Combined Medication List

Class of drug Drug name Drug Indication 1 Indication 2 Indication 3 Dose Type $4 Generic by Store & Quanitity       Insurance Company           Low Cost Patients Assitance Program Insurance Preferred List
  Generic Brand Name           Target Walmart Kroger CVS CIGNA Ambetter UHC Medicaid Blue Cross CIP Drug company  
ACE Inhibitor BENAZEPRIL Lotensin Hypertension     5MG TABLET 30 30 30 30 Day Supply Tier 1, Gap Coverage Tier 1 Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Tier 1 Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor BENAZEPRIL Lotensin Hypertension     10MG TABLET 30 30 30 30 Day Supply Tier 1, Gap Coverage Tier 1 Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Tier 1 Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor BENAZEPRIL Lotensin Hypertension     20MG TABLET 30 30 30 30 Day Supply Tier 1, Gap Coverage Tier 1 Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Tier 1 Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor BENAZEPRIL Lotensin Hypertension     40MG TABLET 30 30 30 30 Day Supply Tier 1, Gap Coverage Tier 1 Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Tier 1 Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor CAPTOPRIL Capoten Hypertension Congestive Heart Failure Kidney Problems 12.5MG TABLET 60 NONE NONE NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor CAPTOPRIL Capoten Hypertension Congestive Heart Failure Kidney Problems 25MG TABLET 60 NONE NONE NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor CAPTOPRIL Capoten Hypertension Congestive Heart Failure Kidney Problems 50MG TABLET 60 NONE NONE NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor CAPTOPRIL Capoten Hypertension Congestive Heart Failure Kidney Problems 100MG TABLET 60 NONE NONE NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor & Diuretic CAPTOPRIL HCTZ Capozide Hypertension Congestive Heart Failure Kidney Problems   TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Medicaid
ACE Inhibitor ENALAPRIL Vasotec Heart Failure Hypertension   2.5MG TABLET 30 30 30 NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor ENALAPRIL Vasotec Heart Failure Hypertension   5MG TABLET 30 30 30 NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor ENALAPRIL Vasotec Heart Failure Hypertension   10MG TABLET 30 30 30 NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor ENALAPRIL Vasotec Heart Failure Hypertension   20MG TABLET 30 30 30 NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor LISINOPRIL Zestril, Prinivil Heart Failure     2.5MG TABLET 30 30 30 NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor LISINOPRIL Zestril, Prinivil Heart Failure     5MG TABLET 30 30 30 30 Day Supply Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor LISINOPRIL Zestril, Prinivil Heart Failure     10MG TABLET 30 30 30 30 Day Supply Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor LISINOPRIL Zestril, Prinivil Heart Failure     12.5MG TABLET NONE NONE NONE 30 Day Supply Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor LISINOPRIL Zestril, Prinivil Heart Failure     20MG TABLET 30 30 30 30 Day Supply Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor TRANDOLAPRIL Mavik Hypertension     1MG TABLET NONE NONE 30 NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Medicaid
ACE Inhibitor & Diuretic ENALAPRIL-HCTZ Vaseretic Hypertension     5/12.5MG TABLET 30 30 30 30 Day Supply Generic, Tier 1, Gap Coverage NONE Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor & Diuretic LISINOPRIL-HCTZ Zestoretic, Prinzide Hypertension     10MG-12.5MG TABLET 30 30 30 30 Day Supply Generic, Tier 1, Gap Coverage NONE Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor & Diuretic LISINOPRIL-HCTZ Zestoretic, Prinzide Hypertension     20MG-12.5MG TABLET 30 30 30 30 Day Supply Generic, Tier 1, Gap Coverage NONE Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor & Diuretic LISINOPRIL-HCTZ Zestoretic, Prinzide Hypertension     20MG-25MGMG TABLET 30 30 30 30 Day Supply Generic, Tier 1, Gap Coverage NONE Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
Alkalinizing Agent CYTRA-2 CYTRA-2 Metabolic Acidosis Kidney Problems   N/A SOLUTION 180ml 80ml 473ml NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Alpha Blocker PRAZOSIN-HCL Minipress Hypertension     1MG CAPSULE 30 NONE NONE 30 Day Supply Generic, Tier 1, Gap Coverage NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE Cigna
Alpha Blocker PRAZOSIN-HCL Minipress Hypertension     2MG CAPSULE 30 NONE NONE 30 Day Supply Generic, Tier 1, Gap Coverage NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE Cigna
Alpha Blocker PRAZOSIN-HCL Minipress Hypertension     5MG CAPSULE 30 NONE NONE 30 Day Supply Generic, Tier 1, Gap Coverage NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE Cigna
Alpha Blocker TERAZOSIN Hytrin Hypertension Benign Prostatic Hyperplasia (BPH)   1MG CAPSULE 30 30 30 30 Day Supply NONE Generic, Tier 1 NONE NONE Generic, Tier 1 NONE NONE NONE
Alpha Blocker TERAZOSIN Hytrin Hypertension Benign Prostatic Hyperplasia (BPH)   2MG CAPSULE 30 30 30 30 Day Supply NONE Generic, Tier 1 NONE NONE Generic, Tier 1 NONE NONE NONE
Alpha Blocker TERAZOSIN Hytrin Hypertension Benign Prostatic Hyperplasia (BPH)   5MG CAPSULE 30 30 30 30 Day Supply NONE Generic, Tier 1 NONE NONE Generic, Tier 1 NONE NONE NONE
Alpha Blocker TERAZOSIN Hytrin Hypertension Benign Prostatic Hyperplasia (BPH)   10MG CAPSULE 30 30 30 30 Day Supply NONE Generic, Tier 1 NONE NONE Generic, Tier 1 NONE NONE NONE
Alpha-1 Blocker DOXAZOSIN Cardura Benign Prostatic Hyperplasia (BPH)     1MG TABLET 30 NONE NONE NONE NONE Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE NONE
Alpha-1 Blocker DOXAZOSIN Cardura Benign Prostatic Hyperplasia (BPH)     2MG TABLET 30 NONE NONE NONE NONE Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE NONE
Alpha-1 Blocker DOXAZOSIN Cardura Benign Prostatic Hyperplasia (BPH)     4MG TABLET 30 NONE NONE NONE NONE Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE NONE
Alpha-1 Blocker DOXAZOSIN Cardura Benign Prostatic Hyperplasia (BPH)     8MG TABLET 30 NONE NONE NONE NONE Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE NONE
Analgesic ANTIPYRINE/BENZOCAINE Auralgan, Aurodex Ear infection     OTIC SOLUTION 10 (15ml-bottle) NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Anesthetic LIDOCAINE N/A Postherpetic Neuralgia Urethritis   2% VISCOUS-SOLUTION 100ml NONE 100ml 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antiarrhythmic SOTALOL HCL Betapace Arrhythmias     80MG TABLET 30 30 30 30 Day Supply Generic, Tier 2, Gap Coverage Generic, Tier 1, Quantity Limit Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE NONE
Antiarrhythmic SOTALOL HCL Betapace Arrhythmias     160MG, 240MG TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1, Quantity Limit Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE NONE
Antiarrhythmic SOTALOL HCL Sorine Arrhythmias       TABLET NONE NONE NONE NONE Tier 2, Gap Coverage NONE Tier 1 NONE Tier 1 Tier 2 NONE NONE
Antiarrhythmic SOTALOL HCL AF Betapace AF Arrhythmias     80MG TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Quantity Limit NONE NONE NONE NONE
Antiarrhythmic SOTALOL HCL AF Betapace AF Arrhythmias     120MG TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE NONE
Antibiotic AMOXICILLIN Amoxil Ear Infection Urinary Tract Infection (UTI) Acute uncomplicated gonorrhea 125MG/5ML SUSPENSION 80, 100, 150 80, 100, 150 80, 100, 150 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic AMOXICILLIN Amoxil Ear Infection Urinary Tract Infection (UTI) Acute uncomplicated gonorrhea 200MG/5ML SUSPENSION 50,75,100 50,75, 100 50, 75, 100 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic AMOXICILLIN Amoxil Ear Infection Urinary Tract Infection (UTI) Acute uncomplicated gonorrhea 250MG/5ML SUSPENSION 80,100, 150 80,100, 150 80, 100, 150 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic AMOXICILLIN Amoxil Ear Infection Urinary Tract Infection (UTI) Acute uncomplicated gonorrhea 400MG/5ML SUSPENSION 50,75,100 50, 75, 100 50, 75, 100 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic AMOXICILLIN Amoxil Ear Infection Urinary Tract Infection (UTI) Acute uncomplicated gonorrhea 250MG CAPSULE 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic AMOXICILLIN Amoxil Ear Infection Urinary Tract Infection (UTI) Acute uncomplicated gonorrhea 500MG CAPSULE 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic AMOXIL Amoxil Ear Infection Urinary Tract Infection (UTI) Acute uncomplicated gonorrhea 50MG/ML DROP 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic BACITRACIN BACiiM Eye Infection     OPHTHALMIC OINTMENT 4 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic CEPHALEXIN Keflex Skin, Bone, & Respiratory Infections Urinary Tract Infection (UTI) Ear infection 250MG CAPSULE 28 28 40 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic CEPHALEXIN Keflex Skin, Bone, & Respiratory Infections Urinary Tract Infection (UTI) Ear infection 500MG CAPSULE 30 30 40 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic CIPROFLOXACIN Cipro Urinary Tract Infection (UTI) Gonorrhea Skin & Bone Infection, Anthrax 250MG TABLET 14 14 20 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic CIPROFLOXACIN Cipro Urinary Tract Infection (UTI) Gonorrhea Skin & Bone Infection, Anthrax 500MG TABLET 20 20 20 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic ERYTHROCIN Erythrocin Pertussis Strep Throat Various Bacterial Infections 250MG TABLET 40 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic ERYTHROMYCIN Erythrocin, E-mycin Pertussis Strep Throat Various Bacterial Infections 2% SOLUTION 60 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic ERYTHROMYCIN Romycin Pertussis Strep Throat Various Bacterial Infections OPHTHALMIC OINTMENT 4 (3.5gm-tube) 3.5gm NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic ERYTHROMYCIN Ery-Ped, Ery-tab, Ery, PCE, Staticin Pertussis Strep Throat Various Bacterial Infections 250MG-EC CAPSULE 28 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic GENTAK Gentak Pink Eye Bacterial Eye Infections   0.30% OPHTHALMIC-SOLUTION NONE 5 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic GENTAMICIN Gentak, Garamycin Pink Eye Bacterial Eye Infections   0.10% CREAM 15 15 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic GENTAMICIN Gentak, Garamycin Pink Eye Bacterial Eye Infections   0.10% OINTMENT 15 15 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic GENTAMICIN Gentak, Garamycin Pink Eye Bacterial Eye Infections   0.30% OPHTHALMIC-SOLUTION 5 5 5 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic GENTAMICIN-SULFATE Genoptic Pink Eye Bacterial Eye Infections   0.30% OPHTHALMIC-SOLUTION NONE NONE NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic ISONIAZID Nydrazid Tuberculosis     300MG TABLET 30 NONE 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic METRONIDAZOLE Flagyl Anaerobic Bacterial Infections     250MG TABLET 28 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic METRONIDAZOLE Flagyl Anaerobic Bacterial Infections     500MG TABLET 14 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic PENICILLIN-VK Penicillin-VK, Veetids Bacterial Infections     125/5ML SOLUTION 200ml 100ml, 200ml 100ml, 200ml 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic PENICILLIN-VK Penicillin-VK, Veetids Bacterial Infections     250/5ML SOLUTION 100ml 100ml NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic PENICILLIN-VK Penicillin-VK, Veetids Bacterial Infections     250MG TABLET 28 28 40 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic POLYMYXIN Polytrim Bacterial Infections     SULFATE/TMP OPTHALMIC-SOLUTION 10ml (10ml-bottle) 10ML NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic SMZ-TMP Septra, Bactrim, Sulfatrim Urinary Tract Infection Ear Infection Bacterial Infection 200MG-40MG/5ML SUSPENSION 120ml 120ml NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic SMZ-TMP Septra, Bactrim, Sulfatrim Urinary Tract Infection Ear Infection Bacterial Infection 400MG-80MG TABLET 28 28 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic SMZ-TMP-DS Septra, Bactrim, Sulfatrim Urinary Tract Infection Ear Infection Bacterial Infection 800MG-160MG TABLET 20 20 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic SULFACETAMIDE-SODIUM Bleph 10 Bacterial Eye Infections     10% OPHTHALMIC-SOLUTION 15 (15ml-bottle) 15GM NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic SULFA-SULFADIAZINE Silvadene, Ssd, Thermazene Urinary Tract Infection Ear Infection Bacterial Infection 1% Cream NONE 50gm-tube NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic SULFAMETHOXAZOLE-TRIMETHOPRIM Septra, Bactrim, Sulfatrim Urinary Tract Infection Ear Infection Bacterial Infection 200MG-40MG/5ML SUSPENSION NONE NONE NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic SULFAMETHOXAZOLE-TRIMETHOPRIM