc.GENERIC adenosine
Antiarrhythmics Type I-AGENERIC procainamide hcl quinidine gluconate quinidine gluconate er quinidine sulfate
PREFERRED QUINIDINE SULFATE
Antiarrhythmics Type I-BGENERIC lidocaine hcl in 7.5% dextrose mexiletine hcl
Antiarrhythmics Type I-CGENERIC flecainide acetate propafenone hcl propafenone hcl er
Antiarrhythmics Type IIIGENERIC amiodarone hcl dofetilide ibutilide fumarate
ANTIASTHMATIC AND BRONCHODILATOR AGENTS
Adrenergic CombinationsPREFERRED ADVAIR DISKUS ADVAIR HFA ANORO ELLIPTA BREO ELLIPTA COMBIVENT RESPIMAT DULERA STIOLTO RESPIMAT SYMBICORT TRELEGY ELLIPTA
NON PREFERRED BEVESPI AEROSPHERE UTIBRON NEOHALER
Anti-IgE Monoclonal AntibodiesNON PREFERRED XOLAIR
Updated January 1, 2019 Page
Beta AdrenergicsGENERIC albuterol sulfate ephedrine sulfate levalbuterol hcl metaproterenol sulfate terbutaline sulfate
PREFERRED ALBUTEROL ARCAPTA NEOHALER PERFOROMIST PROAIR HFA PROAIR RESPICLICK SEREVENT DISKUS VENTOLIN HFA
NON PREFERRED STRIVERDI RESPIMAT VOSPIRE ER
Bronchodilators - AnticholinergicsGENERIC ipratropium bromide ipratropium/albuterol nebulization
PREFERRED INCRUSE ELLIPTA SPIRIVA RESPIMAT
NON PREFERRED ATROVENT SPRAY SEEBRI NEOHALER TUDORZA PRESSAIR
Leukotriene Receptor AntagonistsGENERIC montelukast sodium zafirlukast
NON PREFERRED ACCOLATE
Selective Phosphodiesterase 4 (PDE4) InhibitorsPREFERRED DALIRESP
Steroid InhalantsPREFERRED ARMONAIR RESPICLICK ARNUITY ELLIPTA ASMANEX, HFA FLOVENT DISKUS FLOVENT HFA PULMICORT FLEXHALER QVAR QVAR REDIHALER
NON PREFERRED ALVESCO
Xanthine-ExpectorantsGENERIC difil-g
XanthinesGENERIC aminophylline theophylline anhydrous drops er 12 hr theophylline anhydrous er
NON PREFERRED AMINOPHYLLINE 500MG/20ML AMPUL
ANTICOAGULANTS
Coumarin AnticoagulantsGENERIC warfarin sodium
PREFERRED COUMADIN 5MG VIAL
NON PREFERRED COUMADIN
Direct Factor Xa InhibitorsPREFERRED ELIQUIS XARELTO
Heparins And Heparinoid-Like AgentsGENERIC heparin lock flush heparin sodium in 0.45% nacl heparin sodium in 5% dextrose heparin sodium syringe
NON PREFERRED HEPARIN SODIUM IN 0.45% NACL 12500/500
Low Molecular Weight HeparinsGENERIC enoxaparin sodium
NON PREFERRED FRAGMIN
Synthetic Heparinoid-Like AgentsGENERIC fondaparinux sodium
Thrombin Inhibitors - Hirudin TypeGENERIC bivalirudin
NON PREFERRED ANGIOMAX
Updated January 1, 2019 Page
Thrombin Inhibitors - Selective Direct & ReversibleNON PREFERRED ARGATROBAN
ANTICONVULSANTS
AMPA Glutamate Receptor AntagonistsNON PREFERRED FYCOMPA
Anticonvulsants - BenzodiazepinesGENERIC clonazepam clonazepam odt diazepam diazepam rectal gel
NON PREFERRED ONFI
Anticonvulsants - Misc.GENERIC carbamazepine carbamazepine er gabapentin lamotrigine lamotrigine er levetiracetam levetiracetam er oxcarbazepine primidone roweepra topiramate zonisamide
PREFERRED LYRICA ROWEEPRA XR
NON PREFERRED BANZEL LAMICTAL XR OXTELLAR XR POTIGA QUDEXY XR VIMPAT ZONISAMIDE
CarbamatesGENERIC felbamate
GABA ModulatorsGENERIC tiagabine hcl
NON PREFERRED GABITRIL SABRIL
HydantoinsGENERIC fosphenytoin sodium phenytoin phenytoin sodium
PREFERRED DIAZEPAM POWDER DILANTIN 30MG PEGANONE
NON PREFERRED DILANTIN
SuccinimidesGENERIC ethosuximide
PREFERRED CELONTIN
Valproic AcidGENERIC divalproex sodium divalproex sodium er valproate sodium valproic acid
PREFERRED VALPROIC ACID
ANTIDEPRESSANTS
Alpha-2 Receptor Antagonists (Tetracyclics)GENERIC mirtazapine mirtazapine disintegrating
NON PREFERRED REMERON REMERON ODT
Antidepressants - Misc.GENERIC bupropion er (12 hour) bupropion hcl bupropion hcl er bupropion hcl xl er bupropion sr
Modified CyclicsGENERIC trazodone hcl
PREFERRED VIIBRYD
Monoamine Oxidase Inhibitors (MAOIs)GENERIC
Updated January 1, 2019 Page
phenelzine sulfate tranylcypromine sulfate
Selective Serotonin Reuptake Inhibitors (SSRIs)GENERIC citalopram hbr escitalopram oxalate fluoxetine fluvoxamine maleate er paroxetine hcl paroxetine hcl er
PREFERRED FLUOXETINE POWDER
NON PREFERRED CELEXA FLUOXETINE 60MG PROZAC
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)GENERIC desvenlafaxine succinate er duloxetine venlafaxine hcl venlafaxine hcl er
PREFERRED FETZIMA
NON PREFERRED EFFEXOR XR PRISTIQ
Tricyclic AgentsGENERIC amitriptyline hcl amoxapine 150mg amoxapine 25mg clomipramine hcl desipramine hcl doxepin hcl imipramine hcl imipramine pamoate nortriptyline hcl trimipramine maleate
ANTIDIABETICS
Alpha-Glucosidase InhibitorsGENERIC acarbose
Antidiabetic - Amylin AnalogsPREFERRED SYMLINPEN 120 SYMLINPEN 60
BiguanidesGENERIC metformin hcl metformin hcl er
NON PREFERRED RIOMET
Diabetic OtherPREFERRED GLUCAGEN GLUCAGON PROGLYCEM
Dipeptidyl Peptidase-4 (DPP-4) InhibitorsPREFERRED JANUVIA TRADJENTA
NON PREFERRED ONGLYZA
Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations
PREFERRED JANUMET JANUMET XR JENTADUETO JENTADUETO XR
NON PREFERRED KOMBIGLYZE XR
Human InsulinPREFERRED HUMALOG HUMALOG JUNIOR KWIKPEN HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R 500 UNITS HUMULIN R U-500 KWIKPEN LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR, FLEXTOUCH NOVOLIN 70-30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70-30 TOUJEO MAX SOLOSTAR TOUJEO SOLOSTAR TRESIBA FLEXTOUCH U-100 TRESIBA FLEXTOUCH U-200
NON PREFERRED BASAGLAR KWIKPEN U-100
Incretin Mimetic Agents (GLP-1 Receptor Agonists)PREFERRED BYETTA OZEMPIC TRULICITY VICTOZA
NON PREFERRED BYDUREON BYDUREON BCISE
Updated January 1, 2019 Page
BYDUREON PEN
Insulin-Incretin Mimetic CombinationsPREFERRED SOLIQUA 100-33 XULTOPHY 100-3.6
Meglitinide AnaloguesGENERIC nateglinide repaglinide
Meglitinide-Biguanide CombinationsGENERIC repaglinide/metformin
SGLT2 Inhibitor - DPP-4 Inhibitor CombinationsNON PREFERRED GLYXAMBI
Sodium-Glucose Co-Transporter 2 (SGLT2) InhibitorsPREFERRED FARXIGA INVOKANA
NON PREFERRED JARDIANCE STEGLATRO
Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb
PREFERRED INVOKAMET INVOKAMET XR XIGDUO XR
NON PREFERRED SEGLUROMET SYNJARDY SYNJARDY XR
SulfonylureasGENERIC glimepiride glipizide glipizide er glyburide glyburide micronized glyburide/metformin hcl tolazamide tolbutamide
Sulfonylurea-Thiazolidinedione CombinationsGENERIC pioglitazone/glimepiride
NON PREFERRED ACTOPLUS MET ACTOPLUS MET XR
Thiazolidinedione-Biguanide CombinationsGENERIC
pioglitazone/metformin
ThiazolidinedionesGENERIC pioglitazone hcl
NON PREFERRED ACTOS
ANTIDIARRHEALS
Antiperistaltic AgentsGENERIC diphenoxylate/atropine opium paregoric
NON PREFERRED LOMOTIL TABLET
ANTIDOTES
AntidotesGENERIC deferoxamine fomepizole physostigmine salicylate sodium thiosulfate
PREFERRED PHYSOSTIGMINE SALICYLATE SODIUM THIOSULFATE VISTOGARD
Antidotes - Chelating AgentsPREFERRED CHEMET
NON PREFERRED EXJADE FERRIPROX JADENU JADENU SPRINKLE
Benzodiazepine AntagonistsGENERIC flumazenil
Opioid AntagonistsGENERIC naloxone hcl naltrexone hydrochloride
PREFERRED NALOXONE HCL POWDER NARCAN
NON PREFERRED VIVITROL
Updated January 1, 2019 Page
ANTIDOTES AND SPECIFIC ANTAGONISTS
Antidotes and Specific AntagonistsPREFERRED BAL IN OIL PROTOPAM CHLORIDE
ANTIEMETICS
5-HT3 Receptor AntagonistsGENERIC granisetron hcl granisol ondansetron odt palonosetron hcl
PREFERRED SANCUSO
NON PREFERRED ONDANSETRON HCL
Antiemetic CombinationsPREFERRED AKYNZEO
Antiemetics - AnticholinergicGENERIC dimenhydrinate trimethobenzamide hcl
PREFERRED MECLIZINE HCL POWDER
Substance P/Neurokinin 1 (NK1) Receptor AntagonistsGENERIC aprepitant capsule, dose pack
PREFERRED EMEND 40MG; 125MG CAPSULE VARUBI
NON PREFERRED ALOXI EMEND 125MG/80MG DOSEPACK EMEND 80MG CAPSULE
ANTIFUNGALS
Antifungal - Glucan Synthesis Inhibitors (Echinocandins)
GENERIC caspofungin acetate
PREFERRED MYCAMINE
NON PREFERRED CANCIDAS
AntifungalsGENERIC amphotericin flucytosine griseofulvin griseofulvin ultramicrosize nystatin nystatin terbinafine
PREFERRED AMBISOME LAMISIL NYSTATIN NYSTATIN TERBINAFINE
NON PREFERRED LAMISIL 250MG TABLET
ImidazolesGENERIC ketoconazole
NON PREFERRED KETOCONAZOLE CRYSTALS
TriazolesGENERIC fluconazole fluconazole in dextrose fluconazole in saline itraconazole voriconazole
PREFERRED CRESEMBA NOXAFIL SPORANOX SOLUTION
NON PREFERRED FLUCONAZOLE 100MG/50ML PIGGYBACK ITRACONAZOLE 1GM POWDER SPORANOX CAPSULE
Antihemophilic Products - Monoclonal Antibodies
Antihemophilic Products - Monoclonal AntibodiesNON PREFERRED HEMLIBRA
ANTIHISTAMINES
Antihistamines - AlkylaminesGENERIC dexchlorpheniramine maleate er
Antihistamines - EthanolaminesGENERIC arbinoxa carbinoxamine clemastine fumarate
Updated January 1, 2019 Page
diphenhydramine diphenhydramine hcl
PREFERRED DOXYLAMINE SUCCINATE