Septra, Bactrim, Sulfatrim Urinary Tract Infection Ear Infection Bacterial Infection 400MG-80MG TABLET NONE NONE 20 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic SULFAMETHOXAZOLE-TRIMETHOPRIM Septra, Bactrim, Sulfatrim Urinary Tract Infection Ear Infection Bacterial Infection 800MG-160MG TABLET NONE NONE 20 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic TETRACYCLINE Sumycin Severe Acne     250MG CAPSULE 60 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic TETRACYCLINE Sumycin Severe Acne     500MG CAPSULE 60 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic TOBRAMYCIN Tobi, Tobrex Eye Infections     0.003 OPHTHALMIC-SOLUTION 5 (5ml-bottle) 5ML NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic & Corticosteroid NEOMYCIN/POLYMYXIN/DEXAMETHASONE Maxitrol, Neo-poly-dex, Methedex Eye Inflammation Bacterial Eye Infection   0.10% OPHTHALMIC-OINTMENT 4 (3.5gm-tube) NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antibiotic & Corticosteroid NEOMYCIN/POLYMYXIN/DEXAMETHASONE Maxitrol, Neo-poly-dex, Methedex Eye Inflammation Bacterial Eye Infection   0.10% OPHTHALMIC-SUSPENSION 5 (5ml-bottle) NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Anticholinergic BENZTROPINE Cogentin Parkinson's Disease     2MG TABLET 30 30 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Anticholinergic BENZTROPINE MESYLATE Cogentin Parkinson's Disease     2MG TABLET NONE NONE 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Anticholinergic DICYCLOMINE Bentyl Irritable Bowel Syndrome (IBS)     10MG CAPSULE 90 90 90 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Anticholinergic DICYCLOMINE Bentyl Irritable Bowel Syndrome (IBS)     20MG CAPSULE 60 60 60 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Anticholinergic HYOSCYAMINE Hyosine, Colidrops Irritable Bowel Syndrome (IBS) Peptic Ulcer Infant Colic 0.125/ML DROP 15 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Anticholinergic HYOSCYAMINE Anaspaz, Cystospaz, Donnamar, Levsin Irritable Bowel Syndrome (IBS) Peptic Ulcer Infant Colic 0.125MG SUBLINGUAL-TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Anticholinergic HYOSCYAMINE Anaspaz, Cystospaz, Donnamar, Levsin Irritable Bowel Syndrome (IBS) Peptic Ulcer Infant Colic 0.125MG TABLET 60 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Anticholinergic HYOSCYAMINE Anaspaz, Cystospaz, Donnamar, Levsin Irritable Bowel Syndrome (IBS) Peptic Ulcer Infant Colic 0.375 ER-TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Bronchodilator IPRATROPIUM Atrovent HFA Asthma Allergies COPD 0.02% Nebulizer-solution NONE (25x2.5ml-vials) 62.5ml 30 Day Supply NONE NONE NONE Preferred, Quantity Limit NONE NONE Boehringer Medicaid
Bronchodilator IPRATROPIUM Atrovent HFA Asthma Allergies COPD 0.02% Nebulizer-solution NONE (25x2.5ml-vials) 62.5ml 30 Day Supply NONE NONE NONE Generic, Preferred, Quantity Limit NONE NONE Boehringer Medicaid
Anticholinergic OXYBUTYNIN Ditropan, Gelnique, Oxytrol Overactive Bladder     5MG TABLET 60 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Anticholinergic TRIHEXYPHENIDYL Artane, Trihexane, Tritane Parkinson's Disease Involuntary Movements   2MG TABLET 60 60 60 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Anticholinergic & Barbituate BELLADONNA Belladonna Tincture Stomach cramps and spasms Stomach Ulcers   ALKALOIDS/PB TABLET 60 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Anticoagulant WARFARIN SODIUM Coumadin Venous Thrombosis Pulmonary Embolism Thromboembolic Complications 1MG TABLET NONE 30 30 NONE NONE Tier 3 Tier 1 Preferred Tier 2 Tier 4 NONE Medicaid, Blue Cross
Anticoagulant WARFARIN SODIUM Coumadin Venous Thrombosis Pulmonary Embolism Thromboembolic Complications 2MG TABLET NONE 30 30 NONE NONE Tier 3 Tier 1 Preferred Tier 2 Tier 4 NONE Medicaid, Blue Cross
Anticoagulant WARFARIN SODIUM Coumadin Venous Thrombosis Pulmonary Embolism Thromboembolic Complications 2.5MG TABLET NONE 30 30 NONE NONE Tier 3 Tier 1 Preferred Tier 2 Tier 4 NONE Medicaid, Blue Cross
Anticoagulant WARFARIN SODIUM Coumadin Venous Thrombosis Pulmonary Embolism Thromboembolic Complications 3MG TABLET NONE 30 30 NONE NONE Tier 3 Tier 1 Preferred Tier 2 Tier 4 NONE Medicaid, Blue Cross
Anticoagulant WARFARIN SODIUM Coumadin Venous Thrombosis Pulmonary Embolism Thromboembolic Complications 4MG TABLET NONE 30 30 NONE NONE Tier 3 Tier 1 Preferred Tier 2 Tier 4 NONE Medicaid, Blue Cross
Anticoagulant WARFARIN SODIUM Coumadin Venous Thrombosis Pulmonary Embolism Thromboembolic Complications 5MG TABLET 30 30 30 NONE NONE Tier 3 Tier 1 Preferred Tier 2 Tier 4 NONE Medicaid, Blue Cross
Anticoagulant WARFARIN SODIUM Coumadin Venous Thrombosis Pulmonary Embolism Thromboembolic Complications 6MG TABLET NONE 30 30 NONE NONE Tier 3 Tier 1 Preferred Tier 2 Tier 4 NONE Medicaid, Blue Cross
Anticoagulant WARFARIN SODIUM Coumadin Venous Thrombosis Pulmonary Embolism Thromboembolic Complications 7.5MG TABLET NONE 30 30 NONE NONE Tier 3 Tier 1 Preferred Tier 2 Tier 4 NONE Medicaid, Blue Cross
Anticoagulant WARFARIN SODIUM Coumadin Venous Thrombosis Pulmonary Embolism Thromboembolic Complications 10MG TABLET NONE 30 30 NONE NONE Tier 3 Tier 1 Preferred Tier 2 Tier 4 NONE Medicaid, Blue Cross
Anticoagulant WARFARIN SODIUM Jantoven Venous Thrombosis Pulmonary Embolism Thromboembolic Complications ALL TABLET NONE NONE NONE NONE Tier 1, Gap Coverage NONE Tier 1 NONE Tier 1 Tier 1 NONE Cigna
Anticoagulant WARFARIN SODIUM Coumadin, Jantoven Venous Thrombosis Pulmonary Embolism Thromboembolic Complications ALL TABLET NONE NONE NONE NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Preferred Generic, Tier 1 Generic, Tier 1 NONE Cigna, Medicaid
Anticonvulsant CARBAMAZEPINE Tegretol, Carbatrol, Equetro, Epitol Bipolar Disorder Diabetic Neuorpathy Seizures 200MG TABLET 60 30 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antidiabetic CHLORPROPAMIDE Diabenese Diabetes     100MG TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antidiabetic GLIMEPIRIDE Amaryl Diabetes     1MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antidiabetic GLIMEPIRIDE Amaryl Diabetes     2MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antidiabetic GLIMEPIRIDE Amaryl Diabetes     4MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antidiabetic GLIPIZIDE Glucotrol Diabetes     5MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antidiabetic GLIPIZIDE Glucotrol Diabetes     10MG TABLET 60 60 60 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antidiabetic GLYBURIDE DiaBeta, Glynase PresTab, Micronase Diabetes     2.5MG TABLET 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antidiabetic GLYBURIDE DiaBeta, Glynase PresTab, Micronase Diabetes     5MG TABLET 30 30 (green or blue) 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antidiabetic GLYBURIDE-MICRO Diabeta, Glycron, Glynase, Micronase Diabetes     1.5MG TABLET NONE NONE 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antidiabetic GLYBURIDE-MICRO Diabeta, Glycron, Glynase, Micronase Diabetes     3MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antidiabetic GLYBURIDE-MICRO Diabeta, Glycron, Glynase, Micronase Diabetes     6MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antidopaminergic METOCLOPRAMIDE Reglan GASTRoesophageal Reflux Disease (GERD) Diabetic Gastroparesis   10MG TABLET 60 60 60 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antidopaminergic METOCLOPRAMIDE Reglan GASTRoesophageal Reflux Disease (GERD) Diabetic Gastroparesis   5MG/5ML SYRUP 60ml 60ml 120ml 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antifungal FLUCONAZOLE Diflucan Yeast Infection Urinary Tract Infection (UTI) - fungal Various Fungal Infections 150MG TABLET 1 1 1 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antifungal NYSTATIN Mycostatin Topical, Nyamyc, Nystop, Pediaderm AF, Pedi-Dri Cutaneous or Mucocutaneous Candidiasis     N/A CREAM NONE (15gm-tube), (30gm-tube) 15gm, 30gm NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antifungal NYSTATIN Mycostatin Topical, Nyamyc, Nystop, Pediaderm AF, Pedi-Dri Cutaneous or Mucocutaneous Candidiasis     100000U CREAM 15,30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antifungal NYSTATIN Mycostatin Topical, Nyamyc, Nystop, Pediaderm AF, Pedi-Dri Cutaneous or Mucocutaneous Candidiasis     100000U OINTMENT 15,30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antifungal TERBINAFINE Terbinex, Lamisil Nail fungus Athlete's Foot Chronic Mucocutaneous Canididiasis 250MG TABLET NONE 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antifungal & Steroid NYSTATIN/TRIAMCINOLONE Mycolog-II Cutaneous candidiasis     N/A CREAM 15,30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antifungal & Steroid NYSTATIN/TRIAMCINOLONE Mycolog-II Cutaneous candidiasis     N/A OINTMENT 15 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antihistamine LORATADINE Claritin, Alavert Seasonal Allergies     10MG TABLET 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antihistamine LORATADINE Claritin, Alavert Seasonal Allergies     5MG/5ML SYRUP 120ml NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antihistamine & Decongestant CERON Sudafed PE Sinus & Allergy, Triaminic Cold & Allergy Allergies Cold & Flu     DROPS NONE 30ml NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antihistamine, Antiemetic, & Antispasmodic MECLIZINE Antivert, Bonine, Verticalm Motion Sickness Vertigo   12.5MG TABLET 90 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antihistamine, Antiemetic, & Antispasmodic MECLIZINE Antivert, Bonine, Verticalm Motion Sickness Vertigo   25MG TABLET 90 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antihistamine, Cough Suppresant, & Decongestant CERON DM Alka-Seltzer Plus Cold and Cough, Robitussin Cough & Allergy, Robitussin Pediatric Cough & Cold Nighttime Allergies Cold & Flu     SYRUP NONE 120ml NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antihistamine, Decongestant, & Cough Supressant CHLORPHENIRAMINE-DEXTROMETHORPHAN-PHENYLEPHRINE Trivent-DPC Allergies Cold & Flu   6/2/15/5ML SYRUP 120 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antihypertensive METHYLDOPA Aldomet Hypertension     250MG TABLET 60 60 60 NONE NONE Generic, Tier 1, Quantity Limit Generic, Tier 1, Prior Authorization, High Risk Medication NONE Generic, Tier 1 Generic, Tier 3, Prior Authorization, High Risk Medication NONE CIP
Antihypertensive METHYLDOPA Aldomet Hypertension     500MG TABLET 30 NONE NONE 30 Day Supply NONE Generic, Tier 1, Quantity Limit Generic, Tier 1, Prior Authorization, High Risk Medication NONE Generic, Tier 1 Generic, Tier 3, Prior Authorization, High Risk Medication NONE CIP
Antimanic LITHIUM-CARBONATE Eskalith Mania in Bipolar Disorder     300MG CAPSULE 90 30 90 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antimuscarinic ATROPINE-SULFATE Isopto Atropine Inlfammatory Eye conditions Uveitis   1% OPHTHALMIC-SOLUTION 5 (5ml-bottle) 5ML NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antinflammatory COLCHICINE Colcrys Gout     0.6MG TABLET NONE 30 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antipsychotic FLUPHENAZINE Prolixin Psychosis     1MG TABLET 30 30 90 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antipsychotic HALOPERIDOL Haldol Psychosis Tourette's Disorder   0.5MG TABLET 30 30 60 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antipsychotic HALOPERIDOL Haldol Psychosis Tourette's Disorder   1MG TABLET 30 30 60 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antipsychotic HALOPERIDOL Haldol Psychosis Tourette's Disorder   2MG TABLET 30 30 60 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antipsychotic HALOPERIDOL Haldol Psychosis Tourette's Disorder   5MG TABLET 30 30 60 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antipsychotic PROCHLORPERAZINE Compro Schizophrenia Severe Nausea and Vomiting   5MG TABLET NONE NONE 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antipsychotic PROCHLORPERAZINE Compro Schizophrenia Severe Nausea and Vomiting   10MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antipsychotic THIORIDAZINE Mellaril Schizophrenia     10MG TABLET NONE NONE 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antipsychotic THIORIDAZINE Mellaril Schizophrenia     25MG TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antipsychotic THIORIDAZINE Mellaril Schizophrenia     50MG TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antipsychotic THIORIDAZINE Mellaril Schizophrenia     100MG TABLET NONE NONE 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antipsychotic THIOTHIXENE Navane Schizophrenia     2MG CAPSULE 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antiseptic CHLORHEXIDINE Peridex Wound care Oral cleanser Skin cleanser 0.12% RINSE NONE NONE 473ml 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antiseptic CHLORHEXIDINE-GLUCONATE Periogard Wound care Oral cleanser Skin cleanser 0.12% SOLUTION 473ml NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Antiviral ACYCLOVIR Zovirax Genital Herpes Herpes Zoster Shingles 200MG CAPSULE 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Anxiolytic BUSPIRONE BuSpar Anxiety     5MG TABLET 60 30 60 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Anxiolytic BUSPIRONE BuSpar Anxiety     10MG TABLET 60 30 60 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Beta Adrenergic Blocker LEVOBUNOLOL Betagan Glaucoma     0.50% OPHTHALMIC-SOLUTION NONE opt 5ml NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Beta Adrenergic Blocker TIMOLOL Timoptic Glaucoma     0.0025 EYE-DROPS NONE NONE NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Beta Adrenergic Blocker TIMOLOL-MALEATE Betimol Glaucoma     0.0025 OPTHALMIC-SOLUTION NONE (5ml-bottle) 5ML NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Beta Adrenergic Blocker TIMOLOL-MALEATE Betimol Glaucoma     0.005 OPTHALMIC-SOLUTION NONE (5ml-bottle) 5ML NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Beta Adrenergic Blocker TIMOLOL-MALEATE Blocadren Hypertension Migraine (Preventative)     TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 3 NONE CIP
Biguanide METFORMIN Glumetza Diabetes     500MG ER-TABLET 60 60 60 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Biguanide METFORMIN Glumetza Diabetes     500MG TABLET 60 60 60 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Biguanide METFORMIN Glumetza Diabetes     850MG TABLET 60 60 60 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Biguanide METFORMIN Glumetza Diabetes     1000MG TABLET 60 60 60 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Bisphoshphonate ALENDRONATE SODIUM Fosamax Osteoporosis Paget's Disease   35MG TABLET NONE NONE 4 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Bisphoshphonate ALENDRONATE SODIUM Fosamax Osteoporosis Paget's Disease   70MG TABLET NONE NONE 4 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Bronchodilator ALBUTEROL AccuNeb Asthma COPD Bronchospasm 0.50% NEBULES 20 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Bronchodilator ALBUTEROL AccuNeb Asthma COPD Bronchospasm 2MG TABLET 90 90 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Bronchodilator ALBUTEROL AccuNeb Asthma COPD Bronchospasm 2MG/5ML SYRUP 120 20ml NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Bronchodilator ALBUTEROL AccuNeb Asthma COPD Bronchospasm 4MG TABLET 60 60 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Bronchodilator ALBUTEROL AccuNeb Asthma COPD Bronchospasm 0.50% Nebulizer-soln NONE (20ml-bottle) NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Bronchodilator ALBUTEROL AccuNeb Asthma COPD Bronchospasm 0.08% Nebulizer-soln NONE (25x3ml-vials) NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Bronchodilator ALBUTEROL AccuNeb Asthma COPD Bronchospasm 0.083 Inh-Soln NONE NONE 75ML NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Bronchodilator ALBUTEROL AccuNeb Asthma COPD Bronchospasm N/A Syrup NONE NONE 120ML NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Bronchodilator ALBUTEROL-SULFATE Proventil Asthma COPD Bronchospasm 2MG/5ML Syrup NONE NONE NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Calcium Channel Blocker DILTIAZEM Cardizem LA Hypertension     30MG TABLET 60 NONE NONE 30 Day Supply NONE NONE NONE Preferred, Quantity Limit NONE NONE NONE Medicaid
Calcium Channel Blocker DILTIAZEM Cardizem LA Hypertension     60MG TABLET 60 NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE NONE Medicaid
Calcium Channel Blocker DILTIAZEM Cardizem LA Hypertension     90MG TABLET 60 NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE NONE Medicaid
Calcium Channel Blocker DILTIAZEM Cardizem LA Hypertension     120MG TABLET 30 NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE NONE Medicaid
Calcium Channel Blocker VERAPAMIL Calan Angina Arrythmias Hypertension 80MG TABLET 30 30 60 30 Day Supply NONE NONE NONE Not Preferred, Quantity Limit NONE NONE NONE NONE
Calcium Channel Blocker VERAPAMIL Calan Angina Arrythmias Hypertension 120MG TABLET 30 30 60 30 Day Supply NONE NONE NONE Not Preferred, Quantity Limit NONE NONE NONE NONE
Calcium Channel Blocker VERAPAMIL Calan SR Angina Arrythmias Hypertension ER TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Quantity Limit NONE NONE NONE NONE
Calcium Channel Blocker VERAPAMIL Isoptin SR Angina Arrythmias Hypertension ER TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Quantity Limit NONE NONE NONE NONE
Calcium Channel Blocker VERAPAMIL Calan SR, Isoptin SR Angina Arrythmias Hypertension ER CAPSULE NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 Generic Generic, Tier 1 Generic, Tier 3 NONE CIP
Calcium Channel Blocker VERAPAMIL Verelan PM Angina Arrythmias Hypertension ER PM TABLET NONE NONE NONE NONE NONE NONE NONE NONE Generic, Tier 1, Dose Optimization Required NONE NONE NONE
Calcium Channel Blocker VERAPAMIL Verelan PM Angina Arrythmias Hypertension ER PM TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE
Calcium Channel Blocker VERAPAMIL Calan, Isoptin Angina Arrythmias Hypertension 40MG TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 2 NONE Medicaid
Calcium Channel Blocker VERAPAMIL Calan, Isoptin Angina Arrythmias Hypertension 80MG, 120MG TABLET NONE NONE NONE NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 2 NONE Cigna, Medicaid
Calcium Channel Blocker VERAPAMIL Isoptin Angina Arrythmias Hypertension   INJECTION NONE NONE NONE NONE Generic, Tier 4 NONE Generic, Tier 1 NONE NONE Generic, Tier 4 NONE NONE
Cardiac Glycoside DIGOXIN Digitek Mild to Moderate Heart Failure Chronic Atrial Fibrillation   0.125MG TABLET 30 NONE NONE NONE NONE NONE Tier 1, Quantity Limit, High Risk Medication NONE Tier 1 Tier 2, Quantity Limit, High Risk Medication NONE NONE
Cardiac Glycoside DIGOXIN Digitek Mild to Moderate Heart Failure Chronic Atrial Fibrillation   0.25MG TABLET 30 NONE NONE NONE NONE NONE Tier 1, Prior Authorization, High Risk Medication NONE NONE Tier 2, Prior Authorization, High Risk Medication NONE NONE
Cardiac Glycoside DIGOXIN Digitek, Lanoxin Mild to Moderate Heart Failure Chronic Atrial Fibrillation   0.125MG TABLET 30 NONE NONE NONE Generic, Tier 1, Gap Coverage, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit, High Risk Medication Generic, Preferred Generic, Tier 1 Generic, Tier 2, Quantity Limit, High Risk Medication Covis (Lanoxin) Cigna, Medicaid
Cardiac Glycoside DIGOXIN Digitek, Lanoxin Mild to Moderate Heart Failure Chronic Atrial Fibrillation   0.25MG TABLET 30 NONE NONE NONE Generic, Tier 1, Gap Coverage, Prior Authorization NONE Generic, Tier 1, Prior Authorization, High Risk Medication NONE NONE Generic, Tier 2, Prior Authorization, High Risk Medication Covis (Lanoxin) Cigna
Cardiac Glycoside DIGOXIN Lanoxin Mild to Moderate Heart Failure Chronic Atrial Fibrillation     INJECTION NONE NONE NONE NONE Generic, Tier 4, Prior Authorization NONE Generic, Tier 1 NONE NONE Generic, Tier 4 Covis NONE
Cardiac Glycoside DIGOXIN Lanoxin Mild to Moderate Heart Failure Chronic Atrial Fibrillation     ORAL SOLUTION NONE NONE NONE NONE NONE NONE Generic, Tier 1 NONE NONE Generic, Tier 4 Covis NONE
Cardiac Glycoside DIGOXIN Lanoxin Mild to Moderate Heart Failure Chronic Atrial Fibrillation     INJECTION NONE NONE NONE NONE NONE NONE NONE Preferred NONE NONE Covis Medicaid
Cardiac Glycoside DIGOXIN Lanoxin Mild to Moderate Heart Failure Chronic Atrial Fibrillation   62.5MCG TABLET NONE NONE NONE NONE NONE NONE Tier 1, Quantity Limit, High Risk Medication Not Preferred, Prior Authorization Tier 2 Tier 4, Quantity Limit, High Risk Medication Covis NONE
Cardiac Glycoside DIGOXIN Lanoxin Mild to Moderate Heart Failure Chronic Atrial Fibrillation   125 MCG TABLET 30 NONE NONE NONE NONE NONE Tier 1, Quantity Limit, High Risk Medication NONE Tier 2 Tier 4, Quantity Limit, High Risk Medication Covis NONE
Cardiac Glycoside DIGOXIN Lanoxin Mild to Moderate Heart Failure Chronic Atrial Fibrillation   187.5MCG TABLET NONE NONE NONE NONE NONE NONE Tier 1, Prior Authorization, High Risk Medication Not Preferred, Prior Authorization Tier 2 Tier 4, Prior Authorization, High Risk Medication Covis NONE
Cardiac Glycoside DIGOXIN Lanoxin Mild to Moderate Heart Failure Chronic Atrial Fibrillation   250MCG TABLET 30 NONE NONE NONE NONE NONE Tier 1, Prior Authorization, High Risk Medication NONE Tier 2 Tier 4, Prior Authorization, High Risk Medication Covis NONE
Cardioselective Beta Blocker ATENOLOL Tenormin Hypertension     25MG TABLET 30 30 30 NONE Tier 1, Gap Coverage Tier 1 Tier 1 NONE Tier 1 Tier 1 NONE Cigna
Cardioselective Beta Blocker ATENOLOL Tenormin Hypertension     50MG TABLET 30 30 30 NONE Tier 1, Gap Coverage Tier 1 Tier 1 NONE Tier 1 Tier 1 NONE Cigna
Cardioselective Beta Blocker ATENOLOL Tenormin Hypertension     100MG TABLET 30 30 30 30 Day Supply Tier 1, Gap Coverage Tier 1 Tier 1 NONE Tier 1 Tier 1 NONE Cigna
Cardioselective Beta Blocker BISOPROLOL/HCTZ Ziac Hypertension     2.5/6.25MG TABLET 30 30 30 NONE NONE NONE Tier 1, Quantity Limit NONE NONE Tier 3, Quantity Limit NONE CIP
Cardioselective Beta Blocker BISOPROLOL/HCTZ Ziac Hypertension     5/6.25MG TABLET 30 30 30 30 Day Supply NONE NONE Tier 1, Quantity Limit NONE NONE Tier 3, Quantity Limit NONE CIP
Cardioselective Beta Blocker BISOPROLOL/HCTZ Ziac Hypertension     10/6.25MG TABLET 30 30 30 30 Day Supply Tier 1, Gap Coverage NONE Tier 1 NONE Tier 1 Tier 3 NONE Cigna, CIP
Cardioselective Beta Blocker METOPROLOL Lopressor Angina Myocardial Infarct (MI) Hypertension 25MG TABLET 60 NONE NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Cardioselective Beta Blocker METOPROLOL Lopressor Angina Myocardial Infarct (MI) Hypertension 50MG TABLET 60 NONE NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Cardioselective Beta Blocker METOPROLOL Lopressor Angina Myocardial Infarct (MI) Hypertension 100MG TABLET 60 NONE NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Cardioselective Beta Blocker METOPROLOL-TARTRATE Lopressor Angina Myocardial Infarct (MI) Hypertension 25MG TABLET NONE 60 60 NONE Generic, Tier 1 NONE Generic, Tier 1 NONE NONE Generic, Tier 1 NONE Cigna
Cardioselective Beta Blocker METOPROLOL-TARTRATE Lopressor Angina Myocardial Infarct (MI) Hypertension 50MG TABLET NONE 60 60 NONE Generic, Tier 1 NONE Generic, Tier 1 NONE NONE Generic, Tier 1 NONE Cigna
Cardioselective Beta Blocker METOPROLOL-TARTRATE Lopressor Angina Myocardial Infarct (MI) Hypertension 100MG TABLET NONE 60 60 NONE Generic, Tier 1 NONE Generic, Tier 1 NONE NONE Generic, Tier 1 NONE Cigna
Cardioselective Beta Blocker & Diuretic ATENOLOL/CHLORTHALIDONE Tenoretic Hypertension     50/25MG TABLET 30 NONE NONE NONE Tier 1, Gap Coverage NONE Tier 1, Quantity Limit NONE Tier 1 Tier 1, Quantity Limit NONE Cigna
Cardioselective Beta Blocker & Diuretic ATENOLOL/CHLORTHALIDONE Tenoretic Hypertension     100/25MG TABLET 30 NONE 30 NONE Tier 1, Gap Coverage NONE Tier 1 NONE Tier 1 Tier 1 NONE Cigna
Cardioselective Beta Blocker & Diuretic ATENOLOL/CHLORTHALIDONE Tenoretic Hypertension     100MG TABLET NONE 30 NONE NONE Tier 1, Gap Coverage NONE Tier 1 NONE Tier 1 Tier 1 NONE Cigna
Central Alpha Agonist CLONIDINE Catapres Hypertension     0.1MG TABLET 30 30 30 30 Day Supply Tier 1, Gap Coverage NONE Tier 1 NONE Tier 1 Tier 1 NONE Cigna
Central Alpha Agonist CLONIDINE Catapres Hypertension     0.2MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Central Alpha-2 Agonist GUANFACINE Intuniv Hypertension     1MG TABLET 30 30 30 30 Day Supply NONE Generic, Tier 1, Quantity Limit NONE NONE Generic, Tier 1 NONE NONE NONE