Antihistamines - Non-SedatingGENERIC cetirizine syrup desloratadine desloratadine disintegrating tablets levocetirizine dihydrochloride
Antihistamines - PhenothiazinesGENERIC promethazine hcl promethegan
Antihistamines - PiperidinesGENERIC cyproheptadine hcl
NON PREFERRED CYPROHEPTADINE HCL 4MG/10ML SYRUP
ANTIHYPERLIPIDEMICS
Antihyperlipidemics - Misc.GENERIC omega-3-acid ethyl esters
PREFERRED VASCEPA
Bile Acid SequestrantsGENERIC cholestyramine cholestyramine light colesevelam hcl colestipol hcl
NON PREFERRED WELCHOL
Fibric Acid DerivativesGENERIC fenofibric acid fenofibric acid dr gemfibrozil
PREFERRED FENOFIBRATE LIPOFEN
HMG CoA Reductase InhibitorsGENERIC atorvastatin calcium fluvastatin sodium lovastatin pravastatin sodium rosuvastatin
simvastatin
PREFERRED LIVALO
NON PREFERRED SIMCOR ER
Intest Cholest Absorp Inhib-HMG CoA Reductase Inhib Comb
GENERIC ezetimibe/simvastatin
NON PREFERRED VYTORIN
Intestinal Cholesterol Absorption InhibitorsGENERIC ezetimibe
NON PREFERRED ZETIA
Microsomal Triglyceride Transfer Protein InhibitorsPREFERRED JUXTAPID
Nicotinic Acid DerivativesGENERIC niacin er
ANTIHYPERTENSIVES
ACE Inhibitor & Calcium Channel Blocker Combinations
GENERIC trandolapril/verapamil er
NON PREFERRED TARKA
ACE InhibitorsGENERIC benazepril hcl captopril enalapril maleate enalaprilat fosinopril sodium lisinopril moexipril hcl perindopril erbumine quinapril ramipril trandolapril
NON PREFERRED MAVIK VASOTEC
Updated January 1, 2019 Page
ACE Inhibitors & Thiazide/Thiazide-LikeGENERIC benazepril/hctz captopril/hydrochlorothiazide enalapril maleate/hctz fosinopril/hydrochlorothiazide lisinopril/hctz moexipril/hydrochlorothiazide quinapril/hydrochlorothiazide
Adrenolytics-Central & Thiazide/Thiazide-Like CombGENERIC methyldopa/hydrochlorothiazide
Agents for PheochromocytomaGENERIC phentolamine mesylate
PREFERRED DEMSER
NON PREFERRED PHENTOLAMINE MESYLATE VIAL
Angiotensin II Receptor Antag & Ca Channel Blocker & Diuretic Comb
GENERIC amlodipine/valsartan/hctz
Angiotensin II Receptor Antag & Ca Channel Blocker Comb
GENERIC amlodipine/olmesartan amlodipine/valsartan
NON PREFERRED AZOR
Angiotensin II Receptor Antag & Thiazide/Thiazide-LikeGENERIC candesartan/hydrochlorothiazide irbesartan/hydrochlorothiazide losartan/hydrochlorothiazide olmesartan medoxomil/hctz valsartan/hydrochlorothiazide
NON PREFERRED BENICAR HCT EDARBYCLOR
Angiotensin II Receptor AntagonistsGENERIC candesartan cilexetil irbesartan losartan potassium olmesartan medoxomil valsartan
NON PREFERRED BENICAR EDARBI
Angiotensin II Receptor Ant-Ca Channel Blocker-Thiazides
GENERIC olmesartan/amlodipine/hctz
NON PREFERRED TRIBENZOR
Antiadrenergics - Centrally ActingGENERIC clonidine hcl guanfacine hcl methyldopa methyldopate hcl
Antiadrenergics - Centrally Acting & Thiazide/Thiazide-Like Comb
GENERIC clonidine/chlorthalidone
Antiadrenergics - Peripherally ActingGENERIC doxazosin mesylate prazosin hcl terazosin hcl
Beta Blocker & Angiotensin II Receptor Antagonist Comb
PREFERRED BYVALSON
Beta Blocker & Diuretic CombinationsGENERIC atenolol/chlorthalidone bisoprolol fumarate/hctz metoprolol/hydrochlorothiazide nadolol-bendroflumethiazide propranolol/hctz
Direct Renin InhibitorsNON PREFERRED TEKTURNA
Direct Renin Inhibitors & Thiazide/Thiazide-Like CombNON PREFERRED TEKTURNA HCT
ReserpineGENERIC reserpine
Selective Aldosterone Receptor Antagonists (SARAs)GENERIC eplerenone
VasodilatorsGENERIC hydralazine hcl minoxidil
Updated January 1, 2019 Page
ANTI-INFECTIVE AGENTS - MISC.
Anti-infective Agents - Misc.GENERIC bacitracin bacitracin colistimethate metronidazole tinidazole trimethoprim
PREFERRED NEBUPENT VIBATIV XIFAXAN
NON PREFERRED DALVANCE FLAGYL IMPAVIDO TINDAMAX VANCOMYCIN-D5W VANCOMYCIN-NS
Anti-infective Misc. - CombinationsGENERIC sulfamethoxazole/trimethoprim
NON PREFERRED BACTRIM BACTRIM DS
Antiprotozoal AgentsGENERIC atovaquone
PREFERRED ALINIA
NON PREFERRED MEPRON
Carbapenem CombinationsGENERIC imipenem-cilastatin
CarbapenemsPREFERRED DORIBAX INVANZ MEROPENEM - 0.9% NACL
Cyclic LipopeptidesPREFERRED CUBICIN RF
NON PREFERRED CUBICIN
GlycylcyclinesGENERIC tigecycline
NON PREFERRED TYGACIL
LeprostaticsGENERIC dapsone
LincosamidesGENERIC clindamycin hcl clindamycin palmitate hcl clindamycin phosphate clindamycin phosphate/dextrose
PREFERRED CLINDAMYCIN PHOSPHATE
OxazolidinonesGENERIC linezolid
NON PREFERRED SIVEXTRO TABLET SIVEXTRO VIAL
PolymyxinsGENERIC polymyxin b sulfate
Streptogramin CombinationsPREFERRED SYNERCID
ANTIMALARIALS
Antimalarial CombinationsGENERIC atovaquone/proguanil hcl
PREFERRED COARTEM
NON PREFERRED MALARONE
AntimalarialsGENERIC chloroquine phosphate hydroxychloroquine sulfate mefloquine hcl quinine sulfate
PREFERRED DARAPRIM PRIMAQUINE
Updated January 1, 2019 Page
ANTIMYASTHENIC AGENTS Antimyasthenic Agents
GENERIC guanidine hcl neostigmine methylsulfate pyridostigmine bromide
NON PREFERRED NEOSTIGMINE METHYLSULFATE
Antimyasthenic/Cholinergic AgentsPREFERRED MESTINON SYRUP
NON PREFERRED MESTINON MESTINON ER
ANTIMYCOBACTERIAL AGENTS
Antimycobacterial AgentsGENERIC ethambutol hcl isoniazid pyrazinamide rifabutin
PREFERRED CAPASTAT SULFATE PRIFTIN SIRTURO
NON PREFERRED RIFADIN
Antineoplastic - BCL-2 Inhibitors
Antineoplastic - BCL-2 InhibitorsNON PREFERRED VENCLEXTA VENCLEXTA STARTER PACK
ANTINEOPLASTIC & IMMUNOSUPPRESANT DRUGS
ADJUNCTIVE AGENTSGENERIC amifostine
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
Alkylating AgentsGENERIC carboplatin cisplatin
PREFERRED BUSULFEX CISPLATIN POWDER HEXALEN
MYLERAN
NON PREFERRED BENDEKA OXALIPLATIN THIOTEPA TREANDA
Androgen Biosynthesis InhibitorsPREFERRED ZYTIGA
NON PREFERRED YONSA
AntiadrenalsPREFERRED LYSODREN
AntiandrogensGENERIC bicalutamide flutamide
PREFERRED ERLEADA XTANDI
NON PREFERRED NILANDRON NILUTAMIDE
AntiestrogensGENERIC tamoxifen citrate
PREFERRED FARESTON
AntimetabolitesGENERIC azacitidine capecitabine cladribine cytarabine decitabine floxuridine fludarabine phosphate mercaptopurine methotrexate
PREFERRED ARRANON CLOLAR PURIXAN RASUVO TABLOID
NON PREFERRED ALIMTA DEPOCYT FOLOTYN GEMCITABINE HCL
Updated January 1, 2019 Page
TREXALL
Antineoplastic - Autologous Cellular ImmunotherapyPREFERRED KYMRIAH PROVENGE YESCARTA
Antineoplastic - Bispecific T-cell EngagersNON PREFERRED BLINCYTO
Antineoplastic - BRAF Kinase InhibitorsNON PREFERRED BRAFTOVI TAFINLAR ZELBORAF
Antineoplastic - Hedgehog Pathway InhibitorsNON PREFERRED ERIVEDGE
Antineoplastic - Histone Deacetylase InhibitorsNON PREFERRED ISTODAX ZOLINZA
Antineoplastic - ImmunomodulatorsPREFERRED REVLIMID
NON PREFERRED POMALYST
Antineoplastic - MEK InhibitorsNON PREFERRED COTELLIC MEKINIST MEKTOVI
Antineoplastic - Monoclonal AntibodiesPREFERRED MYLOTARG ONTAK
NON PREFERRED ARZERRA BAVENCIO DARZALEX ERBITUX GAZYVA HERCEPTIN IMFINZI KEYTRUDA LARTRUVO OPDIVO PERJETA TECENTRIQ UNITUXIN VECTIBIX YERVOY
Antineoplastic - mTOR Kinase InhibitorsPREFERRED AFINITOR AFINITOR DISPERZ
NON PREFERRED TORISEL
Antineoplastic - Multikinase InhibitorsPREFERRED NEXAVAR SUTENT
NON PREFERRED RYDAPT STIVARGA
Antineoplastic - Proteasome InhibitorsNON PREFERRED KYPROLIS NINLARO VELCADE
Antineoplastic - Tyrosine Kinase InhibitorsPREFERRED SPRYCEL TARCEVA TASIGNA XALKORI
NON PREFERRED ALECENSA BOSULIF CAPRELSA GILOTRIF ICLUSIG IMATINIB MESYLATE IMBRUVICA INLYTA LENVIMA NERLYNX TAGRISSO TYKERB VOTRIENT ZYKADIA
Antineoplastic AntibioticsGENERIC bleomycin dactinomycin daunorubicin doxorubicin hcl doxorubicin hcl liposomal epirubicin hcl
NON PREFERRED DAUNOXOME IDARUBICIN HCL MITOMYCIN MITOXANTRONE VALSTAR
Updated January 1, 2019 Page
Antineoplastic -Antibody for Radiopharmaceutical Therapy
PREFERRED ZEVALIN
Antineoplastic Antibody-Drug ComplexesNON PREFERRED ADCETRIS BESPONSA KADCYLA
Antineoplastic CombinationsPREFERRED LONSURF
NON PREFERRED RITUXAN RITUXAN HYCELA VYXEOS LIPOSOME
Antineoplastic EnzymesNON PREFERRED ONCASPAR
Antineoplastic RadiopharmaceuticalsPREFERRED QUADRAMET XOFIGO
NON PREFERRED LUTATHERA
Antineoplastics - InterleukinsNON PREFERRED PROLEUKIN
Antineoplastics - Photoactivated AgentsNON PREFERRED PHOTOFRIN
Antineoplastics Misc.GENERIC dacarbazine hydroxyurea
PREFERRED HYDROXYUREA POWDER INTRON A MATULANE THERACYS
NON PREFERRED ACTIMMUNE ALFERON N SYLATRON SYNRIBO TICE BCG TRISENOX
Aromatase InhibitorsGENERIC anastrozole exemestane letrozole
PREFERRED ANASTROZOLE POWDER
NON PREFERRED ARIMIDEX AROMASIN FEMARA
Carboxypeptidase Enzyme AgentsPREFERRED VORAXAZE
Cardiac Protective AgentsGENERIC dexrazoxane
Chemotherapy Adjuncts - Hyperuricemia AgentsNON PREFERRED ELITEK