Cholinergic PILOCARPINE Salagen Glaucoma Ocular Hypertension   1% OPHTHALMIC-SOLUTION 15 (15ml-bottle) NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Cholinergic PILOCARPINE Salagen Glaucoma Ocular Hypertension   2% OPHTHALMIC-SOLUTION 15 (15ml-bottle) NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Contraceptive MEDROXYPROGESTERONE Depo-Provera Birth Control     2.5MG TABLET 30 NONE 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Contraceptive MEDROXYPROGESTERONE Depo-Provera Birth Control     5MG TABLET 30 NONE 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Contraceptive MEDROXYPROGESTERONE Depo-Provera Birth Control     10MG TABLET 10 NONE 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Corticosteroid FLUOCINONIDE Lidex Itchy Skin Inflammation   0.05% CREAM 15,30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Corticosteroid FLUOCINONIDE-ACETONIDE Synalar Itchy Skin Inflammation   0.01% SOLUTION 60 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Corticosteroid HYDROCORTISONE Ala-Cort Skin Irritation Allergic Reactions   1% CREAM 30 (28.35-30g tube 30GM NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Corticosteroid HYDROCORTISONE Ala-Cort Skin Irritation Allergic Reactions   2.50% CREAM 30 (30gm-tube) 30GM 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Corticosteroid HYDROCORTISONE-AC Ala-Cort Hemmorhoids Anorectal Inflammation Pruritus Ani 25MG SUPPOSITORY 12 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Corticosteroid TRIAMCINOLONE Kenalog-40 Inflammation Itch Skin Irritation 0.03% CREAM 15,80 15,80 NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Corticosteroid TRIAMCINOLONE Kenalog-40 Inflammation Itch Skin Irritation 0.10% CREAM 15,80 15, 80 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Corticosteroid TRIAMCINOLONE Kenalog-40 Inflammation Itch Skin Irritation 0.50% CREAM 15 15 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Corticosteroid TRIAMCINOLONE Kenalog-40 Inflammation Itch Skin Irritation 0.10% OINTMENT 15,80 15, 80 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Corticosteroid TRIAMCINOLONE-ACETONIDE Aristocort Inflammation Itch Skin Irritation 0.03% CREAM NONE NONE 15, 80 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Corticosteroid TRIAMCINOLONE-ACETONIDE Aristocort Inflammation Itch Skin Irritation 0.10% CREAM NONE NONE 15, 80 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Corticosteroid TRIAMCINOLONE-ACETONIDE Aristocort Inflammation Itch Skin Irritation 0.50% CREAM NONE NONE 15 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Corticosteroid TRIAMCINOLONE-ACETONIDE Aristocort Inflammation Itch Skin Irritation 0.10% OINTMENT NONE NONE 15, 80 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Cough Supressant BENZONATATE Zonatuss Cough     100MG CAPSULE 14 14 14 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Cough Supressant & Antihistamine Dextromethorphan-Promethazine N/A Cough Allergies Nausea & Vomiting 15-6.25MG/5ML Syrup NONE NONE NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Cough Supressant & Expectorant Dextromethorphan-Guaifenesin Aquatab DM Cough Cold Bronchitis 10-100MG/5ML Liquid NONE NONE NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Diuretic AMILORIDE/HCTZ Moduretic Edema Hypertension Congestive Heart Failure (CHF) 550 TABLET 30 NONE 30 NONE Tier 1, Gap Coverage NONE Tier 1 NONE Tier 1 Tier 2 NONE Cigna
Diuretic BUMETANIDE Bumex Edema Congestive Heart Failure   0.5MG TABLET 30 30 NONE NONE Tier 1, Gap Coverage Tier 1, Quantity Limit Tier 1 NONE Tier 1 Tier 1 NONE Cigna
Diuretic BUMETANIDE Bumex Edema Congestive Heart Failure   1MG TABLET 30 30 NONE NONE Tier 1, Gap Coverage Tier 1, Quantity Limit Tier 1 NONE Tier 1 Tier 1 NONE Cigna
Diuretic BUMETANIDE Bumex Edema Congestive Heart Failure   2MG TABLET NONE NONE NONE NONE Tier 2, Gap Coverage Tier 1, Quantity Limit Tier 1 NONE Tier 1 Tier 1 NONE NONE
Diuretic BUMETANIDE Bumex Edema Congestive Heart Failure     INJECTION NONE NONE NONE NONE Tier 4 NONE Tier 1 NONE NONE Tier 4 NONE NONE
Diuretic CHLOROTHIAZIDE Diuril Hypertension Edema   250MG TABLET NONE NONE 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Diuretic CHLOROTHIAZIDE Diuril Hypertension Edema   500MG TABLET NONE NONE 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Diuretic CHLORTHALIDONE Thalitone Hypertension Edema   25MG TABLET NONE 30 NONE NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Preferred Generic, Tier 1 Generic, Tier 2 NONE Cigna, Medicaid
Diuretic CHLORTHALIDONE Thalitone Hypertension Edema   50MG TABLET NONE 30 NONE NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Preferred Generic, Tier 1 Generic, Tier 2 NONE Cigna
Diuretic FUROSEMIDE Lasix Hypertension Edema   20MG TABLET 30 30 30 30 Day Supply Generic, Tier 1, Gap Coverage NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 1 NONE Cigna
Diuretic FUROSEMIDE Lasix Hypertension Edema   40MG TABLET 30 30 30 30 Day Supply Generic, Tier 1, Gap Coverage NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 1 NONE Cigna
Diuretic FUROSEMIDE Lasix Hypertension Edema   80MG TABLET 30 30 30 30 Day Supply Generic, Tier 1, Gap Coverage NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 1 NONE Cigna
Diuretic FUROSEMIDE Lasix Hypertension Edema     ORAL SOLUTION NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE NONE
Diuretic FUROSEMIDE Lasix Hypertension Edema     INJECTION NONE NONE NONE NONE Generic, Tier 4 Generic, Tier 1 Generic, Tier 1, Medicare Part B/D, Prior Authorization NONE NONE Generic, Tier 4, Medicare Part B/D, Prior Authorization NONE NONE
Diuretic HYDROCHLOROTHIAZIDE Microzide Hypertension Edema   12.5MG CAPSULE 30 NONE 30 30 Day Supply Generic, Tier 1, Gap Coverage Generic, Tier 1, Quantity Limit Generic, Tier 1 Generic, Preferred Generic, Tier 1 Generic, Tier 1 NONE Cigna, Medicaid
Diuretic HYDROCHLOROTHIAZIDE Esidrix Hypertension Edema   12.5MG TABLET NONE 30 NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1, Quantity Limit Generic, Tier 1 Generic, Preferred Generic, Tier 1 Generic, Tier 1 NONE Medicaid
Diuretic HYDROCHLOROTHIAZIDE Esidrix Hypertension Edema   25MG TABLET 30 30 30 30 Day Supply Generic, Tier 1, Gap Coverage Generic, Tier 1, Quantity Limit Generic, Tier 1 Generic, Preferred Generic, Tier 1 Generic, Tier 1 NONE Cigna, Medicaid
Diuretic HYDROCHLOROTHIAZIDE Esidrix Hypertension Edema   50MG TABLET 30 30 30 30 Day Supply Generic, Tier 1, Gap Coverage Generic, Tier 1, Quantity Limit Generic, Tier 1 Generic, Preferred Generic, Tier 1 Generic, Tier 1 NONE Cigna, Medicaid
Diuretic INDAPAMIDE Lozol Hypertension Edema   1.25MG TABLET 30 30 30 NONE Generic, Tier 1, Gap Coverage Generic, Tier 1, Quantity Limit Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE Cigna
Diuretic INDAPAMIDE Lozol Hypertension Edema   2.5MG TABLET 30 30 30 NONE Generic, Tier 1, Gap Coverage Generic, Tier 1, Quantity Limit Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE Cigna
Diuretic SPIRONOLACTONE Aldactone Edema Hypertension   25MG TABLET 30 30 30 30 Day Supply Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 2 NONE Cigna, Medicaid
Diuretic SPIRONOLACTONE Aldactone Edema Hypertension   50MG, 100MG TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 2 NONE Medicaid
Diuretic SPIRONOLACTONE HCTZ Aldactazide Edema Hypertension     TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2, Quantity Limit NONE NONE
Diuretic TRIAMTERENE/HCTZ Dyazide Edema Hypertension   37.5MG/25MG CAPSULE 30 NONE NONE NONE Generic, Tier 1, Gap Coverage NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2, Quantity Limit NONE Cigna
Diuretic TRIAMTERENE/HCTZ Dyazide Edema Hypertension   37.5MG/25MG TABLET 30 30 NONE NONE NONE NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2, Quantity Limit NONE NONE
Diuretic TRIAMTERENE/HCTZ Dyazide Edema Hypertension   75MG/50MG TABLET 30 30 30 NONE NONE NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2, Quantity Limit NONE NONE
Diuretic TRIAMTERENE/HCTZ Dyazide Edema Hypertension   25MG/50MG CAPSULE NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2, Quantity Limit NONE NONE
Estrogen Agonists-Antagonist CLOMIPHENE CITRATE Clomid Female Infertility     50MG TABLET NONE NONE 5 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Expectorant GUAIFENESIN Mucinex Chest and Nasal Congestion Sinus Pressure   DM SYRUP 120 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Expectorant & Decongestant GUAIFENEX Ami-Tex Chest and Nasal Congestion Sinus Pressure Cold & Flu DM ER-TABLET 60 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Glucocorticoid DEXAMETHASONE Dexpak Arthritis Inflammation   0.5MG TABLET 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Glucocorticoid DEXAMETHASONE Dexpak Arthritis Inflammation   0.75MG TABLET 12 12 18 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Glucocorticoid DEXAMETHASONE Dexpak Arthritis Inflammation   4MG TABLET 6 18 12 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Glucocorticoid METHYLPREDNISOLONE Medrol Asthma Allergic Reactions Inflammation 4MG DOSE-PAK 21 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Glucocorticoid METHYLPREDNISOLONE Medrol Asthma Allergic Reactions Inflammation 4MG TABLET 21 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Glucocorticoid PREDNISONE Deltasone Corticosteroid-responsive Disorders Inflammation Severe Allergies 5MG DOSEPACK 6, 21,48 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Glucocorticoid PREDNISONE Deltasone Corticosteroid-responsive Disorders Inflammation Severe Allergies 10MG DOSEPACK 21,48 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Glucocorticoid PREDNISONE Deltasone Corticosteroid-responsive Disorders Inflammation Severe Allergies 2.5MG TABLET 30 NONE 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Glucocorticoid PREDNISONE Deltasone Corticosteroid-responsive Disorders Inflammation Severe Allergies 5MG TABLET 30 NONE 21,30,48 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Glucocorticoid PREDNISONE Deltasone Corticosteroid-responsive Disorders Inflammation Severe Allergies 10MG TABLET 30 NONE 21,48 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Glucocorticoid PREDNISONE Deltasone Corticosteroid-responsive Disorders Inflammation Severe Allergies 20MG TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
H2 Blocker FAMOTIDINE Pepcid, Fluxid Gastroesophageal Reflux Disease (GERD) Gastrointestinal Ulcers   20MG TABLET 60 60 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
H2 Blocker RANITIDINE Zantac, Deprizine Gastroesophageal Reflux Disease (GERD) Pathological Hypersecretory Conditions Gastrointestinal Ulcers 150MG TABLET 60 60 60 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
H2 Blocker RANITIDINE Zantac, Deprizine Gastroesophageal Reflux Disease (GERD) Pathological Hypersecretory Conditions Gastrointestinal Ulcers 300MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Histamine-H2 Blocker CIMETIDINE Tagamet Gastroesophageal Reflux Disease (Gerd) Heartburn Gastrointenstinal Ulcers 800MG TABLET 30 30 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
HMG-CoA Reductase Inhibitor LOVASTATIN Altoprev Hypercholesterolemia Coronary Artery Disease (Preventative)   10MG TABLET 30 30 30 30 Day Supply NONE NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE
HMG-CoA Reductase Inhibitor LOVASTATIN Altoprev Hypercholesterolemia Coronary Artery Disease (Preventative)   20MG TABLET 30 30 30 30 Day Supply NONE NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE
HMG-CoA Reductase Inhibitor LOVASTATIN Altoprev, Mevacor Hypercholesterolemia Coronary Artery Disease (Preventative)   10MG TABLET 30 30 30 30 Day Supply Generic, Tier 1, Gap Coverage, Quantity Limit NONE Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1, Quantity Limit, Dose Optimization Required Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
HMG-CoA Reductase Inhibitor LOVASTATIN Altoprev, Mevacor Hypercholesterolemia Coronary Artery Disease (Preventative)   20MG TABLET 30 30 30 30 Day Supply Generic, Tier 1, Gap Coverage, Quantity Limit NONE Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1, Quantity Limit, Dose Optimization Required Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
HMG-CoA Reductase Inhibitor LOVASTATIN Altoprev, Mevacor Hypercholesterolemia Coronary Artery Disease (Preventative)   40MG TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage, Quantity Limit NONE Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1, Quantity Limit, Dose Optimization Required Generic, Tier 1, Quantity Limit NONE Medicaid
HMG-CoA Reductase Inhibitor LOVASTATIN Mevacor Hypercholesterolemia Coronary Artery Disease (Preventative)   10MG, 20MG TABLET 30 30 30 30 Day Supply NONE NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE
HMG-CoA Reductase Inhibitor LOVASTATIN Mevacor Hypercholesterolemia Coronary Artery Disease (Preventative)   40MG TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE
HMG-CoA Reductase Inhibitor PRAVASTATIN Pravachol Coronary Artery Disease Myocardial Infarction (preventative)   20MG TABLET 30 NONE NONE NONE Generic, Tier 1, Gap Coverage, Quantity Limit Generic, Tier 1, Quantity Limit Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1, Quantity Limit, Dose Optimization Required Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
HMG-CoA Reductase Inhibitor PRAVASTATIN Pravachol Coronary Artery Disease Myocardial Infarction (preventative)   40MG TABLET 30 NONE NONE NONE Generic, Tier 1, Gap Coverage, Quantity Limit Generic, Tier 1, Quantity Limit Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1, Quantity Limit, Dose Optimization Required Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
HMG-CoA Reductase Inhibitor PRAVASTATIN Pravachol Coronary Artery Disease Myocardial Infarction (preventative)   10MG TABLET 30 NONE NONE NONE Generic, Tier 1, Gap Coverage, Quantity Limit Generic, Tier 1, Quantity Limit Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1, Quantity Limit, Dose Optimization Required Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
HMG-CoA Reductase Inhibitor PRAVASTATIN Pravachol Coronary Artery Disease Myocardial Infarction (preventative)   80MG TABLET NONE NONE NONE NONE Generic, Tier 1, Gap Coverage, Quantity Limit Generic, Tier 1, Quantity Limit Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1, Quantity Limit, Dose Optimization Required Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
HMG-CoA Reductase Inhibitor PRAVASTATIN Pravachol Coronary Artery Disease Myocardial Infarction (preventative)   10MG, 20MG, 40MG TABLET 30 NONE NONE NONE NONE NONE NONE Not Preferred, Quantity Limit NONE NONE NONE NONE
HMG-CoA Reductase Inhibitor PRAVASTATIN Pravachol Coronary Artery Disease Myocardial Infarction (preventative)   80MG TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Quantity Limit NONE NONE NONE NONE
Hormone NORGESTIMATE-ETHINYL ESTRADIOL (TRIPHASIC) Sprintec Contraceptive     0.25/0.035 TABLET NONE NONE 28 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Hormone NORGESTIMATE-ETHINYL ESTRADIOL Tri-Sprintec Contraception Acne   6X28CT TABLET NONE NONE 28 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Laxative LACTULOSE Constulose Constipation     10GM/15ML SYRUP 237ml 37ml 473ml 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Mineral (Fluoride) FLUORIDE N/A Dental Caries (Preventative) Tooth Decay (Preventative)   CHW-TAB 0.35MG* NONE NONE 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Mineral (Potassium Chloride) POTASSIUM-CHLORIDE KLORCON Hypokalemia     M10 TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Mineral (Potassium Chloride) POTASSIUM-CHLORIDE KLORCON-8 Hypokalemia     8MEQ ER-TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Mineral (Potassium Chloride) POTASSIUM-CHLORIDE KLORCON-10 Hypokalemia     10MEQ ER-TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Mineral (Sodium Fluoride) SODIUM FLUORIDE ETHEDENT Dental Caries (Preventative) Tooth Decay (Preventative)   0.25MG CHEWABLE-TABLET 120 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Mineral Supplement MAGNESIUM-CHLORIDE MAG64 Low Magnesium     64MG TABLET 60 60 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Mineral Supplement MAGNESIUM-CHLORIDE MAG-SR Low Magnesium     64MG TABLET NONE NONE 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Mineral Supplement SELENIUM N/A Atherosclerosis Stroke Arthritis 2.50% LOTION-SHAMPOO NONE NONE NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Mineral Supplement SELENIUM-SULFATE N/A Atherosclerosis Stroke Arthritis 2.50% LOTION 120 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Mineral Supplement or Laxative MAGNESIUM-OXIDE N/A Low Magnesium Constipation   400MG TABLET 30 30 60 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Muscle Relaxant BACLOFEN Kemstro Multiple Sclerosis Spinal Cord Injury or Disease   10MG TABLET 30 30 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Muscle Relaxant CYCLOBENZAPRINE Amrix Muscle Spasms     5MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Muscle Relaxant CYCLOBENZAPRINE Amrix Muscle Spasms     10MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Nitrate ISOSORBIDE-DINITRATE Isordil Titradose Prophylaxis Angina   2.5MG SL NONE NONE 60 NONE NONE Generic, Tier 1 Generic, Tier 1 Generic, Preferred Generic, Tier 1 Generic, Tier 2 NONE Medicaid
Nitrate ISOSORBIDE-DINITRATE Isordil Titradose Prophylaxis Angina   5MG SL NONE NONE 60 NONE NONE Generic, Tier 1 Generic, Tier 1 Generic, Preferred Generic, Tier 1 Generic, Tier 2 NONE Medicaid
Nitrate ISOSORBIDE-MONONITRATE Monoket, Imdur, Ismo Prophylaxis Angina   30MG ER-TABLET 30 30 30 NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 NONE NONE Generic, Tier 2 NONE NONE
Nitrate ISOSORBIDE-MONONITRATE Monoket, Imdur, Ismo Prophylaxis Angina   60MG ER-TABLET 30 30 30 NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 NONE NONE Generic, Tier 2 NONE NONE
Nitrate ISOSORBIDE-MONONITRATE Monoket, Imdur, Ismo Prophylaxis Angina     TABLET NONE NONE NONE NONE Generic, Tier 3, Gap Coverage NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE Cigna
Noncardioselective Beta Blocker PROPRANOLOL Inderal Angina Arrythmias Hypertension 10MG TABLET 60 60 NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Noncardioselective Beta Blocker PROPRANOLOL Inderal Angina Arrythmias Hypertension 20MG TABLET 60 60 NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Noncardioselective Beta Blocker PROPRANOLOL Inderal Angina Arrythmias Hypertension 40MG TABLET 60 60 NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Noncardioselective Beta Blocker PROPRANOLOL Inderal Angina Arrythmias Hypertension 80MG TABLET 60 60 NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Noncardioselective beta-blocker NADOLOL Corgard Angina Hypertension   20MG TABLET 30 NONE NONE NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Preferred Generic, Tier 1 Generic, Tier 3 NONE Cigna, Medicaid, CIP
Noncardioselective beta-blocker NADOLOL Corgard Angina Hypertension   40MG TABLET 30 NONE NONE NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Preferred Generic, Tier 1 Generic, Tier 3 NONE Cigna, Medicaid, CIP
Noncardioselective beta-blocker NADOLOL Corgard Angina Hypertension   80MG TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Preferred Generic, Tier 1 Generic, Tier 3 NONE Medicaid, CIP
Noncardioselective beta-blocker PINDOLOL Visken Hypertension     5MG TABLET 30 NONE NONE NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 3 NONE Cigna, CIP
Noncardioselective beta-blocker PINDOLOL Visken Hypertension     10MG TABLET 30 NONE NONE NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 3 NONE Cigna, CIP
Noncardioselective beta-blocker/alpha-1 blocker Carvedilol Coreg Heart Failure (Mild to Severe) Hypertension   3.125mg TABLET 60 60 60 30 Day Supply Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 1 GlaxoSmithKline Cigna
Noncardioselective beta-blocker/alpha-1 blocker Carvedilol Coreg Heart Failure (Mild to Severe) Hypertension   6.25mg TABLET 60 60 60 30 Day Supply Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 1 GlaxoSmithKline Cigna
Noncardioselective beta-blocker/alpha-1 blocker Carvedilol Coreg Heart Failure (Mild to Severe) Hypertension   12.5mg TABLET 60 60 60 30 Day Supply Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 1 GlaxoSmithKline Cigna
Noncardioselective beta-blocker/alpha-1 blocker Carvedilol Coreg Heart Failure (Mild to Severe) Hypertension   25mg TABLET 60 60 60 30 Day Supply Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 1 GlaxoSmithKline Cigna
Noncardioselective beta-blocker/alpha-1 blocker Carvedilol Coreg Heart Failure (Mild to Severe) Hypertension     TABLET 60 60 60 30 Day Supply NONE NONE NONE Not Preferred, Quantity Limit NONE NONE GlaxoSmithKline NONE
Noncardioselective beta-blocker/alpha-1 blocker Carvedilol Coreg CR Heart Failure (Mild to Severe) Hypertension   EXTENDED RELEASE TABLET 60 60 60 30 Day Supply Tier 3 NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE GlaxoSmithKline Cigna
Nonsteroidal Anti-Inflammatory Drug (NSAID) DICLOFENAC Voltaren Osteoarthritis     75MG-DR TABLET 60 60 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Nonsteroidal Anti-Inflammatory Drug (NSAID) IBUPROFEN Advil, Motrin Pain Arthritis   100/5ML SUSPENSION 120 20 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Nonsteroidal Anti-Inflammatory Drug (NSAID) IBUPROFEN Advil, Motrin Pain Arthritis   400MG TABLET 90 90 90 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Nonsteroidal Anti-Inflammatory Drug (NSAID) IBUPROFEN Advil, Motrin Pain Arthritis   600MG TABLET 60 60 60 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Nonsteroidal Anti-Inflammatory Drug (NSAID) IBUPROFEN Advil, Motrin Pain Arthritis   800MG TABLET 30 30 60 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Nonsteroidal Anti-Inflammatory Drug (NSAID) INDOMETHACIN Indocin Acute Shoulder Pain Rheumatoid Arthritis & Osteoarthritis Gouty Arthritis 25MG CAPSULE 60 60 60 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Nonsteroidal Anti-Inflammatory Drug (NSAID) MELOXICAM Mobic Osteoarthritis Rheumatoid Arthritis Juvenile Rheumatoid Arthritis 7.5MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Nonsteroidal Anti-Inflammatory Drug (NSAID) MELOXICAM Mobic Osteoarthritis Rheumatoid Arthritis Juvenile Rheumatoid Arthritis 15MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Nonsteroidal Anti-Inflammatory Drug (NSAID) NAPROXEN Aleve Pain Arthritis   250MG TABLET NONE NONE 60 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Nonsteroidal Anti-Inflammatory Drug (NSAID) NAPROXEN Aleve Pain Arthritis   375MG TABLET 60 60 60 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Nonsteroidal Anti-Inflammatory Drug (NSAID) NAPROXEN Aleve Pain Arthritis   500MG TABLET 60 60 60 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Nonsteroidal Anti-Inflammatory Drug (NSAID) PIROXICAM Feldene Pain Arthritis Inflammation 20MG CAPSULE 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Nonsteroidal Anti-Inflammatory Drug (NSAID) SALSALATE Disalcid Inflammation Arthritis Pain 500MG TABLET 60 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
NSAID + Prostaglandin E1 Analog DICLOFENAC SOD Voltaren Osteoarthritis Rheumatoid Arthritis   TAB 75MG NONE NONE 60 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Nutritional Supplement FOLIC-ACID N/A Pregnancy (Prenatal & Postnatal) Anemia (certain types)   1MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Nutritional Supplement MULTI-VITAMIN N/A Nutrient Deficiency (Preventative)     0.25MG CHEWABLE-TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Nutritional Supplement MULTI-VITAMIN/FL/FE N/A Nutrient Deficiency (Preventative)       CHEWABLE-TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Nutritional Supplement MULTI-VITBET N/A Nutrient Deficiency (Preventative)     0.5MGFL CHEWABLE-TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Nutritional Supplement MULTI-VITBET/FL N/A Nutrient Deficiency (Preventative)     1MG CHEWABLE-TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Opioid TRAMADOL-HCL Ultram Pain     50MG TABLET 60 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Prenatal Vitamin NATALCARE N/A Pregnancy (Prenatal)     PIC TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Prenatal Vitamin NATALCARE N/A Pregnancy (Prenatal)     PLUS TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Prenatal Vitamin PRENATAL N/A Pregnancy (Prenatal)     RX TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Prenatal Vitamin PRENATAL PLUS N/A Pregnancy (Prenatal)     VITAMIN TABLET NONE NONE 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Prenatal Vitamin PRENATAL-VITAMINS N/A Pregnancy (Prenatal)     N/A TABLET NONE NONE NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Sedative & Antihistamine HYDROXYZINE-HCL Atarax Anxiety Tension Allergic Reactions 10MG/5ML SYRUP 120 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Selective Serotonin Reuptake Inhibitor (SSRI) CITALOPRAM Celexa Depression     20MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Selective Serotonin Reuptake Inhibitor (SSRI) CITALOPRAM Celexa Depression     40MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Selective Serotonin Reuptake Inhibitor (SSRI) FLUOXETINE Prozac Panic Disorder Obsessive Compulsive Disorder (OCD) Major Depressive Disorder (MDD) 10MG TABLET 30 30 NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Selective Serotonin Reuptake Inhibitor (SSRI) FLUOXETINE Prozac Panic Disorder Obsessive Compulsive Disorder (OCD) Major Depressive Disorder (MDD) 10MG CAPSULE 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Selective Serotonin Reuptake Inhibitor (SSRI) FLUOXETINE Prozac Panic Disorder Obsessive Compulsive Disorder (OCD) Major Depressive Disorder (MDD) 20MG CAPSULE 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Selective Serotonin Reuptake Inhibitor (SSRI) FLUOXETINE Prozac Panic Disorder Obsessive Compulsive Disorder (OCD) Major Depressive Disorder (MDD) 40MG* CAPSULE 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Selective Serotonin Reuptake Inhibitor (SSRI) FLUVOXAMINE MALEATE Luvox Obsessive Compulsive Disorder (OCD) Depression   25MG TABLET NONE NONE 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Selective Serotonin Reuptake Inhibitor (SSRI) PAROXETINE Paxil Panic Disorder, Social Anxiety Disorder Premenstrual Dysphoric Disorder (PMDD) Major Depressive Disorder (MDD) 10MG TABLET 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Selective Serotonin Reuptake Inhibitor (SSRI) PAROXETINE Paxil Panic Disorder, Social Anxiety Disorder Premenstrual Dysphoric Disorder (PMDD) Major Depressive Disorder (MDD) 20MG TABLET 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Selective Serotonin Reuptake Inhibitor (SSRI) PAROXETINE-HCL Paxil Panic Disorder, Social Anxiety Disorder Premenstrual Dysphoric Disorder (PMDD) Major Depressive Disorder (MDD) 10MG TABLET NONE NONE NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Selective Serotonin Reuptake