Chemotherapy Adjuncts - Keratinocyte Growth FactorsNON PREFERRED KEPIVANCE
Cyclin-Dependent Kinases (CDK) InhibitorsNON PREFERRED IBRANCE
Estrogen Receptor AntagonistNON PREFERRED FASLODEX
Estrogens-AntineoplasticPREFERRED EMCYT
Folic Acid Antagonists Rescue AgentsGENERIC calcium folinate leucovorin calcium levoleucovorin calcium
NON PREFERRED FUSILEV
Gonadotropin Releasing Hormone (GnRH) AntagonistsNON PREFERRED FIRMAGON
ImidazotetrazinesNON PREFERRED TEMODAR 100MG VIAL TEMODAR CAPSULES
Updated January 1, 2019 Page
TEMOZOLOMIDE
Isocitrate Dehydrogenase-2 (IDH2) InhibitorsNON PREFERRED IDHIFA
Janus Associated Kinase (JAK) InhibitorsNON PREFERRED JAKAFI
LHRH AnalogsPREFERRED LUPRON DEPOT 11.25MG LUPRON DEPOT 3.75MG TRELSTAR VIAL ZOLADEX
NON PREFERRED ELIGARD LEUPROLIDE ACETATE LUPRON DEPOT (FOR PROSTATE CANCER) TRELSTAR MIXJECT (LA) VANTAS
Mitotic InhibitorsGENERIC etoposide
PREFERRED ETOPOSIDE POWDER JEVTANA MARQIBO
NON PREFERRED ABRAXANE DOCEFREZ DOCETAXEL ETOPOPHOS HALAVEN IXEMPRA PACLITAXEL TENIPOSIDE VINBLASTINE SULFATE
Nitrogen MustardsGENERIC cyclophosphamide ifosfamide-mesna
PREFERRED CYCLOPHOSPHAMIDE
NON PREFERRED ALKERAN 2MG ALKERAN 50MG IFOSFAMIDE MELPHALAN HCL MUSTARGEN
NitrosoureasPREFERRED BICNU CEENU
LEUKERAN
NON PREFERRED GLEOSTINE LOMUSTINE ZANOSAR
Progestins-AntineoplasticGENERIC hydroxyprogesterone caproate megestrol acetate
PREFERRED DEPO-PROVERA 400 MG/ML
RetinoidsNON PREFERRED TRETINOIN CAP
Selective Retinoid X Receptor AgonistsNON PREFERRED TARGRETIN 75 CAPSULE
Topoisomerase I InhibitorsNON PREFERRED HYCAMTIN 4MG VIAL HYCAMTIN CAPSULES IRINOTECAN HCL ONIVYDE TOPOTECAN HCL
Urinary Tract Protective AgentsPREFERRED MESNEX 400MG TABLET
NON PREFERRED MESNA MESNEX 100MG/ML VIAL
Vascular Endothelial Growth Factor (VEGF) InhibitorsPREFERRED ZALTRAP
NON PREFERRED AVASTIN CYRAMZA
ANTIPARKINSON AGENTS
Antiparkinson AnticholinergicsGENERIC benztropine benztropine mesylate trihexyphenidyl hcl
Antiparkinson DopaminergicsGENERIC amantadine hcl
Updated January 1, 2019 Page
Antiparkinson Monoamine Oxidase InhibitorsGENERIC rasagiline mesylate selegiline hcl
NON PREFERRED AZILECT
Levodopa CombinationsGENERIC carbidopa/levodopa carbidopa/levodopa er carbidopa/levodopa odt carbidopa/levodopa/entacapone
Nonergoline Dopamine Receptor AgonistsGENERIC pramipexole er ropinirole hcl ropinirole hcl er
NON PREFERRED APOKYN
Peripheral COMT InhibitorsGENERIC entacapone
ANTIPSYCHOTICS/ANTIMANIC AGENTS
Antimanic AgentsGENERIC lithium carbonate lithium carbonate er
Antipsychotics - Misc.GENERIC ziprasidone hcl
PREFERRED LATUDA
BenzisoxazolesGENERIC risperidone
PREFERRED RISPERDAL CONSTA
NON PREFERRED RISPERDAL RISPERDAL M-TAB DISINTEGRATING
ButyrophenonesGENERIC haloperidol haloperidol decanoate haloperidol lactate
NON PREFERRED HALDOL
DibenzodiazepinesGENERIC clozapine clozapine odt
NON PREFERRED CLOZAPINE ODT
DibenzothiazepinesGENERIC quetiapine fumarate quetiapine fumarate er
DibenzoxazepinesGENERIC loxapine succinate
PhenothiazinesGENERIC chlorpromazine fluphenazine decanoate fluphenazine hcl perphenazine prochlorperazine edisylate prochlorperazine maleate thioridazine hcl trifluoperazine hcl
PREFERRED FLUPHENAZINE DECANOATE 2.5%
NON PREFERRED FLUPHENAZINE DECANOATE 1GM LIQUID PERPHENAZINE
Quinolinone DerivativesGENERIC aripiprazole odt aripiprazole tablets
PREFERRED ABILIFY MAINTENA, ER ARISTADA
ThienbenzodiazepinesGENERIC olanzapine olanzapine odt
ThioxanthenesGENERIC thiothixene
Updated January 1, 2019 Page
Antiretrovirals - CD4-Directed Post-Attachment Inhibitor
Antiretrovirals - CD4-Directed Post-Attachment Inhibitor
NON PREFERRED TROGARZO
ANTISEPTICS & DISINFECTANTS
Chlorine AntisepticsGENERIC chlorhexidine gluconate
NON PREFERRED CHLORHEXIDINE GLUCONATE
ANTIVIRALS
Antiretroviral CombinationsGENERIC abacavir sulfate/lamivudine abacavir/lamivudine/zidovudine lamivudine/zidovudine lopinavir-ritonavir oral soln
PREFERRED ATRIPLA KALETRA TABLETS TRUVADA
NON PREFERRED BIKTARVY COMPLERA DESCOVY EPZICOM GENVOYA KALETRA ORAL SOLN ODEFSEY STRIBILD SYMFI SYMFI LO TRIUMEQ
Antiretrovirals - CCR5 Antagonists (Entry Inhibitor)NON PREFERRED SELZENTRY
Antiretrovirals - Fusion InhibitorsNON PREFERRED FUZEON
Antiretrovirals - Integrase InhibitorsNON PREFERRED ISENTRESS ISENTRESS HD TIVICAY
Antiretrovirals - Protease InhibitorsGENERIC atazanavir sulfate capsule fosamprenavir calcium ritonavir
PREFERRED APTIVUS CRIXIVAN INVIRASE LEXIVA ORAL SUSP NORVIR CAPSULE, ORAL SOLN & PACKET NORVIR TABLET VIRACEPT
NON PREFERRED APTIVUS SOLN LEXIVA TABLETS PREZISTA REYATAZ CAPSULE
Antiretrovirals - RTI-Non-Nucleoside AnaloguesGENERIC efavirenz
PREFERRED RESCRIPTOR SUSTIVA
NON PREFERRED EDURANT INTELENCE RETROVIR VIAL VIRAMUNE
Antiretrovirals - RTI-Nucleoside Analogues-PurinesGENERIC abacavir didanosine
PREFERRED VIDEX SOLN
NON PREFERRED VIDEX ZIAGEN
Antiretrovirals - RTI-Nucleoside Analogues-PyrimidinesGENERIC lamivudine hbv
PREFERRED EMTRIVA
NON PREFERRED LAMIVUDINE
Antiretrovirals - RTI-Nucleoside Analogues-ThymidinesGENERIC stavudine zidovudine
Updated January 1, 2019 Page
NON PREFERRED RETROVIR
Antiretrovirals - RTI-Nucleotide AnaloguesGENERIC tenofovir disoproxil 300mg tablet
PREFERRED VIREAD TABLET 150MG; 200MG; 250MG
NON PREFERRED VIREAD 300MG TABLET
CMV AgentsGENERIC cidofovir valganciclovir hcl
NON PREFERRED CIDOFOVIR GANCICLOVIR PREVYMIS VALCYTE
Hepatitis B AgentsGENERIC adefovir dipivoxil entecavir
PREFERRED VEMLIDY
NON PREFERRED TYZEKA
Hepatitis C AgentsPREFERRED PEGASYS PEGASYS PROCLICK VICTRELIS
NON PREFERRED DAKLINZA RIBAVIRIN SOVALDI
Herpes Agents - Purine AnaloguesGENERIC acyclovir valacyclovir
Herpes Agents - Thymidine AnaloguesGENERIC famciclovir foscarnet sodium
Influenza AgentsGENERIC rimantadine hcl
Neuraminidase InhibitorsGENERIC oseltamivir phosphate
PREFERRED RELENZA
NON PREFERRED RAPIVAB TAMIFLU
ASSORTED CLASSES
AntileproticsPREFERRED THALOMID
B-Lymphocyte Stimulator (BLyS)-Specific InhibitorsNON PREFERRED BENLYSTA
Chelating AgentsPREFERRED CUPRIMINE DEPEN
Cyclosporine AnalogsGENERIC cyclosporine
PREFERRED SANDIMMUNE SOLUTION 100MG/ML SOLUTION
NON PREFERRED SANDIMMUNE SOLUTION
EnzymesNON PREFERRED XIAFLEX
Immune Globulin ImmunosuppressantsNON PREFERRED ATGAM THYMOGLOBULIN
Inosine Monophosphate Dehydrogenase InhibitorsGENERIC mycophenolate acid del rel mycophenolic acid del rel
PREFERRED CELLCEPT 500MG VIAL
NON PREFERRED CELLCEPT ORAL SUSP MYCOPHENOLATE MOFETIL
Updated January 1, 2019 Page
Irrigation SolutionsGENERIC water water intravenous solution water solution; irrigation
PREFERRED WATER
Macrolide ImmunosuppressantsGENERIC sirolimus tacrolimus
PREFERRED RAPAMUNE SOLUTION
NON PREFERRED PROGRAF 5MG/ML AMPUL PROGRAF CAPSULES RAPAMUNE ZORTRESS
Monoclonal AntibodiesPREFERRED BEXXAR 14MG/ML SIMULECT
NON PREFERRED BEXXAR
Peritonial Dialysis SolutionsGENERIC delflex w/dextrose
PREFERRED EXTRANEAL ICODEXTRIN DIALYSIS
NON PREFERRED DELFLEX W/DEXTROSE
Potassium Removing ResinsGENERIC sodium polystyrene sulfonate
PREFERRED VELTASSA
ProstaglandinsGENERIC alprostadil
Purine AnalogsGENERIC azathioprine azathioprine sodium
NON PREFERRED AZASAN
Sclerosing AgentsPREFERRED ETHAMOLIN SOTRADECOL
Selective T-Cell Costimulation BlockersPREFERRED NULOJIX
BETA BLOCKERS
Alpha-Beta BlockersGENERIC carvedilol er labetalol hcl
NON PREFERRED COREG CR
Beta Blockers Cardio-SelectiveGENERIC acebutolol hcl atenolol betaxolol hcl bisoprolol fumarate metoprolol succinate er metoprolol tartrate
PREFERRED BYSTOLIC
NON PREFERRED SECTRAL TENORMIN
Beta Blockers Non-SelectiveGENERIC nadolol pindolol propranolol hcl propranolol hcl er sotalol timolol maleate
PREFERRED SOTALOL HCL SOTYLIZE
NON PREFERRED BETAPACE BETAPACE AF
Bile Acid Synthesis Disorder Agents
Bile Acid Synthesis Disorder AgentsNON PREFERRED CHOLBAM
Updated January 1, 2019 Page
BIOLOGICALS MISC
Allergenic ExtractsPREFERRED GRASTEK RAGWITEK
Biologicals MiscNON PREFERRED ADAGEN
Calcitonin Gene-Related Peptide (CGRP) Receptor Antag
Calcitonin Gene-Related Peptide (CGRP) Receptor Antag
PREFERRED AIMOVIG
CALCIUM CHANNEL BLOCKERS
Calcium Channel BlockersGENERIC amlodipine besylate diltiazem diltiazem 24hr cd diltiazem er diltiazem er 24 hour diltiazem hcl felodipine er isradipine nicardipine hcl nimodipine verapamil er verapamil er pm verapamil hcl
NON PREFERRED CLEVIPREX
CARDIOTONICS
Cardiac GlycosidesGENERIC digoxin
PREFERRED LANOXIN PEDIATRIC
NON PREFERRED LANOXIN
Phosphodiesterase InhibitorsGENERIC milrinone in 5% dextrose milrinone lactate
CARDIOVASCULAR AGENTS - MISC.
Calcium Channel Blocker & HMG CoA Reductase Inhibit Comb
GENERIC amlodipine-atorvastatin
Peripheral VasodilatorsGENERIC isoxsuprine hcl papaverine hcl papaverine hcl er
Prostaglandin - Impotence AgentsPREFERRED CAVERJECT MUSE
Prostaglandin VasodilatorsGENERIC epoprostenol
NON PREFERRED FLOLAN REMODULIN TYVASO VENTAVIS
Pulm Hyperten-Soluble Guanylate Cyclase Stimulator (sGC)
PREFERRED ADEMPAS
Pulmonary Hypertension - Endothelin Receptor Antagonists
PREFERRED LETAIRIS OPSUMIT TRACLEER
Pulmonary Hypertension - Phosphodiesterase Inhibitors
GENERIC tadalafil
NON PREFERRED ADCIRCA REVATIO SILDENAFIL CITRATE
Selective cGMP Phosphodiesterase Type 5 InhibitorsGENERIC sildenafil citrate tablet
PREFERRED CIALIS
NON PREFERRED VIAGRA
Updated January 1, 2019 Page
Vasoactive Natriuretic PeptidesPREFERRED NATRECOR
Cardiovascular, Hypertension & Lipids
ANTICOAGULANTSPREFERRED REFLUDAN
MISC. CARDIOVASCULAR AGENTSPREFERRED RETAVASE
MISC. COAGULATION AGENTSNON PREFERRED ATRYN HELIXATE FS
Cephalosporin Combinations
Cephalosporin CombinationsPREFERRED AVYCAZ ZERBAXA
CEPHALOSPORINS
Cephalosporins - 1st GenerationGENERIC cefazolin cephalexin
NON PREFERRED CEFAZOLIN/DEXTROSE KEFLEX
Cephalosporins - 2nd GenerationGENERIC cefaclor cefoxitin cefoxitin/dextrose cefprozil cefuroxime axetil cefuroxime sodium
PREFERRED CEFUROXIME 75G BULK BAG
Cephalosporins - 3rd GenerationGENERIC cefdinir cefotetan cefpodoxime proxetil ceftazidime ceftibuten ceftriaxone
PREFERRED CEFTAZIDIME IV PIGGYBACK FORTAZ IN ISO-OSMOTIC DEXTROSE
NON PREFERRED CEFTRIAXONE 100G BULK BAG
Cephalosporins - 4th GenerationGENERIC cefepime cefotaxime
NON PREFERRED CEFEPIME/DEXTROSE
Cephalosporins - 5th GenerationPREFERRED TEFLARO
CONTRACEPTIVES
Biphasic Contraceptives - OralGENERIC kariva
Combination Contraceptives - OralGENERIC altavera alyacen apri aubra aviane azurette balziva briellyn caziant chateal cryselle cyclafem dasetta drospirenone/eth estra/levomef elinest emoquette enpresse enskyce estarylla falmina gianvi gildagia gildess gildess fe junel junel fe kelnor 1-35 kurvelo leena lessina levora loryna low-ogestrel lutera marlissa microgestin microgestin fe
Updated January 1, 2019 Page
mono-linyah mononessa myzilra necon norethindrone/eth estradiol/iron norethindrone/ethinyl estradiol norethin-eth estra ferrous fum nortrel ocella ogestrel orsythia philith pirmella portia reclipsen sprintec sronyx syeda vestura viorele wera wymzya fe zarah zenchent zenchent fe zeosa zovia
PREFERRED LO LOESTRIN FE MINASTRIN 24 FE TAYTULLA
NON PREFERRED BEYAZ SAFYRAL
Combination Contraceptives - VaginalPREFERRED NUVARING
Emergency ContraceptivesGENERIC levonorgestrel
Extended-Cycle Contraceptives - OralGENERIC amethia amethia lo camrese camrese lo daysee introvale jolessa quasense
Four Phase Contraceptives - OralPREFERRED NATAZIA
Progestin Contraceptives - ImplantsPREFERRED NEXPLANON
Progestin Contraceptives - InjectableNON PREFERRED DEPO-PROVERA
Progestin Contraceptives - IUDPREFERRED KYLEENA MIRENA SKYLA
Progestin Contraceptives - OralGENERIC errin heather jencycla jolivette lyza nora-be norethindrone acetate
Triphasic Contraceptives - OralGENERIC aranelle tilia fe tri-estarylla tri-legest fe tri-linyah trinessa trivora velivet
CORTICOSTEROIDS
GlucocorticosteroidsGENERIC a-hydrocort budesonide budesonide budesonide ec budesonide er cortisone acetate dexamethasone dexamethasone sodium phosphate fludrocortisone acetate methylprednisolone methylprednisolone acetate methylprednisolone sod succ prednisolone prednisolone sodium phosphate prednisone veripred 20
PREFERRED ARISTOSPAN BETAMETHASONE BETAMETHASONE ACETATE BETAMETHASONE SODIUM PHOSPHATE
NON PREFERRED DEPO-MEDROL KENALOG MEDROL SOLU-CORTEF SOLU-MEDROL VIAL
Updated January 1, 2019 Page
UCERIS ER
COUGH/COLD/ALLERGY
Antitussive - NonnarcoticGENERIC benzonatate
Antitussive - OpioidGENERIC hydrocodone/homatropine
DecongestantGENERIC pseudoephedrine hcl er
NON PREFERRED PSEUDOEPHEDRINE SULFATE ER
Decongestant-AntihistamineGENERIC brompheniramine/pseudoephedrine phenylephrine/chlorpheniramine 10peh-4cpm
Decongestant-Antihistamine w/ ExpectorantNON PREFERRED PSEUDOEPH/CHLOPHEDIANOL/GG 12.5CPD-100GFN-30PSE
MucolyticsGENERIC acetylcysteine
Non-Narc Antitussive-AntihistamineGENERIC promethazine/dextromethorphan
Non-Narc Antitussive-Decongestant-AntihistamineGENERIC chlorphen/pse/dm tannate d-chlorphenira/pse/chlophedian 12.5cpd-1dcpm-30pse dm/phenyleph/chlorpheniramine 10peh-4cpm-20dm
Opioid Antitussive-AntihistamineGENERIC hydrocodone/chlorpheniramine er promethazine w/codeine
NON PREFERRED TUSSICAPS
Opioid Antitussive-Decongestant-AntihistamineGENERIC dihydrocodeine/bpm/pe promethazine vc/codeine
Opioid Antitussive-ExpectorantGENERIC guaifenesin/codeine
NON PREFERRED GUAIFENESIN/CODEINE
Cyclin-Dependent Kinases (CDK) Inhibitors
Cyclin-Dependent Kinases (CDK) InhibitorsNON PREFERRED VERZENIO
DERMATOLOGICALS
Acne AntibioticsGENERIC clindamycin phosphate topical erythromycin solution sulfacetamide sodium sulfacetamide sodium
NON PREFERRED ACZONE SULFACETAMIDE SODIUM
Acne CombinationsGENERIC erythromycin-benzoyl peroxide sodium sulfacetamide/sulfur
PREFERRED EPIDUO FORTE ONEXTON
NON PREFERRED EPIDUO SODIUM SULFACETAMIDE/SULFUR GEL ZIANA
Acne ProductsGENERIC adapalene cream, gel adapalene-benzoyl peroxide gel benprox benzoyl peroxide clindamycin phos-tretinoin clindamycin/benzoyl peroxide tretinoin tretinoin microsphere
PREFERRED ABSORICA DIFFERIN
NON PREFERRED ADAPALENE LOTION ISOTRETINOIN TRETINOIN TRETIN-X
Antibiotics - TopicalGENERIC mupirocin
Updated January 1, 2019 Page
Antifungals - TopicalGENERIC ciclopirox clotrimazole
NON PREFERRED LOPROX GEL & SHAMPOO PENLAC
Antifungals - Topical CombinationsGENERIC clotrimazole/betamethasone nystatin w/triamcinolone
Anti-inflammatory Agents - TopicalPREFERRED FLECTOR
Antineoplastic Alkylating Agents - TopicalPREFERRED VALCHLOR
Antineoplastic Antimetabolites - TopicalGENERIC fluorouracil
PREFERRED CARAC
NON PREFERRED FLUOROURACIL 0.5% CREAM
Antineoplastic or Premalignant Lesions - Topical Misc.PREFERRED PICATO
ANTIPERSPIRANTSGENERIC aluminum chloride topical
AntipsoriaticsGENERIC calcipotriene calcitriol
PREFERRED ANTHRALIN TAZORAC GEL
NON PREFERRED CALCITRIOL TAZORAC CREAM
Antipsoriatics - SystemicGENERIC acitretin
PREFERRED STELARA
NON PREFERRED COSENTYX TREMFYA
Antiseborrheic ProductsGENERIC selenium sulfide
Antivirals - TopicalGENERIC acyclovir 5% oint
PREFERRED ZOVIRAX 5% CREAM
NON PREFERRED ZOVIRAX 5% OINT
Burn ProductsGENERIC mafenide acetate silver sulfadiazine
PREFERRED SULFAMYLON CREAM
NON PREFERRED SILVADENE SULFAMYLON PACKET
Corticosteroids - TopicalGENERIC alclometasone dipropionate amcinonide betamethasone dipropionate augment betamethasone valerate betamethasone valerate foam clobetasol e clobetasol propionate desonide desoximetasone diflorasone diacetate cream diflorasone diacetate oint fluocinolone acetonide fluocinonide fluticasone propionate halobetasol propionate hydrocortisone hydrocortisone hydrocortisone acetate hydrocortisone butyrate hydrocortisone butyrate/emoll hydrocortisone valerate mometasone furoate
NON PREFERRED DESONATE DESOWEN DIPROLENE AF CREAM DIPROLENE LOTION DIPROLENE OINT FLUTICASONE PROPIONATE 50MCG SPRAY LUXIQ PSORCON CREAM
Updated January 1, 2019 Page
VERDESO
Depigmenting AgentsGENERIC alphaquin hp hydroquinone cream hydroquinone er cream lustra-ultra
Emollient/Keratolytic AgentsGENERIC urea
EmollientsGENERIC ammonium lactate hpr hpr plus lactic acid
PREFERRED AMMONIUM LACTATE
Enzymes - TopicalPREFERRED SANTYL
Imidazole-Related Antifungals - TopicalGENERIC econazole nitrate
Immunomodulators Imidazoquinolinamines - TopicalGENERIC imiquimod
Keratolytic/Antimitotic AgentsGENERIC podofilox salicylic acid
PREFERRED SALICYLIC ACID
NON PREFERRED CONDYLOX GEL/SOLUTION
Local Anesthetics - TopicalGENERIC cocaine hcl lidocaine lidocaine hcl
PREFERRED COCAINE HCL
NON PREFERRED LIDOCAINE LIDOCAINE HCL
Macrolide Immunosuppressants - TopicalPREFERRED ELIDEL
Misc. Dermatological ProductsGENERIC dexpanthenol eletone emulsion sb mb hydrogel nuquin hp pruclair prumyx tl-cermide
PREFERRED CHLORHEXIDINE GLUCONATE 0.2 SOLUTION DEXPANTHENOL DUPIXENT ETHYL ALCOHOL LACTIC ACID 88 TO 92 % UREAM POWDER, BEADS
NON PREFERRED ETHYL ALCOHOL 1 LIQUID
Pigmenting AgentsPREFERRED OXSORALEN 1% LOTION
Rosacea AgentsPREFERRED FINACEA MIRVASO ORACEA SOOLANTRA
Scabicides & PediculicidesGENERIC lindane malathion permethrin spinosad
PREFERRED PERMETHRIN
NON PREFERRED ELIMITE
Topical Anesthetic CombinationsGENERIC lidocaine/prilocaine
Topical Anesthetic GassesGENERIC ethyl chloride
Topical Selective Retinoid X Receptor AgonistsPREFERRED TARGRETIN GEL
Updated January 1, 2019 Page
Topical Steroid CombinationsPREFERRED ENSTILAR TACLONEX SUSPENSION
NON PREFERRED TACLONEX OINTMENT
Wound Care - Growth Factor AgentsPREFERRED REGRANEX
Wound DressingsGENERIC avo cream prutect sonafine
DIAGNOSTIC PRODUCTS
Diagnostic BiologicalsGENERIC candin
PREFERRED APLISOL TUBERSOL
Diagnostic DrugsGENERIC cosyntropin
PREFERRED KINEVAC LEXISCAN
NON PREFERRED ACTHREL COSYNTROPIN THYROGEN
Diagnostic Radiopharmaceuticals - CardiacNON PREFERRED THALLOUS CHLORIDE TL-201
Miscellaneous Contrast MediaPREFERRED EOVIST
NON PREFERRED MAGNEVIST PROHANCE
Radiographic Contrast Media - IodinatedGENERIC md-gastroview
PREFERRED OMNIPAQUE
NON PREFERRED ISOVUE ISOVUE-M VISIPAQUE
DIAGNOSTICS & MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONSGENERIC neomycin-polymyxin b
MISCELLANEOUS AGENTSPREFERRED BROMHEXINE HYDROCHLORIDE SEROTONIN HCL TRYPSIN
NON PREFERRED KALEXATE PROSTAMEN
NEUTRACEUTICALSPREFERRED UVA URSI LEAF FLUID EXTRACT
DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS
Dietary Management Product CombinationsGENERIC folbee folbic folic acid folic acid/cyancobal/pyridoxine foltanx l-mefolate-pyridox-mecobalamin l-methyl-b6-b12 l-methylfolate-mecobalamin-nac metafolbic metafolbic plus methyl-b6-b12 virt-vite forte
NON PREFERRED FOLBIC RF FOLIC ACID-VIT B12 METHYLFOLATE MECOBALAMIN-NAC 6-600-2MG
Dietary Management ProductsGENERIC l-methylfolate calcium
DIGESTIVE AIDS
Digestive EnzymesGENERIC pancrelipase
Updated January 1, 2019 Page
PREFERRED CREON SUCRAID VIOKACE ZENPEP DEL-REL
NON PREFERRED PANCREAZE
DIURETICS
Carbonic Anhydrase InhibitorsGENERIC acetazolamide acetazolamide er methazolamide
NON PREFERRED DIAMOX SEQUELS
Diuretic CombinationsGENERIC amiloride hcl w/hctz spironolactone/hctz
Loop DiureticsGENERIC bumetanide ethacrynate sodium furosemide torsemide
NON PREFERRED EDECRIN TABLET EDECRIN VIAL FUROSEMIDE 40MG/4ML SOLUTION TORSEMIDE
Osmotic DiureticsGENERIC mannitol
Potassium Sparing DiureticsGENERIC amiloride hcl metolazone spironolactone
Thiazides and Thiazide-Like DiureticsGENERIC chlorothiazide chlorothiazide sodium chlorthalidone hydrochlorothiazide indapamide methyclothiazide
ENDOCRINE AND METABOLIC AGENTS - MISC.