Inhibitor (SSRI) PAROXETINE-HCL Paxil Panic Disorder, Social Anxiety Disorder Premenstrual Dysphoric Disorder (PMDD) Major Depressive Disorder (MDD) 20MG TABLET NONE NONE NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Serotonin antagonist and reuptake inhibitor TRAZODONE Desyrel Depression     50MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Serotonin antagonist and reuptake inhibitor TRAZODONE Desyrel Depression     100MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Serotonin antagonist and reuptake inhibitor TRAZODONE Desyrel Depression     150MG TABLET 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Steroid & Antifungal BETAMETHASONE-DIPROPIONATE Diprolene Fungal Skin Infection     0.05% CREAM NONE 15,45 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Steroid & Antifungal BETAMETHASONE-VALERATE Luxiq Fungal Skin Infection     0.10% CREAM NONE 15,45 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Steroid & Antifungal BETAMETHASONE-VALERATE Luxiq Fungal Skin Infection     0.10% OINTMENT NONE 15,45 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Steroid Hormone ESTRADIOL Estring, Vagifem Menopause Osteoporosis   0.5MG TABLET 30 NONE 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Steroid Hormone ESTRADIOL Estring, Vagifem Menopause Osteoporosis   1MG TABLET 30 NONE 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Steroid Hormone ESTRADIOL Estring, Vagifem Menopause Osteoporosis   2MG TABLET 30 NONE 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Steroid Hormone ESTROPIPATE Ogen Menopause Osteoporosis   0.75MG TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Steroid Hormone ESTROPIPATE Ogen Menopause Osteoporosis   1.5MG TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Supplement POTASSIUM-CHLORIDE Klor Con Hypokalemia Digitalis Intoxication (without AV block)   10% LIQUID 473ml NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Synthetic Steroid Hormone MEGESTROL Megace Breast Cancer Uterine Cancer   20MG TABLET 30 NONE 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Synthetic Thyroid Hormone LEVOTHYROXINE Synthroid Hypothyroidism     25mcg TABLET 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Synthetic Thyroid Hormone LEVOTHYROXINE Synthroid Hypothyroidism     50mcg TABLET 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Synthetic Thyroid Hormone LEVOTHYROXINE Synthroid Hypothyroidism     75mcg TABLET 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Synthetic Thyroid Hormone LEVOTHYROXINE Synthroid Hypothyroidism     88mcg TABLET 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Synthetic Thyroid Hormone LEVOTHYROXINE Synthroid Hypothyroidism     100mcg TABLET 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Synthetic Thyroid Hormone LEVOTHYROXINE Synthroid Hypothyroidism     112mcg TABLET 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Synthetic Thyroid Hormone LEVOTHYROXINE Synthroid Hypothyroidism     125mcg TABLET 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Synthetic Thyroid Hormone LEVOTHYROXINE Synthroid Hypothyroidism     137mcg TABLET NONE 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Synthetic Thyroid Hormone LEVOTHYROXINE Synthroid Hypothyroidism     150mcg TABLET 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Synthetic Thyroid Hormone LEVOTHYROXINE Synthroid Hypothyroidism     175mcg TABLET 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Synthetic Thyroid Hormone LEVOTHYROXINE Synthroid Hypothyroidism     200mcg TABLET 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tetracycline DOXYCYCLINE-HYC Doryx Severe Acne     50MG CAPSULE 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tetracycline DOXYCYCLINE-HYC Doryx Severe Acne     100MG CAPSULE 20 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tetracycline DOXYCYCLINE-HYC Doryx Severe Acne     100MG TABLET 20 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tricyclic DOXEPIN-HCL Silenor Anxiety Depression   10MG CAPSULE 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tricyclic DOXEPIN-HCL Silenor Anxiety Depression   25MG CAPSULE 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tricyclic DOXEPIN-HCL Silenor Anxiety Depression   50MG CAPSULE 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tricyclic DOXEPIN-HCL Silenor Anxiety Depression   75MG CAPSULE 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tricyclic DOXEPIN-HCL Silenor Anxiety Depression   100MG CAPSULE 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tricyclic NORTRIPTYLINE Pamelor Depression     10MG CAPSULE 30 30 30 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tricyclic NORTRIPTYLINE Pamelor Depression     25MG CAPSULE 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tricyclic PROMETHAZINE Phenergan Motion Sickness Perioperative Nausea and Vomiting   25MG TABLET 12 12 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tricyclic PROMETHAZINE Phenergan Motion Sickness Perioperative Nausea and Vomiting   6.25/5ML* SYRUP 180ml 80ml 120ml 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tricyclic PROMETHAZINE-HYDROCHLORIDE Phenergan Motion Sickness Perioperative Nausea and Vomiting   25MG TABLET NONE NONE NONE 30 Day Supply Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tricyclic & Cough Suppressant PROMETHAZINE DEXTROMETHORPHAN N/A Cold Allergies Hay Fever DM SYRUP 120ml 120ml 120ml NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tricyclic antidepressant AMITRIPTYLINE Elavil Depression     100MG TABLET 30 30 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tricyclic antidepressant AMITRIPTYLINE Elavil Depression     10MG TABLET 30 30 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tricyclic antidepressant AMITRIPTYLINE Elavil Depression     25MG TABLET 30 30 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tricyclic antidepressant AMITRIPTYLINE Elavil Depression     50MG TABLET 30 30 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Tricyclic antidepressant AMITRIPTYLINE Elavil Depression     75MG TABLET 30 30 NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Urinary Tract Analgesic PHENAZOPYRIDINE Phenzo Urinary Tract Discomfort     100MG TABLET 6 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Urinary Tract Analgesic PHENAZOPYRIDINE Phenzo Urinary Tract Discomfort     200MG TABLET 30 NONE NONE NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Vasodilator HYDRALAZINE Apresoline Heart Failure     10MG TABLET 30 30 30 30 Day Supply Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 NONE NONE Generic, Tier 2 NONE NONE
Vasodilator HYDRALAZINE Apresoline Heart Failure     25MG TABLET 30 30 30 NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE NONE
Vasodilator HYDRALAZINE Apresoline Heart Failure       INJECTION NONE NONE NONE NONE Generic, Tier 4 NONE Generic, Tier 1 NONE NONE Generic, Tier 4 NONE NONE
Xanthine oxidase inhibitor ALLOPURINOL Zyloprim Gout     100MG TABLET 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Xanthine oxidase inhibitor ALLOPURINOL Zyloprim Gout     300MG TABLET 30 30 30 NONE Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted Unlisted
Beta Blocker ACEBUTOLOL HCL Sectral Angina Hypertension Arrythmias   CAPSULE NONE NONE NONE NONE Tier 2, Gap Coverage Tier 1 Tier 1 NONE Tier 1 Tier 3 NONE Cigna
Carbonic Anhydrase Inhibitor ACETAZOLAMIDE Diamox Sequels Gluacoma Altitude Sickness Epileptic Seizure ER TABLET NONE NONE NONE NONE Tier 2, Gap Coverage NONE Tier 1 NONE NONE Tier 4 NONE NONE
Carbonic Anhydrase Inhibitor ACETAZOLAMIDE Diamox Gluacoma Altitude Sickness Epileptic Seizure   TABLET NONE NONE NONE NONE NONE Tier 1, Quantity Limit Tier 1 NONE NONE Tier 2 NONE CIP
Carbonic Anhydrase Inhibitor ACETAZOLAMIDE-SODIUM Diamox Gluacoma Altitude Sickness Epileptic Seizure   INJECTION NONE NONE NONE NONE Tier 4 NONE Tier 1 NONE NONE Tier 4 NONE NONE
Calcium Channel Blocker NIFEDIPINE Adalat Angina Hypertension       NONE NONE NONE NONE NONE NONE NONE Not Preferred, Quantity Limit NONE NONE NONE NONE
Bronchiodilator & Corticosteroid SALMETEROL-FLUTICASONE PROPIONATE Advair Diskus HFA Asthma       NEBULIZER-SOLUTION NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE GlaxoSmithKline Medicaid
Antihyperlipidemic NIACIN XR-LOVASTATIN Advicor Hypercholesterolemia       TABLET NONE NONE NONE NONE NONE Tier 3 NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE
Corticosteroid FLUNISOLIDE Aerospan Asthma       INHALATION AEROSOL NONE NONE NONE NONE NONE NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE
Calcium Channel Blocker NIFEDIPINE Afeditab CR Angina Hypertension Arrythmias   TABLET NONE NONE NONE NONE Tier 2, Gap Coverage NONE Tier 1 NONE Tier 1, Dose Optimization Required Tier 2 NONE Medicaid
Calcium Channel Blocker NIFEDIPINE Nifediac CC Angina Hypertension Arrythmias   TABLET NONE NONE NONE NONE Tier 2, Gap Coverage NONE NONE NONE Tier 1, Dose Optimization Required NONE NONE NONE
Calcium Channel Blocker NIFEDIPINE Nifediac XL Angina Hypertension Arrythmias   TABLET NONE NONE NONE NONE Tier 2, Gap Coverage NONE Tier 1 NONE Tier 1, Dose Optimization Required Tier 2 NONE NONE
Calcium Channel Blocker NIFEDIPINE Adalat, Afeditab CR, Nifediac CC, Nifediac XL Angina Hypertension Arrythmias   TABLET NONE NONE NONE NONE NONE NONE NONE NONE Generic, Tier 1 NONE NONE NONE
Calcium Channel Blocker NIFEDIPINE Procardia XL Angina Hypertension Arrythmias ER TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Preferred, Quantity Limit Generic, Tier 1, Dose Optimization Required Generic, Tier 2 NONE Medicaid
Calcium Channel Blocker NIFEDIPINE Procardia XL Angina Hypertension Arrythmias ER TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Quantity Limit NONE NONE NONE NONE
Salicylate & Anticoagulant ASPIRIN-DIPYRIMADOLE Aggrenox Stroke (Preventative)       CAPSULE NONE NONE NONE NONE Tier 3, Quantity Limit Tier 2 Tier 1 Preferred NONE Tier 3 Boehringer Cigna, Ambetter, Medicaid, CIP
Anticholinergic & Bronchiodilator ALBUTEROL-IPRATROPIUM Combivent Respimat COPD Severe Asthma     NEBULIZER-SOLUTION NONE NONE NONE NONE NONE NONE NONE Generic, Not Preferred, Prior Authorization, Quantity Limit NONE NONE Boehringer NONE
Anticholinergic & Bronchiodilator ALBUTEROL-IPRATROPIUM Combivent Respimat COPD Severe Asthma     NEBULIZER-SOLUTION NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE Boehringer NONE
Corticosteroid CICLESONIDE Alvesco Asthma       INHALATION AEROSOL NONE NONE NONE NONE NONE NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE
Diuretic AMILORIDE Midamor Hypertension Congestive Heart Failure (CHF)     TABLET NONE NONE NONE NONE Tier 2, Gap Coverage Tier 1 Tier 1 NONE Tier 1 Tier 2 NONE NONE
Antifibrinolytic AMINOCAPROIC ACID Amicar Bleeding         NONE NONE NONE NONE NONE NONE NONE NONE Tier 3 NONE NONE NONE
Antiarrhythmic AMIODORONE Pacerone Arrhythmias       TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Preferred Generic, Tier 1 Generic, Tier 1 NONE Medicaid
Antiarrhythmic AMIODORONE Pacerone Arrhythmias       TABLET NONE NONE NONE NONE NONE Tier 2, Gap Coverage Tier 1, Gap Coverage NONE Tier 1 Tier 1, Gap Coverage NONE Ambetter
Antiarrhythmic AMIODORONE Pacerone Arrhythmias       INJECTION NONE NONE NONE NONE Generic, Tier 4 Generic, Tier 1 Generic, Tier 1 Generic, Preferred NONE Generic, Tier 4 NONE Medicaid
Calcium Channel Blocker AMLODIPINE Norvasc Angina Hypertension     TABLET NONE NONE NONE NONE Tier 1, Gap Coverage Tier 1 Tier 1 Preferred, Quantity Limit Tier 1, Dose Optimization Required Tier 1 NONE Cigna, Medicaid
Calcium Channel Blocker AMLODIPINE Norvasc Angina Hypertension     TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Quantity Limit NONE NONE NONE NONE
Calcium Channel Blocker & HMO CoA Reductase Inhibitor AMLODIPINE-ATORVASTATIN Caduet Angina Hypertension Hypercholesterolemia   TABLET NONE NONE NONE NONE NONE NONE Tier 1, Quantity Limit Generic, Not Preferred, Prior Authorization, Quantity Limit Tier 1, Dose Optimization Required, Quantity Limit Tier 1, Quantity Limit Pfizer NONE
Calcium Channel Blocker & ACE Inhibitor AMLODIPINE-BENAZEPRIL Lotrel Hypertension       CAPSULE NONE NONE NONE NONE Tier 2, Gap Coverage NONE Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Tier 1 Tier 1, Quantity Limit NONE Medicaid
Calcium Channel Blocker & Angiotensin Receptor Blocker AMLODIPINE-VALSARTAN Exforge Hypertension       TABLET NONE NONE NONE NONE Tier 3 NONE Tier 1, Quantity Limit Preferred, Prior Authorization, Quantity Limit NONE Tier 4, Quantity Limit NONE Cigna, Medicaid
Calcium Channel Blocker & Angiotensin Receptor Blocker AMLODIPINE-VALSARTAN Exforge Hypertension       TABLET NONE NONE NONE NONE NONE NONE Generic, Tier 1, Quantity Limit Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Dose Optimization Required, Quantity Limit Generic, Tier 4, Quantity Limit NONE NONE