BisphosphonatesGENERIC alendronate sodium etidronate disodium ibandronate risedronate dr risedronate sodium
PREFERRED ZOMETA INFUSION BOTTLE
NON PREFERRED ACTONEL BONIVA FOSAMAX HECTOROL IBANDRONATE SODIUM PAMIDRONATE DISODIUM ZOLEDRONIC ACID ZOMETA VIAL
Calcimimetic AgentsPREFERRED SENSIPAR
CalcitoninsGENERIC calcitonin salmon nasal
PREFERRED MIACALCIN VIAL
NON PREFERRED MIACALCIN AEROSOL
Carnitine Replenisher - AgentsGENERIC levocarnitine
Dopamine Receptor AgonistsGENERIC cabergoline
Fabry Disease - AgentsNON PREFERRED FABRAZYME
GAA Deficiency Treatment - AgentsNON PREFERRED LUMIZYME
Growth Hormone Receptor AntagonistsNON PREFERRED SOMAVERT
Growth Hormone Releasing Hormones (GHRH)PREFERRED GENOTROPIN NORDITROPIN
Updated January 1, 2019 Page
NON PREFERRED EGRIFTA HUMATROPE OMNITROPE
Growth HormonesNON PREFERRED SEROSTIM
Hereditary Orotic Aciduria Treatment - AgentsPREFERRED XURIDEN
Hereditary Tyrosinemia Type 1 (HT-1) Treatment - Agents
NON PREFERRED NITYR ORFADIN
Homocystinuria Treatment - AgentsPREFERRED CYSTADANE
Hyperammonemia Treatment - AgentsNON PREFERRED CARBAGLU
Hyperparathyroid Treatment - Vitamin D AnalogsGENERIC doxercalciferol paricalcitol
NON PREFERRED ZEMPLAR
Hypophosphatasia (HPP) AgentsNON PREFERRED STRENSIQ
Insulin-Like Growth Factors (Somatomedins)NON PREFERRED INCRELEX
LHRH/GnRH Agonist Analog Pituitary SuppressantsPREFERRED LUPRON DEPOT-PED SYNAREL
Lysosomal Acid Lipase (LAL) Deficiency - AgentsNON PREFERRED KANUMA
Lysosomal Storage Disease Treatment - AgentsPREFERRED MYOZYME
Mucopolysaccharidosis I (MPS I) - AgentsNON PREFERRED ALDURAZYME
Mucopolysaccharidosis II (MPS II) - AgentsNON PREFERRED ELAPRASE
Mucopolysaccharidosis VI (MPS VI) - AgentsNON PREFERRED NAGLAZYME
Ovulation Stimulants-GonadotropinsPREFERRED FOLLISTIM AQ NOVAREL 5000 UNIT
NON PREFERRED BRAVELLE CHORIONIC GONADOTROPIN GONAL-F GONAL-F RFF GONAL-F RFF REDI-JECT MENOPUR NOVAREL 10000 UNIT PREGNYL
Ovulation Stimulants-SyntheticGENERIC clomiphene citrate
Parathyroid Hormone And DerivativesPREFERRED FORTEO
NON PREFERRED NATPARA TYMLOS
Phenylketonuria Treatment - AgentsNON PREFERRED KUVAN
RANK Ligand (RANKL) InhibitorsNON PREFERRED XGEVA
Selective Estrogen Receptor Modulators (SERMs)NON PREFERRED OSPHENA
Selective Vasopressin V2-Receptor AntagonistsNON PREFERRED SAMSCA
Somatostatic AgentsPREFERRED SANDOSTATIN KIT SIGNIFOR
Updated January 1, 2019 Page
NON PREFERRED OCTREOTIDE ACETATE SANDOSTATIN SANDOSTATIN LAR DEPOT SOMATULINE DEPOT
Urea Cycle Disorder - AgentsGENERIC sodium phenylbutyrate
PREFERRED AMMONUL
NON PREFERRED BUPHENYL RAVICTI
VasopressinGENERIC desmopressin acetate vasopressin vasopressin-ns
NON PREFERRED STIMATE SPRAY
ENDOCRINE/DIABETES
INSULIN SYRINGES/MISCELLANEOUS DMEPREFERRED SOLOSITE SURE-T PARADIGM VGO 20 VGO 30 VGO 40
ESTROGENS
Estrogen & AndrogenGENERIC estrogen/methyltestosterone
Estrogen & ProgestinGENERIC estradiol/norethindrone acetate
PREFERRED COMBIPATCH PREMPHASE PREMPRO
EstrogensGENERIC estradiol patch estradiol tablet/cream estradiol valerate estropipate yuvafem
PREFERRED DEPO-ESTRADIOL DIVIGEL MINIVELLE PREMARIN
NON PREFERRED ENJUVIA ESTRACE TABLET
Estrogen-Selective Estrogen Receptor Modulator Comb
Estrogen-Selective Estrogen Receptor Modulator CombPREFERRED DUAVEE
Fentanyl Combinations
Fentanyl CombinationsGENERIC fentanyl
NON PREFERRED FENTANYL
FLUOROQUINOLONES
FluoroquinolonesGENERIC ciprofloxacin ciprofloxacin er ciprofloxacin suspension ciprofloxacin/dextrose moxifloxacin hcl
PREFERRED MOXIFLOXACIN HCL IV PIGGYBACK
NON PREFERRED AVELOX IV LEVOFLOXACIN HEMIHYDRATE SOLUTION
GASTROENTEROLOGY
ANTIVERTIGO & ANTIEMETIC AGENTSGENERIC dronabinol droperidol meclizine hcl
MISC. GASTROINTESTINAL AGENTSGENERIC citra ph sodium bicarbonate
PREFERRED GLUTAMENT GLUTASOLVE
Updated January 1, 2019 Page
NON PREFERRED SODIUM CHLORIDE/SODIUM BICARB
GASTROINTESTINAL AGENTS - MISC.
Farnesoid X Receptor (FXR) AgonistsNON PREFERRED OCALIVA
Gallstone Solubilizing AgentsGENERIC ursodiol
NON PREFERRED ACTIGALL CHENODAL URSO URSO FORTE
Gastrointestinal Chloride Channel ActivatorsPREFERRED AMITIZA
Gastrointestinal StimulantsGENERIC metoclopramide hcl
IBS Agent - Guanylate Cyclase-C (GC-C) AgonistsPREFERRED LINZESS
IBS Agent - Mu-Opioid Receptor AgonistsPREFERRED VIBERZI
IBS Agent - Selective 5-HT3 Receptor AntagonistsNON PREFERRED LOTRONEX
Inflammatory Bowel AgentsGENERIC balsalazide disodium mesalamine sulfasalazine sulfasalazine dr
PREFERRED CANASA DELZICOL PENTASA
NON PREFERRED ASACOL HD LIALDA
Peripheral Opioid Receptor AntagonistsPREFERRED MOVANTIK RELISTOR
Phosphate Binder AgentsGENERIC eliphos lanthanum carbonate sevelamer carbonate
PREFERRED PHOSLYRA VELPHORO
NON PREFERRED FOSRENOL CHEW TABLET RENVELA
Tumor Necrosis Factor Alpha BlockersNON PREFERRED REMICADE RENFLEXIS
GENERAL ANESTHETICS
Anesthetics - Misc.GENERIC etomidate ketamine hcl midodrine hcl propofol
NON PREFERRED KETAMINE HCL 50MG/ML SYRINGE
Barbiturate AnestheticsPREFERRED BREVITAL
GENITOURINARY AGENTS - MISCELLANEOUS
5-Alpha Reductase InhibitorsGENERIC finasteride
NON PREFERRED PROSCAR
Alpha 1-Adrenoceptor AntagonistsGENERIC alfuzosin hcl er tamsulosin hcl er 24 hr
PREFERRED RAPAFLO
NON PREFERRED FLOMAX
Updated January 1, 2019 Page
CitratesGENERIC potassium citrate er tricitrates
Cystinosis AgentsPREFERRED CYSTAGON
Genitourinary IrrigantsGENERIC acetic acid irrigation glycine
PREFERRED AMINOACETIC ACID RENACIDIN RESECTISOL
Interstitial Cystitis AgentsPREFERRED ELMIRON
PhosphatesGENERIC k-phos neutral
PREFERRED K-PHOS ORIGINAL
Urinary AnalgesicsGENERIC phenazopyridine hcl phenazopyridine plus
GOUT AGENTS
Gout AgentsGENERIC allopurinol allopurinol sodium
PREFERRED COLCRYS ULORIC
NON PREFERRED COLCHICINE KRYSTEXXA MITIGARE
UricosuricsGENERIC probenecid
HEMATOLOGICAL AGENTS - MISC.