Calcium Channel Blocker, Angiotensin Receptor Blocker, & Diuretic AMLODIPINE-VALSARTAN-HCTZ Exforge HCTZ Hypertension       TABLET NONE NONE NONE NONE Tier 3 NONE Tier 1, Quantity Limit Preferred, Prior Authorization, Quantity Limit NONE Tier 4, Quantity Limit NONE Cigna, Medicaid
Calcium Channel Blocker, Angiotensin Receptor Blocker, & Diuretic AMLODIPINE-VALSARTAN-HCTZ Exforge HCTZ Hypertension       TABLET NONE NONE NONE NONE NONE NONE Generic, Tier 1, Quantity Limit Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Dose Optimization Required, Quantity Limit Generic, Tier 4, Quantity Limit NONE NONE
Calcium Channel Bolcker & Diuretic ALISKIREN-AMLODIPINE Amturnide Hypertension       TABLET NONE NONE NONE NONE Tier 2, Step Therapy NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE
Calcium Channel Bolcker & Diuretic ALISKIREN-AMLODIPINE Tekamlo Hypertension       TABLET NONE NONE NONE NONE Tier 3, Step Therapy NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE Cigna
Platelet Reducing Agent ANAGRELIDE HCL Agrylin Thrombocythemia       CAPSULE NONE NONE NONE NONE NONE Tier 1 Tier 1 NONE Tier 1 Tier 2 NONE NONE
Anticholinergic & Bronchiodilator UMECLIDINIUM-VILANTEROL Anoro Ellipta COPD       INHALATION POWDER NONE NONE NONE NONE NONE NONE NONE Not preferred, Prior Authorization, Quantity Limit NONE NONE GlaxoSmithKline NONE
Peroxisome Proliferator Receptor Alpha Agonist FENOFIBRATE Antara Hypercholesterolemia Hyperlipidemia     CAPSULE NONE NONE NONE NONE NONE NONE Tier 1 Not Preferred, Prior Authorization, Quantity Limit NONE Tier 3 NONE CIP
Peroxisome Proliferator Receptor Alpha Agonist FENOFIBRATE Tricor Hypercholesterolemia Hyperlipidemia   ALL EXCEPT 48MG,145MG CAPSULE NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1 Generic, Tier 1 NONE NONE
Peroxisome Proliferator Receptor Alpha Agonist FENOFIBRATE Tricor Hypercholesterolemia Hyperlipidemia   48 MG & 145MG CAPSULE NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Tier 1, Quantity Limit Generic, Tier 1 Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 2 NONE Medicaid
Peroxisome Proliferator Receptor Alpha Agonist FENOFIBRATE Tricor Hypercholesterolemia Hyperlipidemia     MICRONIZED NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 NONE NONE Generic, Tier 1 NONE NONE
Peroxisome Proliferator Receptor Alpha Agonist FENOFIBRATE Triglide Hypercholesterolemia Hyperlipidemia     TABLET NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE NONE Medicaid
Erythropoiesis stimulator DARBAPOETIN ALFA Aranesp Albumin Free Anemia       INJECTION NONE NONE NONE NONE NONE Tier 4, Prior Authorization Tier 1, Prior Authorization NONE NONE Tiers 4 & 5, Prior Authorization NONE NONE
Thrombin Inhibtor ARGATROBAN NONE Thrombocytopenia       INJECTION NONE NONE NONE NONE NONE NONE Tier 1, Medicare Part B or Part D, Prior Authorization NONE NONE NONE NONE NONE
Anticoagulant FONDAPARINUX Arixtra Blood Clot       INJECTION NONE NONE NONE NONE NONE NONE Tier 1 Not Preferred, Prior Authorization, Quantity Limit NONE Tier 5 NONE NONE
Anticoagulant FONDAPARINUX Arixtra Blood Clot     2.5mg/0.5ml INJECTION NONE NONE NONE NONE Generic, Tier 4, Quantity Limit Generic, Tier 4, Quantity Limit, Prior Authorization Generic, Tier 1 Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1 Generic, Tier 4 NONE NONE
Anticoagulant FONDAPARINUX Arixtra Blood Clot     All Other Doses (except 2.5/0.5) INJECTION NONE NONE NONE NONE Generic, Tier 5, Quanitity Limit Generic, Tier 4, Quantity Limit, Prior Authorization Generic, Tier 1 Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1 Generic, Tier 4 NONE NONE
Corticosteroid MOMETASONE Asmanex Twisthaler Asthma (Preventative)     110MCG INHALATION AEROSOL NONE NONE NONE NONE NONE NONE NONE Preferred, Prior Authorization, Quantity Limit NONE NONE Merck Medicaid
Corticosteroid MOMETASONE Asmanex Twisthaler Asthma (Preventative)     220MCG INHALATION AEROSOL NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE Merck Medicaid
Angiotensin Receptor Blocker CANDESARTAN CILEXETIL Atacand Hypertension       TABLET NONE NONE NONE NONE NONE Tier 3, Quantity Limit, Step Therapy NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE
Angiotensin Receptor Blocker CANDESARTAN CILEXETIL Atacand Hypertension     GENERIC TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1, Quantity Limit Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Quantity Limit Generic, Tier 1, Quantity Limit NONE NONE
Angiotensin Receptor Blocker & Diuretic CANDESARTAN CILEXETIL HYDROCHLOROTHIAZIDE Atacand HCT Hypertension       TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE
Angiotensin Receptor Blocker & Diuretic CANDESARTAN CILEXETIL HYDROCHLOROTHIAZIDE Atacand HCT Hypertension     GENERIC TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1, Quantity Limit Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Quantity Limit Generic, Tier 1, Quantity Limit NONE NONE
HMG-CoA Reductase Inhibitor ATORVASTATIN Lipitor Hypercholesterolemia Hyperlipidemia     TABLET NONE NONE NONE NONE Tier 2, Gap Coverage, Quantity Limit Tier 1, Quantity Limit Tier 1, Quantity Limit Preferred, Quantity Limit Tier 1, Dose Optimization Required, Quantity Limit Tier 1, Quantity Limit NONE Medicaid
HMG-CoA Reductase Inhibitor ATORVASTATIN Lipitor Hypercholesterolemia Hyperlipidemia     TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Quantity Limit NONE NONE NONE NONE
Calcium Channel Blocker & Angiotensin Receptor Blocker AMLODIPINE-OLMESARTAN Azor Hypertension       TABLET NONE NONE NONE NONE NONE NONE Tier 1, Quantity Limit Not Preferred, Prior Authorization, Quantity Limit NONE NONE DaiichiSankyo NONE
ACE Inhibitor & Diuretic BENAZEPRIL-HCTZ Lotensin HCT Hypertension       TABLET NONE NONE NONE NONE Tier 2, Gap Coverage NONE Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Tier 1 Tier 1, Quantity Limit NONE Medicaid
Angiotensin II Receptor Antagonist OLMESARTAN-MEDOXOMIL Benicar Hypertension       TABLET NONE NONE NONE NONE Tier 3, Quantity Limit, Step Therapy Tier 2, Quantity Limit, Step Therapy Tier 1, Quantity Limit Preferred, Prior Authorization, Quantity Limit NONE Tier 3, Quantity Limit DaiichiSankyo Cigna, Ambetter, Medicaid, CIP
Angiotensin II Receptor Antagonist & Diuretic OLMESARTAN-MEDOXOMIL-HYDROCHLOROTHIAZIDE Benicar HCT Hypertension       TABLET NONE NONE NONE NONE Tier 3, Quantity Limit, Step Therapy NONE Tier 1, Quantity Limit Preferred, Prior Authorization, Quantity Limit NONE Tier 3, Quantity Limit DaiichiSankyo Cigna, Medicaid, CIP
Beta Blocker BETAXOLOL HCL Kerlone Hypertension       TABLET NONE NONE NONE NONE Tier 2, Gap Coverage Tier 1 Tier 1 NONE Tier 1 Tier 3 NONE CIP
Vasodilator ISOSORBIDE DINITRATE-HYDRALAZINE Bidil Congestive Heart Failure       TABLET NONE NONE NONE NONE NONE Tier 2 Tier 1, Quantity Limit Not Preferred, Prior Authorization, Quantity Limit NONE Tier 3, Quantity Limit Arbor Ambetter, CIP
Beta Blocker BISOPROLOL FUMARATE Zebeta Hypertension       TABLET NONE NONE NONE NONE Tier 2, Gap Coverage Tier 1 Tier 1 NONE Tier 1 Tier 3 NONE CIP
Corticosteroid & Beta 2 Agonist FLUTICASONE-VILANTEROL Breo Ellipta COPD Asthma     INHALATION POWDER NONE NONE NONE NONE NONE NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE GlaxoSmithKline NONE
Anticoagulant TICAGRELOR Brilinta Thrombotic Cardiovascular Events (Preventative)       TABLET NONE NONE NONE NONE Tier 3, Quantity Limit NONE Tier 1, Quantity Limit Preferred, Quantity Limit NONE Tier 3, Quantity Limit Astrazeneca Cigna, Medicaid, CIP
Corticosteroid BUDESONIDE Pulmicort Respules Asthma COPD Allergies, Hay Fever   INHALATION SUSPENSION NONE NONE NONE NONE NONE NONE NONE Generic, Not Preferred, Prior Authorization, Quantity Limit NONE NONE Astrazeneca NONE
Corticosteroid BUDESONIDE Pulmicort Respules Asthma COPD Allergies, Hay Fever   INHALATION SUSPENSION NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE Astrazeneca Medicaid
Corticosteroid BUDESONIDE Pulmicort Flexhaler Asthma COPD Allergies, Hay Fever   INHALATION POWDER NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE Astrazeneca Medicaid
Beta Blocker NEBIVOLOL Bystolic Hypertension       TABLET NONE NONE NONE NONE NONE Tier 2, Quantity Limit, Step Therapy Tier 1 Not Preferred, Prior Authorization, Quantity Limit NONE Tier 3 Actavis Allergan Ambetter, CIP
Phosphate Binder CALCIUM ACETATE Eliphos Kidney Disease       TABLET NONE NONE NONE NONE NONE NONE NONE NONE Generic, Tier 1 NONE NONE NONE
Phosphate Binder CALCIUM ACETATE Eliphos Kidney Disease       TABLET NONE NONE NONE NONE NONE NONE NONE NONE Tier 1 NONE NONE NONE
Calcium Channel Blocker NICARDIPINE HYDROCHLORIDE Cardene Hypertension Angina     IV INJECTION NONE NONE NONE NONE NONE NONE Tier 1 Not Preferred, Prior Authorization, Quantity Limit NONE Tier 4 NONE NONE
Calcium Channel Blocker NICARDIPINE HYDROCHLORIDE Cardene Hypertension Angina     IV INJECTION NONE NONE NONE NONE Generic, Tier 4 NONE Generic, Tier 1 NONE NONE Generic, Tier 4 NONE NONE
Calcium Channel Blocker NICARDIPINE Cardene Hypertension Angina     TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1 Generic, Tier 3 NONE CIP
Calcium Channel Blocker DILTIAZEM HYDROCHLORIDE Cartia XT Hypertension Angina Arrythmias EXTENDED RELEASE CAPSULE NONE NONE NONE NONE Tier 2, Gap Coverage NONE Tier 1 NONE Tier 1, Dose Optimization Required, Quantity Limit Tier 3 NONE CIP
Calcium Channel Blocker DILTIAZEM CD Cardizem CD Hypertension     360 MG TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE
Diuretic CHLOROTHIAZIDE NONE Hypertension Edema   500MG INJECTION NONE NONE NONE NONE Tier 2, Gap Coverage NONE Tier 1 Generic, Preferred Tier 1 Tier 2 NONE Medicaid
Diuretic CHLOROTHIAZIDE SODIUM Diuril Hypertension Edema     INJECTION NONE NONE NONE NONE Generic, Tier 4 Generic, Tier 1 Generic, Tier 1, Medicare Part B or Part D, Prior Authorization NONE NONE Generic, Tier 4, Medicare Part B or D, Prior Authorization NONE NONE
Diuretic CHLOROTHIAZIDE SODIUM Diuril Hypertension Edema     INJECTION NONE NONE NONE NONE NONE NONE Tier 1 NONE NONE Tier 4 NONE NONE
Bile Acid Sequestrant CHOLESTYRAMINE Questran Hypercholesterolemia Hyperlipidemia     POWDER NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 NONE NONE Generic, Tier 1 NONE NONE NONE
Bile Acid Sequestrant CHOLESTYRAMINE-CHOLESTYRAMINE LIGHT Questran Light Hypercholesterolemia Hyperlipidemia     POWDER NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE NONE Generic, Preferred NONE NONE NONE Medicaid
Bile Acid Sequestrant CHOLESTYRAMINE-CHOLESTYRAMINE LIGHT Questran Light Hypercholesterolemia Hyperlipidemia     PACKETS NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Not Preferred, Prior Authorization Generic, Tier 1 Generic, Tier 4 NONE NONE
Phosphodiesterase 3 Inhibitor CILOSTAZOL Pletal Intermittent Claudication       TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Preferred Generic, Tier 1 Generic, Tier 2 NONE Medicaid
Central Alpha Agonist CLONIDINE Catapres TTS Hypertension       PATCH NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE NONE Medicaid
Central Alpha Agonist CLONIDINE Catapres TTS Hypertension     WEEKLY PATCH NONE NONE NONE NONE NONE Generic, Tier 1 Generic, Tier 1 Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1 Generic, Tier 3 NONE CIP
Central Alpha Agonist CLONIDINE Catapres TTS Hypertension     24 HOUR PATCH NONE NONE NONE NONE Tier 2, Gap Coverage, Quantity Limit NONE NONE NONE NONE NONE NONE NONE
Anticoagulant CLOPIDOGREL Plavix Heart Attack (Preventative) Stroke (Preventative) Cornary Thrombosis 75MG TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage, Quantity Limit NONE Generic, Tier 1, Quantity Limit Generic, Preferred NONE Generic, Tier 2, Quantity Limit NONE Medicaid
Anticoagulant CLOPIDOGREL Plavix Heart Attack (Preventative) Stroke (Preventative) Cornary Thrombosis 300MG TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Quantity Limit Generic, Tier 4, Quantity Liimt NONE NONE
Anticoagulant CLOPIDOGREL Plavix Heart Attack (Preventative) Stroke (Preventative) Cornary Thrombosis 75MG TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Quantity Limit NONE NONE NONE NONE
Anticoagulant CLOPIDOGREL Plavix Heart Attack (Preventative) Stroke (Preventative) Cornary Thrombosis 300MG TABLET NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE NONE Medicaid
Central Alpha Agonist & Diuretic CLONIDINE-CHLORTHALIDONE Clorpres Hypertension     0.1MG-15MG TABLET NONE NONE NONE NONE NONE NONE Tier 1 NONE Tier 1 Tier 4 NONE NONE
Central Alpha Agonist & Diuretic CLONIDINE-CHLORTHALIDONE Clorpres Hypertension     0.2MG-15MG TABLET NONE NONE NONE NONE NONE NONE Tier 1 NONE Tier 1 Tier 4 NONE NONE
Bile Acid Sequestrant COLESTIPOL Colestid Hypercholesterolemia       TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Prior Authorization NONE NONE Pfizer NONE
Bile Acid Sequestrant COLESTIPOL Colestid Hypercholesterolemia       TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Preferred Generic, Tier 1 Generic, Tier 3 Pfizer CIP, Medicaid