Antihemophilic ProductsPREFERRED ADVATE H ADVATE L ADVATE N ADVATE SH ADVATE UH BEBULIN VH IMMUNO CORIFACT OBIZUR TRETTEN XYNTHA
NON PREFERRED ADVATE ADYNOVATE AFSTYLA ALPHANATE ALPHANINE SD ALPROLIX BEBULIN BENEFIX COAGADEX ELOCTATE FEIBA NF HEMOFIL HUMATE-P IXINITY KOATE-DVI KOGENATE FS KOVALTRY MONOCLATE-P MONONINE NOVOEIGHT NOVOSEVEN RT NUWIQ PROFILNINE PROFILNINE SD RECOMBINATE RIASTAP VONVENDI WILATE XYNTHA SOLOFUSE
Bradykinin B2 Receptor AntagonistsNON PREFERRED FIRAZYR
C1 InhibitorsNON PREFERRED BERINERT CINRYZE
Complement InhibitorsNON PREFERRED SOLIRIS
Cyclopentyltriazolopyrimidine (CPTP) DerivativesPREFERRED BRILINTA
Updated January 1, 2019 Page
Glycoprotein IIb/IIIa Receptor InhibitorsGENERIC eptifibatide
PREFERRED REOPRO
NON PREFERRED AGGRASTAT INTEGRILIN
Hematorheologic AgentsGENERIC pentoxifylline
HeminPREFERRED PANHEMATIN
Human Protein CNON PREFERRED CEPROTIN
Phosphodiesterase III InhibitorsGENERIC cilostazol
Plasma ExpandersGENERIC hetastarch w/sodium chloride
PREFERRED HEXTEND LACTATED ELECTROLYTE
Plasma Kallikrein InhibitorsNON PREFERRED KALBITOR
Plasma ProteinsGENERIC albumin
NON PREFERRED THROMBATE III
Platelet Aggregation Inhibitor CombinationsGENERIC aspirin / dipyridamole er
Platelet Aggregation InhibitorsGENERIC dipyridamole
ProtamineGENERIC protamine sulfate
Quinazoline AgentsGENERIC anagrelide hydrochloride
Thienopyridine DerivativesGENERIC clopidogrel prasugrel hcl
NON PREFERRED EFFIENT
Tissue Plasminogen ActivatorsPREFERRED CATHFLO ACTIVASE
NON PREFERRED ACTIVASE
HEMATOPOIETIC AGENTS
Agents for Gaucher DiseaseNON PREFERRED CERDELGA CEREZYME ELELYSO VPRIV ZAVESCA
CobalaminsGENERIC hydroxocobalamin
PREFERRED NASCOBAL
CXCR4 Receptor AntagonistPREFERRED MOZOBIL
Cytotoxic AgentsPREFERRED DROXIA
Erythropoiesis-Stimulating Agents (ESAs)PREFERRED PROCRIT
NON PREFERRED ARANESP
Folic Acid/FolatesNON PREFERRED FOLIC ACID 20MG CAP
Granulocyte Colony-Stimulating Factors (G-CSF)PREFERRED GRANIX NEULASTA
Updated January 1, 2019 Page
NEUPOGEN
NON PREFERRED ZARXIO
Granulocyte/Macrophage Colony-Stimulating Factor(GM-CSF)
NON PREFERRED LEUKINE
IronGENERIC dexferrum
PREFERRED VENOFER
NON PREFERRED INFED
Iron CombinationsGENERIC centratex fe 90 plus fe c ferocon ferotrinsic ferraplus 90 ferrex 150 forte ferrex 150 forte plus ferrex 28 ferrocite plus ferrogels forte tl-hem 150 er 24 hr
Iron w/ Folic AcidGENERIC therapeutic hematinic vp-heme one
Thrombopoietin (TPO) Receptor AgonistsNON PREFERRED NPLATE PROMACTA
HEMOSTATICS
Hemostatics - SystemicGENERIC tranexamic acid
PREFERRED AMICAR
NON PREFERRED CYKLOKAPRON LYSTEDA
Hepatitis C Agent - Combinations
Hepatitis C Agent - CombinationsNON PREFERRED EPCLUSA MAVYRET TECHNIVIE VIEKIRA PAK VIEKIRA XR VOSEVI ZEPATIER
HYPNOTICS
Barbiturate HypnoticsGENERIC phenobarbital phenobarbital sodium seconal sodium
PREFERRED AMYTAL NEMBUTAL SODIUM
Benzodiazepine HypnoticsGENERIC flurazepam hcl midazolam hcl temazepam triazolam
NON PREFERRED MIDAZOLAM HCL
Non-Benzodiazepine - GABA-Receptor ModulatorsGENERIC zaleplon zolpidem tartrate zolpidem tartrate er
NON PREFERRED AMBIEN AMBIEN CR SONATA
Selective Melatonin Receptor AgonistsPREFERRED ROZEREM
IMMUNOLOGY, VACCINES & BIOTECHNOLOGY
VACCINES & MISCELLANEOUS IMMUNOLOGICALSPREFERRED CERVARIX COMVAX CROFAB
NON PREFERRED BOTOX
Updated January 1, 2019 Page
Implanon IMPLANT 68 MG Subcutaneous
CONTRACEPTIVESPREFERRED IMPLANON
Integrin Receptor Antagonists
Integrin Receptor AntagonistsNON PREFERRED ENTYVIO
Interleukin-6 (IL-6) Antagonists
Interleukin-6 (IL-6) AntagonistsNON PREFERRED SYLVANT
LAXATIVES
Bowel Evacuant CombinationsGENERIC peg 3350-electrolyte polyethylene glycol
PREFERRED CLENPIQ POLYETHYLENE GLYCOL PREPOPIK SUCLEAR SUPREP
NON PREFERRED POLYETHYLENE GLYCOL
Laxatives - MiscellaneousGENERIC lactulose
Leptin Analogues
Leptin AnaloguesNON PREFERRED MYALEPT
LOCAL ANESTHETICS-Parenteral
Local Anesthetic & SympathomimeticGENERIC bupivacaine/epinephrine lidocaine hcl w/epinephrine
NON PREFERRED BUPIVACAINE/EPINEPHRINE CARTRIDGE LIDOCAINE HCL W/EPINEPHRINE
Local Anesthetics - AmidesGENERIC bupivacaine hcl bupivacaine/dextrose ropivacaine sensorcaine 5mg/ml vial
PREFERRED BENZOCAINE
NON PREFERRED CARBOCAINE MEPIVACAINE HCL 30MG/ML CARTRIDGE NESACAINE SENSORCAINE 2.5MG/ML VIAL
Local Anesthetics - EstersGENERIC chloroprocaine
MACROLIDES
AzithromycinGENERIC azithromycin
NON PREFERRED ZITHROMAX
ClarithromycinGENERIC clarithromycin clarithromycin er
ErythromycinsGENERIC erythromycin erythromycin del rel erythromycin ethylsuccinate erythromycin stearate erythromycin/sulfisoxazole
PREFERRED ERYTHROCIN LACTOBIONATE
NON PREFERRED E.E.S.200MG/5ML ORAL RECON SUSP
MEDICAL DEVICES
Cervical CapsPREFERRED FEMCAP
DiaphragmsPREFERRED ORTHO-DIAPHRAGM
Updated January 1, 2019 Page
Glucose Monitoring Test SuppliesPREFERRED 1ST CHOICE LANCETS ACCU-CHEK FASTCLIX, MULTICLIX, SOFTCLIX LANCETS ACCU-CHEK SOFTCLIX LANCETS DEVICE DEXCOM G4 METER DEXCOM G4 SENSOR DEXCOM G4 TRANSMITTER DEXCOM G5 METER DEXCOM G5 TRANSMITTER FORA LANCING DEVICE FREESTYLE CONTROL SOLUTION FREESTYLE FREEDOM KIT FREESTYLE FREEDOM LITE FREESTYLE FREEDOM LITE METER FREESTYLE INSULINX FREESTYLE INSULINX GLUCOSE SYSTEM FREESTYLE INSULINX TEST STRIPS FREESTYLE LITE METER FREESTYLE LITE TEST STRIPS FREESTYLE TEST STRIPS MEDISENSE MEDISENSE GLUCOSE KETONE CONTR ONE TOUCH ULTRA 2 ONE TOUCH ULTRA TEST STRIPS ONE TOUCH VERIO ONE TOUCH VERIO FLEX ONE TOUCH VERIO IQ ONE TOUCH VERIO SYNC PRECISION XTRA B-KETONE STRIPS PRECISION XTRA MONITOR PRECISION XTRA TEST STRIPS
NON PREFERRED OPTIUM EZ
Needles & SyringesPREFERRED MINIMED MINIMED RESERVOIR NOVOFINE NOVOFINE AUTOCOVER PARADIGM INFUSION PARADIGM INSULIN PUMP PARADIGM SILHOUETTE POLYFIN QR PRODIGY INSULIN SYRINGE PRODIGY PEN NEEDLE QUICK RELEASE SOFT TEFLON SILHOUETTE SNAP INSULIN PUMP CONTROLLER SOF-SET SOF-SET MICRO SOFT TOUCH
MIGRAINE PRODUCTS
Ergot CombinationsGENERIC ergotamine-caffeine
MIGRAINE PRODUCTSPREFERRED ISOMETHEPTENE MUCATE
Selective Serotonin Agonist-NSAID CombinationsNON PREFERRED TREXIMET
Selective Serotonin Agonists 5-HT(1)GENERIC eletriptan hbr naratriptan hcl rizatriptan rizatriptan disintegrating tablets sumatriptan succinate zolmitriptan zolmitriptan odt
PREFERRED ZOMIG SPRAY
NON PREFERRED RELPAX SUMAVEL DOSEPRO ZOLMITRIPTAN ZOMIG TABLET
MINERALS & ELECTROLYTES
BicarbonatesGENERIC sodium acetate sodium lactate
PREFERRED NEUT SODIUM LACTATE
CalciumGENERIC calcium acetate calcium chloride calcium gluconate
PREFERRED CALCIUM CHLORIDE CALCIUM GLUCONATE 61MG
NON PREFERRED CALCIUM ACETATE CALCIUM GLUCONATE 50MG
ChloridePREFERRED AMMONIUM CHLORIDE
CitrateGENERIC citric acid
Electrolytes & DextroseGENERIC dextrose in lactated ringers dextrose with sodium chloride potassium chloride/dextrose
Updated January 1, 2019 Page
PREFERRED IONOSOL B WITH DEXTROSE 5% ISOLYTE S
Electrolytes ParenteralGENERIC nutrilyte nutrilyte ii potassium chloride ringers ringers irrigation
PREFERRED NORMOSOL-M AND DEXTROSE NORMOSOL-R AND DEXTROSE NORMOSOL-R PH 7.4 PLASMA-LYTE 148 POTASSIUM CHLORIDE TPN ELECTROLYTES 18-18-5MEQ
NON PREFERRED TPN ELECTROLYTES 35-20-5MEQ
Iodine ProductsPREFERRED IODOPEN
MagnesiumGENERIC magnesium sulfate
PREFERRED MAGNESIUM SULFATE MAGNESIUM SULFATE IN DEXTROSE
NON PREFERRED MAGNESIUM SULFATE 100MG CAPSULE
ManganeseGENERIC manganese manganese sulfate
PhosphateGENERIC sodium phosphate 3mmol/ml vial
PREFERRED GLYCOPHOS SODIUM PHOSPHATE
PotassiumGENERIC pot chloride/dextrose/ns potassium acetate potassium bicarbonate potassium chl-normal saline
PREFERRED POTASSIUM ACETATE POTASSIUM BICARBONATE
Trace Mineral CombinationsPREFERRED MULTITRACE-4 MULTITRACE-5 PEDITRACE
Trace MineralsGENERIC chromium chloride copper chloride selenium
PREFERRED ADDAMEL N TRACE ELEMENTS
NON PREFERRED CUPRIC SULFATE SELENIUM
ZincGENERIC zinc chloride
PREFERRED ZINC CHLORIDE
Mixed Allergenic Extracts
Mixed Allergenic ExtractsPREFERRED ODACTRA
Monobactams
MonobactamsGENERIC aztreonam
PREFERRED AZACTAM-ISO-OSMOTIC DEXTROSE
MOUTH/THROAT/DENTAL AGENTS
Anti-infective Combinations - ThroatPREFERRED FIRST-BXN FIRST-MOUTHWASH BLM
Fluoride Dental ProductsGENERIC sodium fluoride
PREFERRED SODIUM FLUORIDE
Updated January 1, 2019 Page
Saliva StimulantsGENERIC cevimeline hcl
Tripeptidyl Peptidase 1 Deficiency Treatment - AgentsNON PREFERRED BRINEURA
Mucopolysaccharidosis IV (MPS IV) - Agents
Mucopolysaccharidosis IV (MPS IV) - AgentsNON PREFERRED VIMIZIM
Mucopolysaccharidosis VII (MPS VII) - Agents
Mucopolysaccharidosis VII (MPS VII) - AgentsNON PREFERRED MEPSEVII
MULTIVITAMINS
B-Complex VitaminsGENERIC b-complex
NON PREFERRED B-COMPLEX
B-Complex w/ C & Folic AcidGENERIC dailyvite folbee plus mynephrocaps nephro-vite rx renal caps renalpren rena-vite rx reno caps triphrocaps
B-Complex w/ C-Biotin-E-Minerals & Folic AcidGENERIC dialyvite 800
NON PREFERRED DIALYVITE 800
B-Complex w/ C-Zn & Folic AcidGENERIC nephplex rx
Multiple Vitamins w/ CalciumGENERIC advanced am/pm
Multiple Vitamins w/ MineralsGENERIC folivane-plus nutri-tab ob strovite therapeutic vitamin/minerals v-c forte vp-zel
Multiple Vitamins w/ Minerals & Calcium-Folic AcidGENERIC tl g-fol os
Multiple Vitamins w/ Minerals & Folic AcidGENERIC corvita
MultivitaminsGENERIC m.v.i. adult
PREFERRED INFUVITE M.V.I. PEDIATRIC M.V.I.-12
Prenatal MV & Min w/FE-FAGENERIC bal-care dha elite ob elite-ob fabb folcaps folcaps omega-3 folivane-ob hemenatal ob inatal advance inatal gt inatal ultra mynatal mynatal advance mynatal caps mynatal plus mynatal-z mynate 90 plus er obstetrix dha pnv-first pnv-omega pnv-select pnv-total prenaplus prenatabs fa prenatabs rx prenatal ad prenatal low iron prenatal plus prenatal-u relnate dha se-natal 19 se-tan plus taron forte taron prenatal taron-bc tl-fol 500 er tri rx triadvance trinatal gt
Updated January 1, 2019 Page
trinatal rx 1 trinate vena-bal dha vinate gt vinate ic vinate ii vinate one vinate ultra vinate-m virt-pn plus virt-vite v-natal vol-care rx vol-nate vol-plus vol-tab rx vp-ch plus zatean-pn zatean-pn plus
NON PREFERRED STUART ONE VITAFOL-OB
Prenatal MV & Min w/FE-FA-CA-Omega 3 Fish OilGENERIC complete natal dha pr natal 400 pr natal 400 ec pr natal 430 pr natal 430 ec triveen-duo dha
Prenatal MV & Min w/FE-FA-DHAGENERIC folivane-prx dha nf hemenatal ob + dha macnatal cn dha natal-v rx natalvirt 90 dha natalvirt ca natalvirt flt pnv ob+dha pnv-dha prefol-dha prena1 prena1 plus prenaissance prenaissance 90 dha prenaissance balance prenaissance dha prenaissance harmony dha prenaissance plus se-tan dha prenatal taron-c dha taron-duo ec tl-select triveen-prx rnf ultimate ob dha vemavite-prx 2 venatal complete dha venatal-fa vinate dha virt-bal dha virt-pn dha virt-select vitafol-pn vp-ch-pnv zatean-ch
zatean-pn dha
PREFERRED LEVOMEFOLATE DHA
Prenatal VitaminsGENERIC prena1 chew prenaissance next
MUSCULOSKELETAL THERAPY AGENTS
Central Muscle RelaxantsGENERIC baclofen chlorzoxazone cyclobenzaprine hcl methocarbamol orphenadrine citrate orphenadrine compound tizanidine hcl
PREFERRED CYCLOBENZAPRINE HCL
NON PREFERRED GABLOFEN LIORESAL ROBAXIN
Direct Muscle RelaxantsGENERIC dantrolene sodium
ViscosupplementsNON PREFERRED MONOVISC ORTHOVISC SYNVISC SYNVISC-ONE
NASAL AGENTS - SYSTEMIC AND TOPICAL
Antihistamine-SteroidPREFERRED DYMISTA
Nasal AnticholinergicsGENERIC ipratropium bromide spray
Nasal AntihistaminesGENERIC azelastine hcl
Nasal SteroidsGENERIC flunisolide nasal spray fluticasone nasal spray mometasone furoate nasal
Updated January 1, 2019 Page
triamcinolone acetonide
PREFERRED QNASL
NON PREFERRED BECONASE AQ NASONEX
Topical DecongestantsGENERIC oxymetazoline hcl 12 hour
Neprilysin Inhib (ARNI)-Angiotensin II Recept Antag Comb
Neprilysin Inhib (ARNI)-Angiotensin II Recept Antag Comb
PREFERRED ENTRESTO
NEUROMUSCULAR AGENTS
BenzathiazolesGENERIC riluzole
Depolarizing Muscle RelaxantsGENERIC anectine
Neuromuscular Blocking Agent - NeurotoxinsNON PREFERRED MYOBLOC
NUTRIENTS
Amino Acid MixturesGENERIC amino acid
PREFERRED CLINIMIX CLINIMIX E PROCALAMINE
NON PREFERRED AMINO ACID 700MG TABLETS AMINOSYN FREAMINE HBC FREAMINE III HEPATAMINE NEPHRAMINE PREMASOL PROSOL TRAVASOL TROPHAMINE
CarbohydratesGENERIC dextrose in water
LipidsGENERIC intralipid
NON PREFERRED INTRALIPID
OBSTETRICS & GYNECOLOGY
DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES
PREFERRED TODAY CONTRACEPTIVE SPONGE
OPHTHALMIC AGENTS
Artificial TearsGENERIC sodium chloride drops
Beta-blockers - OphthalmicGENERIC betaxolol ophth solution carteolol hcl levobunolol hcl drops metipranolol drops
PREFERRED BETOPTIC S
NON PREFERRED BETAGAN
Beta-blockers - Ophthalmic CombinationsGENERIC dorzolamide/timolol
PREFERRED COMBIGAN
Cycloplegic MydriaticsGENERIC atropine sulfate cyclopentolate ophth solution homatropine hydrobromide tropicamide
PREFERRED HOMATROPINE HYDROBROMIDE
NON PREFERRED CYCLOGYL MYDRIACYL
Updated January 1, 2019 Page
Lymphocyte Function-Associated Antigen-1 (LFA-1) Antag
PREFERRED XIIDRA
Miotics - Cholinesterase InhibitorsPREFERRED PHOSPHOLINE IODIDE DROPS
Miotics - Direct ActingGENERIC pilocarpine hcl pilocarpine hcl
PREFERRED CARBACHOL ISOPTO CARBACHOL 0.015 PILOPINE HS
NON PREFERRED ISOPTO CARBACHOL 0.03 ISOPTO CARPINE
Ophthalmic AntiallergicGENERIC azelastine hcl ophth solution cromolyn sodium cromolyn sodium epinastine hcl olopatadine hcl (ophthalmic)
PREFERRED PAZEO
NON PREFERRED ELESTAT PATADAY
Ophthalmic AntibioticsGENERIC ciprofloxacin ophth solution erythromycin ointment gatifloxacin gentasol levofloxacin hemihydrate neomycin/polymyxin/gramicidin ofloxacin tobramycin sulfate drops
PREFERRED AZASITE BESIVANCE MOXEZA
NON PREFERRED OCUFLOX TOBREX VIGAMOX
Ophthalmic AntifungalPREFERRED NATACYN
Ophthalmic Anti-infective CombinationsGENERIC bacitracin/polymyxin ophth oint
Ophthalmic AntiviralsGENERIC trifluridine
NON PREFERRED VIROPTIC
Ophthalmic Carbonic Anhydrase InhibitorsGENERIC dorzolamide hcl
Ophthalmic DecongestantsGENERIC naphazoline hcl
Ophthalmic Diagnostic ProductsGENERIC proparacaine/fluorescein
PREFERRED FLUORESCEIN SODIUM
Ophthalmic EnzymesNON PREFERRED JETREA
Ophthalmic ImmunomodulatorsPREFERRED RESTASIS RESTASIS MULTIDOSE
Ophthalmic Irrigation SolutionsGENERIC balanced salt ophth irrigation
PREFERRED BEPREVE
NON PREFERRED PATANOL
Ophthalmic Local AnestheticsGENERIC proparacaine hcl tetcaine drops
Ophthalmic Nonsteroidal Anti-inflammatory AgentsGENERIC bromfenac ophth flurbiprofen flurbiprofen sodium ketorolac tromethamine ketorolac tromethamine drops
PREFERRED ILEVRO NEVANAC
Updated January 1, 2019 Page
PROLENSA
Ophthalmic Photodynamic Therapy AgentsNON PREFERRED VISUDYNE
Ophthalmic Rho Kinase InhibitorsPREFERRED RHOPRESSA
Ophthalmic Selective Alpha Adrenergic AgonistsGENERIC apraclonidine ophth solution brimonidine ophth solution
PREFERRED ALPHAGAN P 0.001%
NON PREFERRED ALPHAGAN P 0.0015%
Ophthalmic Steroid CombinationsGENERIC neomycin/bacitracin/poly/hc sulfacetamide w/prednisolone tobramycin/dexamethasone
PREFERRED TOBRADEX OINTMENT TOBRADEX ST ZYLET
NON PREFERRED BLEPHAMIDE S.O.P. TOBRADEX SUSPENSION
Ophthalmic SteroidsGENERIC dexamethasone sod phos ophth fluorometholone prednisolone acetate prednisolone sodium phosphate drops
PREFERRED ALREX FML S.O.P. LOTEMAX
NON PREFERRED PRED MILD
Ophthalmic SulfonamidesNON PREFERRED BLEPH-10
Ophthalmics - Cystinosis AgentsPREFERRED CYSTARAN
Prostaglandins - OphthalmicGENERIC bimatoprost latanoprost drops travoprost
PREFERRED TRAVATAN Z
NON PREFERRED LATANOPROST DROPS 1GM OIL LUMIGAN
Vascular Endothelial Growth Factor (VEGF) Antagonists
NON PREFERRED LUCENTIS
Ophthalmic Gene Therapy
Ophthalmic Gene TherapyPREFERRED LUXTURNA
OPHTHALMOLOGY
macular degenerationNON PREFERRED EYLEA
OTIC AGENTS
Otic Agents - MiscellaneousGENERIC acetic acid otic solution acetic acid/aluminum otic sol
PREFERRED ACETIC ACID
Otic Analgesic CombinationsGENERIC antipyrine/benzocaine otic sol antipyrine/benzocaine/poly otic sol chloroxylenol/benzocaine/hc acetate otic susp
Otic Anti-infectivesGENERIC ciprofloxacin hcl ofloxacin otic drops
PREFERRED CIPROFLOXACIN HCL
Otic Steroid-Anti-infective CombinationsGENERIC neomycin/polymyxin/hc otic susp & soln
Updated January 1, 2019 Page
PREFERRED CIPRO HC CIPRODEX OTOVEL
NON PREFERRED COLY-MYCIN S
Otic SteroidsGENERIC acetic acid/hydrocortisone otic sol
NON PREFERRED DERMOTIC
OXYTOCICS
Abortifacients/Cervical Ripening - ProstaglandinsPREFERRED HEMABATE
OxytocicsGENERIC methylergonovine maleate oxytocin
PREFERRED ERGONOVINE MALEATE
PASSIVE IMMUNIZING AGENTS
Antiviral Monoclonal AntibodiesNON PREFERRED SYNAGIS
Immune SerumsPREFERRED CYTOGAM GAMASTAN S-D GAMUNEX HYPERHEP B S-D HYPERTET S-D VARIZIG
NON PREFERRED GAMMAGARD LIQUID GAMMAGARD S-D GAMUNEX-C HEPAGAM B HIZENTRA HYPERRAB S-D HYPERRHO S-D IMOGAM RABIES-HT PRIVIGEN
PCSK9 Inhibitors
PCSK9 InhibitorsPREFERRED PRALUENT PEN PRALUENT SYRINGE REPATHA PUSHTRONEX REPATHA SURECLICK REPATHA SYRINGE
PENICILLINS
AminopenicillinsGENERIC amoxicillin ampicillin
Natural PenicillinsGENERIC penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium
PREFERRED PENICILLIN GK-ISO-OSM DEXTROSE
NON PREFERRED BICILLIN L-A
Penicillin CombinationsGENERIC amoxicillin/clavulanate er ampicillin/sulbactam piperacillin-tazobactam
PREFERRED AUGMENTIN 125-31.25 MG/5ML TIMENTIN ZOSYN IV SOLUTION
NON PREFERRED AUGMENTIN BICILLIN C-R ZOSYN VIAL
Penicillinase-Resistant PenicillinsGENERIC dicloxacillin sodium nafcillin dextrose nafcillin sodium oxacillin sodium
NON PREFERRED ORABACTIV
Updated January 1, 2019 Page
Phosphatidylinositol 3-Kinase (PI3K) Inhibitors
Phosphatidylinositol 3-Kinase (PI3K) InhibitorsNON PREFERRED ALIQOPA ZYDELIG
Poly (ADP-ribose) Polymerase (PARP) Inhibitors
Poly (ADP-ribose) Polymerase (PARP) InhibitorsNON PREFERRED LYNPARZA
Poly (ADP-ribose) Polymerase (PARP) Inhibitors
Poly (ADP-ribose) Polymerase (PARP) InhibitorsNON PREFERRED RUBRACA ZEJULA
Postherpetic Neuralgia (PHN)/Neuropathic Pain Agents
Postherpetic Neuralgia (PHN)/Neuropathic Pain AgentsNON PREFERRED GRALISE
PROGESTINS
ProgestinsGENERIC medroxyprogesterone acetate progesterone in oil progesterone micronized
PREFERRED MAKENA
Protease-Activated Receptor-1 (PAR-1) Antagonists
Protease-Activated Receptor-1 (PAR-1) AntagonistsPREFERRED ZONTIVITY
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
Agents for Narcotic WithdrawalNON PREFERRED LUCEMYRA
Alcohol DeterrentsGENERIC acamprosate calcium disulfiram
Anti-Cataplectic AgentsPREFERRED XYREM
Antidementia Agent CombinationsPREFERRED NAMZARIC NAMZARIC THERAPY PACK
Benzodiazepines & Tricyclic AgentsGENERIC amitriptyline/chlordiazepoxide
Cholinomimetics - ACHE InhibitorsGENERIC donepezil hcl galantamine rivastigmine
Fibromyalgia Agent - SNRIsPREFERRED SAVELLA
Movement Disorder Drug TherapyNON PREFERRED XENAZINE
Multiple Sclerosis AgentsNON PREFERRED COPAXONE GLATOPA
Multiple Sclerosis Agents - InterferonsPREFERRED AVONEX PLEGRIDY
NON PREFERRED BETASERON EXTAVIA REBIF REBIF REBIDOSE
Multiple Sclerosis Agents - Monoclonal AntibodiesNON PREFERRED LEMTRADA OCREVUS TYSABRI
Multiple Sclerosis Agents - Nrf2 Pathway ActivatorsPREFERRED TECFIDERA
Multiple Sclerosis Agents - Potassium Channel Blockers
NON PREFERRED AMPYRA
Updated January 1, 2019 Page
N-Methyl-D-Aspartate (NMDA) Receptor AntagonistsGENERIC memantine memantine dose pack
PREFERRED NAMENDA XR
Phenothiazines & Tricyclic AgentsGENERIC perphenazine/amitriptyline
Pseudobulbar Affect Agent CombinationsPREFERRED NUEDEXTA
Smoking DeterrentsGENERIC buproban
PREFERRED CHANTIX
NON PREFERRED ZYBAN
Sphingosine 1-Phosphate (S1P) Receptor ModulatorsPREFERRED GILENYA
Thienbenzodiazepines & SSRIsGENERIC olanzapine/fluoxetine hcl
Vasomotor Symptom Agents - SSRIsPREFERRED BRISDELLE
Pulmonary Hypertension - Prostacyclin Receptor Agonist
Pulmonary Hypertension - Prostacyclin Receptor Agonist
PREFERRED UPTRAVI
RESPIRATORY AGENTS - MISC.
Alpha-Proteinase Inhibitor (Human)NON PREFERRED ARALAST NP PROLASTIN C ZEMAIRA
CFTR PotentiatorsNON PREFERRED KALYDECO
Cystic Fibrosis Agent - CombinationsPREFERRED SYMDEKO
NON PREFERRED ORKAMBI
Hydrolytic EnzymesNON PREFERRED PULMOZYME
Interleukin-5 Antagonists (IgG1 kappa)PREFERRED FASENRA
NON PREFERRED NUCALA
Pulmonary Fibrosis AgentsNON PREFERRED ESBRIET
SGLT2 Inhibitor - DPP-4 Inhibitor Combinations
SGLT2 Inhibitor - DPP-4 Inhibitor CombinationsNON PREFERRED STEGLUJAN
Sinus Node Inhibitors
Sinus Node InhibitorsPREFERRED CORLANOR
Spinal Muscular Atrophy Agents (SMA)
Spinal Muscular Atrophy Agents (SMA)PREFERRED SPINRAZA
Tazarotene CREAM 0.1 % External
DERMATOLOGICALSGENERIC tazarotene cream
TETRACYCLINES
TetracyclinesGENERIC demeclocycline hcl doxycycline hyclate doxycycline monohydrate minocycline hcl minocycline hcl er ocudox
Updated January 1, 2019 Page
PREFERRED COREMINO MINOCIN 100MG VIAL SOLODYN ER TETRACYCLINE
NON PREFERRED MINOCIN
Tetrahydroisoquinolines
TetrahydroisoquinolinesNON PREFERRED YONDELIS
THYROID AGENTS
Antithyroid AgentsGENERIC methimazole propylthiouracil
NON PREFERRED TAPAZOLE
Thyroid HormonesGENERIC levothyroxine sodium liothyronine sodium
PREFERRED ARMOUR THYROID LEVOTHYROXINE SODIUM
NON PREFERRED CYTOMEL SYNTHROID TIROSINT
TOXOIDS
Toxoid CombinationsPREFERRED ADACEL BOOSTRIX INFANRIX PEDIARIX PENTACEL QUADRACEL DTAP-IPV TETANUS DIPHTHERIA TOXOIDS TETANUS DIPHTHERIA TOXOIDS - PED
Tryptophan Hydroxylase Inhibitors
Tryptophan Hydroxylase InhibitorsNON PREFERRED XERMELO
ULCER DRUGS
AntispasmodicsGENERIC dicyclomine hcl
Belladonna AlkaloidsGENERIC hyoscyamine sulfate hyoscyamine sulfate disinegrating tablets hyoscyamine sulfate er
PREFERRED LEVSIN 0.5MG/ML AMPUL
NON PREFERRED ATROPEN LEVSIN 0.125MG TABLET
H-2 AntagonistsGENERIC cimetidine famotidine nizatidine ranitidine hcl
NON PREFERRED ZANTAC RX
Misc. Anti-UlcerGENERIC carafate sucralfate
NON PREFERRED CARAFATE
Proton Pump Inhibitor-Antacid CombinationsGENERIC omeprazole sodium bicarbonate
NON PREFERRED OMEPRAZOLE SODIUM BICARBONATE
Proton Pump InhibitorsGENERIC esomeprazole lansoprazole omeprazole pantoprazole sodium
PREFERRED NEXIUM (RX) SUSP NEXIUM 24HR
NON PREFERRED NEXIUM (RX) CAPSULE NEXIUM (RX) VIAL
Updated January 1, 2019 Page
Quaternary AnticholinergicsGENERIC glycopyrrolate
Ulcer Anti-Infective w/ Proton Pump InhibitorsGENERIC lansoprazole/amoxicillin/clarithromycin
Ulcer Drugs - ProstaglandinsGENERIC misoprostol
NON PREFERRED CYTOTEC
URINARY ANTI-INFECTIVES
Urinary Anti-infectivesGENERIC methenamine hippurate methenamine mandelate nitrofurantoin nitrofurantoin macrocrystal
NON PREFERRED MACROBID MACRODANTIN
Urinary Antiseptic-Antispasmodic &/or AnalgesicsGENERIC hyophen phosphasal uretron d-s urimar-t urin d.s. urogesic ustell
URINARY ANTISPASMODICS
Beta-3 Adrenergic AgonistsPREFERRED MYRBETRIQ ER 24 HR
Urinary Antispasmodic - Antimuscarinic (Anticholinergic)
GENERIC darifenacin er trospium chloride er
NON PREFERRED ENABLEX
Urinary Antispasmodic - Antimuscarinics (Antichol)(new)
GENERIC oxybutynin chloride oxybutynin chloride er tolterodine tartrate
PREFERRED GELNIQUE TOVIAZ VESICARE
NON PREFERRED DITROPAN XL
Urinary Antispasmodics - Cholinergic Agonists (new)GENERIC bethanechol chloride
Urinary Antispasmodics - Direct Muscle RelaxantsGENERIC flavoxate hcl
VACCINES
Bacterial VaccinesPREFERRED ACTHIB BEXSERO BIOTHRAX MENACTRA MENOMUNE-A-C-Y-W-135 PEDVAXHIB PNEUMOVAX 23 PREVNAR 13 TRUMENBA TYPHIM VI VAXCHORA VACCINE VIVOTIF BERNA DEL REL
Viral Vaccine CombinationsPREFERRED M-M-R II VACCINE W/DILUENT PROQUAD TWINRIX
Viral VaccinesPREFERRED AFLURIA AFLURIA QUAD ENGERIX-B FLUAD FLUBLOK FLUBLOK QUAD FLUCELVAX QUAD FLULAVAL QUAD FLUMIST FLUZONE HIGH-DOSE FLUZONE QUAD GARDASIL 9 HAVRIX IMOVAX RABIES VACCINE IPOL IXIARO RABAVERT RECOMBIVAX HB ROTATEQ SHINGRIX STAMARIL VAQTA VIAL VARIVAX VACCINE
Updated January 1, 2019 Page
YF-VAX
NON PREFERRED VAQTA SYRINGES
VAGINAL PRODUCTS
Imidazole-Related AntifungalsGENERIC miconazole 1 terconazole
PREFERRED MICONAZOLE 1
Vaginal Anti-infectivesGENERIC clindamycin phosphate vaginal
Vaginal EstrogensPREFERRED ESTRING PREMARIN CREAM
Vaginal ProgestinsPREFERRED CRINONE FEMRING
NON PREFERRED ENDOMETRIN ESTRACE CREAM
VASOPRESSORS
Anaphylaxis Therapy AgentsGENERIC epinephrine ampule/vial epinephrine auto-injector
NON PREFERRED EPINEPHRINE 1MG/ML AMPUL EPIPEN EPIPEN JR.
VasopressorsGENERIC dobutamine dobutamine/dextrose dopamine hcl dopamine hcl in 5% dextrose norepinephrine bitartrate phenylephrine hcl phenylephrine hcl-ns
PREFERRED PHENYLEPHRINE HCL-NS
NON PREFERRED LEVOPHED AMPULE/VIAL PHENYLEPHRINE HCL-NS 200MCG/5ML SYRINGE
PHENYLEPHRINE HCL-NS 40MG/5ML SYRINGE
VITAMINS
Vitamin AGENERIC vitamin a
PREFERRED AQUASOL A VITAMIN A
NON PREFERRED VITAMIN A
Vitamin B-6GENERIC pyridoxine hcl
PREFERRED PYRIDOXINE HCL
NON PREFERRED PYRIDOXINE HCL 500MG TABLETS
Vitamin CGENERIC ascorbic acid
PREFERRED ASCORBIC ACID
Vitamin KGENERIC phytonadione
PREFERRED PHYTONADIONE
NON PREFERRED MEPHYTON
VITAMINS, HEMATINICS & ELECTROLYTES
VITAMINS & HEMATINICSGENERIC cavan-alpha kit cavan-ec sod dha choice-ob + dha choice-tabs elite-ob 400 folbecal folivane-f folplex 2.2 hematinic plus hematinic with folic acid hematogen hematogen fa hematogen forte hemetab iferex 150 forte
Updated January 1, 2019 Page
mefolate-pyridox-mecobalamin multigen multigen folic multigen plus multivitamin w/fluoride & iron multivitamin with fluoride poly-iron 150 forte polysaccharide iron forte setonet setonet ec thiamine hcl tl gard rx tl icon tl-care dha tricon trigels-f forte trinatal ultra triveen-one triveen-ten triveen-u trust natal dha ultimatecare one ultimatecare one nf vinacal vinate az vinate c vinate calcium virt-bal dha plus virt-pn vitacirc-b vp-era ob plus vp-ggr-b6 zingiber
PREFERRED FERAHEME
NON PREFERRED CENOLATE CONCEPTION XR MOTILITY DULEEK-MET NEW THIAMINE HCL VITASPIRE VYNATAL-FA
X-Linked Hypophosphatemia (XLH) Treatment - Agents
X-Linked Hypophosphatemia (XLH) Treatment - AgentsPREFERRED CRYSVITA
Updated January 1, 2019 Page