Antiarrhythmic AMIODORONE Cordarone Arrhythmias       TABLET NONE NONE NONE NONE NONE NONE NONE NONE Tier 2 NONE NONE Blue Cross
Beta Blocker & Diuretic NADOLOL-BENDROFLUMETHIAZIDE Corzide Hypertension       TABLET NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE NONE Medicaid
Beta Blocker & Diuretic NADOLOL-BENDROFLUMETHIAZIDE Corzide Hypertension     5MG-40MG TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1, Quantity Limit Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1 Generic, Tier 3, Quantity Limit NONE CIP
Beta Blocker & Diuretic NADOLOL-BENDROFLUMETHIAZIDE Corzide Hypertension     5MG-80MG TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 NONE NONE Generic, Tier 3 NONE CIP
Anticoagulant WARFARIN Coumadin Venous Thrombosis Pulmonary Embolism Thromboembolic Complications   INJECTION NONE NONE NONE NONE Tier 4 NONE NONE Preferred NONE NONE NONE Medicaid
HMG-CoA Reductase Inhibitor ROSUVASTATIN Crestor Hypercholesterolemia Hyperlipidemia     TABLET NONE NONE NONE NONE Tier 2, Quantity Limit Tier 2, Quantity Limit, Step Therapy Tier 1, Quantity Limit Not Preferred, Prior Authorization, Quantity Limit NONE Tier 3, Quantity Limit Astrazeneca Ambetter, CIP
Antihypertensive METYROSINE Demser Hypertension due to Pheochromocytoma       CAPSULE NONE NONE NONE NONE Tier 5 NONE Tier 1 NONE NONE Tier 5 NONE NONE
Alpha Blockers PHENOXYBENZAMINE Dibenzyline Hypertension due to Pheochromocytoma Sweating due to Pheochromocytoma     CAPSULE NONE NONE NONE NONE Tier 3 Tier 3, Quantity Limit Tier 1 NONE NONE Tier 4 NONE Cigna
Calcium Channel Blocker DILTIAZEM HYDROCHLORIDE Dilacor XR Hypertension Angina Arrythmias EXTENDED RELEASE CAPSULE NONE NONE NONE NONE NONE NONE NONE Not Preferred, Quantity Limit NONE NONE NONE NONE
Calcium Channel Blocker DILTIAZEM CD Cardizem CD Hypertension Angina Arrythmias   CAPSULE NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Preferred, Quantity Limit Generic, Tier 1, Dose Optimization Required Generic, Tier 3 NONE CIP, Medicaid
Calcium Channel Blocker DILTIAZEM CD/ER Cardizem CD Hypertension Angina Arrythmias EXTENDED RELEASE CAPSULE NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 Generic, Preferred, Quantity Limit Generic, Tier 1, Dose Optimization Required NONE NONE Medicaid
Calcium Channel Blocker DILTIAZEM CD/ER Cardizem CD Hypertension Angina Arrythmias EXTENDED RELEASE 360MG CAPSULE NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE NONE Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Dose Optimization Required Generic, Tier 3 NONE CIP
Calcium Channel Blocker DILTIAZEM ER Dilacor XR Hypertension Angina Arrythmias EXTENDED RELEASE CAPSULE NONE NONE NONE NONE Generic, Tier 1, Gap Coverage NONE NONE Generic, Preferred, Quantity Limit Generic, Tier 1 NONE NONE Cigna, Medicaid
Calcium Channel Blocker DILTIAZEM ER Tiazac ER Hypertension Angina Arrythmias EXTENDED RELEASE CAPSULE NONE NONE NONE NONE NONE NONE Generic, Tier 1 Generic, Preferred, Quantity Limit Generic, Tier 1, Quantity Limit NONE NONE Medicaid
Calcium Channel Blocker DILTIAZEM HYDROCHLORIDE Tiazac Hypertension Angina Arrythmias   CAPSULE NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE NONE Medicaid
Calcium Channel Blocker DILTIAZEM ER Taztia XT Hypertension Angina Arrythmias EXTENDED RELEASE CAPSULE NONE NONE NONE NONE Tier 2, Gap Coverage NONE Tier 1 NONE Tier 1, Quantity Limit Tier 3 NONE CIP
Calcium Channel Blocker DILTIAZEM HYDROCHLORIDE Cardizem Hypertension Angina Arrythmias   INJECTION NONE NONE NONE NONE Generic, Tier 4 NONE Generic, Tier 1 NONE NONE Generic, Tier 4 NONE NONE
Calcium Channel Blocker DILTIAZEM HYDROCHLORIDE Dilt-XR Hypertension Angina Arrythmias EXTENDED RELEASE CAPSULE NONE NONE NONE NONE Tier 2, Gap Coverage NONE Tier 1 NONE Tier 1, Dose Optimization Required Tier 3 NONE CIP
Angiotensin Receptor Blocker VALSARTAN Diovan Hypertension Heart Failure     TABLET NONE NONE NONE NONE NONE Tier 2, Quantity Limit, Step Therapy Tier 1, Quantity Limit Preferred, Prior Authorization, Quantity Limit NONE Tier 3, Quantity Limit NONE Ambetter, Medicaid, CIP
Angiotensin Receptor Blocker VALSARTAN Diovan Hypertension Heart Failure     TABLET NONE NONE NONE NONE NONE NONE Generic, Tier 1, Quantity Limit Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Quantity Limit, Dose Optimization Required Generic, Tier 1, Quantity Limit NONE NONE
Angiotensin Receptor Blocker & Diuretic VALSARTAN HCTZ Diovan HCT Hypertension Heart Failure     TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1, Quantity Limit Generic, Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Quantity Limit Generic, Tier 1, Quantity Limit NONE Medicaid
Anticoagulant DIPYRIMADOLE Persantine Coronary Thrombosis Vascular Graft Occlusion     TABLET NONE NONE NONE NONE NONE Generic, Tier 1 NONE Generic, Preferred Generic, Tier 1 NONE NONE Medicaid
Antiarrhythmic DISOPYRAMIDE Norpace Arrhythmias       CAPSULE NONE NONE NONE NONE NONE Generic, Tier 1 NONE NONE Generic, Tier 1 NONE Pfizer NONE
Corticosteroid & Bronchiodilator MOMETASONE-FORMOTEROL Dulera Asthma       INHALATION AEROSOL NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE Merck Medicaid
Cardioselective Beta Blocker & Diuretic METOPROLOL-HYDROCHLOROTHIAZIDE Dutoprolol Hypertension       TABLET NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE NONE Medicaid
Cardioselective Beta Blocker & Diuretic METOPROLOL-HYDROCHLOROTHIAZIDE Dutoprolol Hypertension     25MG-50MG, 25MG-100MG TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1 Generic, Tier 3, Quantity Limit NONE CIP
Cardioselective Beta Blocker & Diuretic METOPROLOL-HYDROCHLOROTHIAZIDE Dutoprolol Hypertension     50MG-100MG TABLET NONE NONE NONE NONE NONE Generic, Tier 1 Generic, Tier 1 Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1 Generic, Tier 3 NONE CIP
Calcium Channel Blocker ISRADIPINE Dynacirc CR Hypertension Prinzmetal's Angina     TABLET NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE NONE Medicaid
Calcium Channel Blocker ISRADIPINE Dynacirc CR Hypertension Prinzmetal's Angina     TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 NONE Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1 NONE NONE NONE
Diuretic TRIAMTERENE Dyrenium Hypertension Edema     CAPSULE NONE NONE NONE NONE NONE Tier 3, Quantity Limit Tier 1 NONE NONE Tier 4 NONE NONE
Angiotensin II Receptor Antagonist AZILSARTAN MEDOXOMIL Edarbi Hypertension       TABLET NONE NONE NONE NONE NONE Tier 3, Quantity Limit, Step Therapy Tier 1, Quantity Limit Not Preferred, Prior Authorization, Quantity Limit NONE Tier 4, Quantity Limit NONE NONE
Angiotensin II Receptor Antagonist & Diuretic AZILSARTAN MEDOXOMIL-CHLORTHALIDONE Edarbyclor Hypertension       TABLET NONE NONE NONE NONE NONE NONE Tier 1, Quantity Limit Not Preferred, Prior Authorization, Quantity Limit NONE Tier 4, Quantity Limit NONE NONE
Diuretic ETACRYNIC ACID Edecrin Edema       TABLET NONE NONE NONE NONE NONE Tier 3, Quantity Limit Tier 1 NONE NONE Tier 4 NONE NONE
Anticoagulant PRASUGREL Effient Heart Disease Angioplasty     TABLET NONE NONE NONE NONE NONE Tier 2 Tier 1, Quantity Limit Not Preferred, Prior Authorization, Quantity Limit NONE Tier 3, Quantity Limit LillyCares Ambetter, CIP
Anticoagulant Apixaban Eliquis Venous Thromboembolic Events       TABLET NONE NONE NONE NONE Tier 3, Prior Authorization, Quantity Limit NONE Tier 1, Prior Authorization Not Preferred, Prior Authorization, Quantity Limit NONE Tier 3, Prior Authorization, Quantity Limit BristolMyers-Squibb CIGNA, CIP
ACE Inhibitor ENALAPRILAT Vasotec Heart Failure Hypertension     INJECTION NONE NONE NONE NONE NONE NONE NONE Generic, Preferred, Quantity Limit NONE NONE NONE Medicaid
Anticoagulant ENOXAPARIN SODIUM Lovenox Blood Clot Heart Attack     INJECTION NONE NONE NONE NONE Generic, Tier 4, Quanitity Limit Generic, Tier 4, Quanity Limit, Prior Authorization Generic, Tier 1, Quantity Limit Generic, Not Preferred, Quantity Limit, Prior Authorization Generic, Tier 3 Generic, Tier 4, Quantity Limit Sanofi NONE
Anticoagulant ENOXAPARIN SODIUM Lovenox Blood Clot Heart Attack   100mg/0.8ml INJECTION NONE NONE NONE NONE Generic, Tier 5, Quanitity Limit Generic, Tier 4, Quanity Limit, Prior Authorization Generic, Tier 1, Quantity Limit Generic, Not Preferred, Quantity Limit, Prior Authorization Generic, Tier 3 Generic, Tier 5, Quantity Limit Sanofi NONE
Anticoagulant ENOXAPARIN SODIUM Lovenox Blood Clot Heart Attack   120mg/0.8ml INJECTION NONE NONE NONE NONE Generic, Tier 5, Quanitity Limit Generic, Tier 4, Quanity Limit, Prior Authorization Generic, Tier 1, Quantity Limit Generic, Not Preferred, Quantity Limit, Prior Authorization Generic, Tier 3 Generic, Tier 5, Quantity Limit Sanofi NONE
Anticoagulant ENOXAPARIN SODIUM Lovenox Blood Clot Heart Attack     INJECTION NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE Sanofi Medicaid
Ace Inhibitor ENALAPRIL Epaned Heart Failure Hypertension     POWDER NONE NONE NONE NONE NONE NONE Tier 1 Preferred, Prior Authorization, Quantity Limit NONE Tier 4 NONE Medicaid
Antimineralocorticoid EPLERENONE Inspra Hypertension Congestive Heart Failure (CHF)     TABLET NONE NONE NONE NONE NONE Generic, Tier 1 Generic, Tier 1 Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1 Generic, Tier 3 Pfizer CIP
Erythropoiesis stimulator EPOETIN ALFA Epogen Anemia       INJECTION NONE NONE NONE NONE NONE Tier 4, Prior Authorization Tier 1, Prior Authorization NONE NONE Tier 4, Prior Authorization NONE NONE
Erythropoiesis stimulator EPOETIN ALFA Procrit Anemia       INJECTION NONE NONE NONE NONE NONE Tier 4, Prior Authorization Tier 1, Prior Authorization NONE Tier 3, Prior Authorization NONE NONE NONE
Angiotensin II Receptor Antagonist EPROSARTAN MESYLATE Teveten Hypertension       TABLET NONE NONE NONE NONE NONE NONE Generic, Tier 1, Quantity Limit Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Quantity Limit Generic, Tier 1, Quantity Limit NONE NONE
Angiotensin II Receptor Antagonist EPROSARTAN MESYLATE HCTZ Teveten Hypertension       TABLET NONE NONE NONE NONE NONE Tier 3, Quantity Limit, Step Therapy NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE
Angiotensin II Receptor Antagonist & Diuretic EPROSARTAN MESYLATE Teveten HCT Hypertension       TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE
Calcium Channel Blocker FELODIPINE ER Plendil ER Hypertension       TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Dose Optimization Required Generic, Tier 3 NONE CIP
Antihyperlipidemic FENOFRIBRIC ACID Trilipix Hypercholesterolemia Hyperlipidemia     CAPSULE NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1 Generic, Tier 1 NONE NONE
Antihyperlipidemic FENOFRIBRIC ACID Trilipix Hypercholesterolemia Hyperlipidemia     CAPSULE NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE NONE Medicaid
Antihyperlipidemic FENOFRIBRIC ACID Fibricor Hypercholesterolemia Hyperlipidemia     TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE
Antihyperlipidemic FENOFIBRATE Fenoglide Hypercholesterolemia Hyperlipidemia     TABLET NONE NONE NONE NONE NONE NONE NONE Not preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE
Antiarrhythmic FLECAINIDE ACETATE Tambocor Arrhythmias       TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 NONE NONE Generic, Tier 2 NONE NONE
Glucocorticoid FLUTICASONE-PROPIONATE Flovent Diskus Asthma       INHALATION SOLUTION NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE GlaxoSmithKline Medicaid
Glucocorticoid FLUTICASONE-PROPIONATE HFA Flovent HFA Asthma       INHALATION SOLUTION NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE GlaxoSmithKline Medicaid
HMG-CoA Reductase Inhibitor FLUVASTATIN Lescol Hypercholesterolemia Hyperlipidemia     CAPSULE NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 2 Generic, Tier 1, Quantity Limit Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Dose Optimization Required Generic, Tier 1, Quantity Limit NONE Ambetter
HMG-CoA Reductase Inhibitor FLUVASTATIN Lescol Hypercholesterolemia Hyperlipidemia     CAPSULE NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE NONE Medicaid
ACE Inhibitor FOSINOPRIL Monopril Hypertension Congestive Heart Failure     TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Medicaid
ACE Inhibitor & Diuretic FOSINOPRIL HCTZ Monopril HCT Hypertension Congestive Heart Failure     TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Medicaid
Anticoagulant DALTEPARIN Fragmin Blood Clot       INJECTION NONE NONE NONE NONE NONE Tier 4, Prior Authorization Tier 1 Preferred, Quantity Limit NONE Tier 5 NONE Medicaid
Antihyperlipidemic GEMFIBROZIL Lopid Hypercholesterolemia Hyperlipidemia     TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 2 NONE Medicaid
Hemapoetic Growth Factor TBO-FILGRASTIM Granix Neutropenia       INJECTION NONE NONE NONE NONE NONE NONE Tier 1, Prior Authorization NONE NONE Tier 5, Prior Authorization TevaCares NONE
Antihypertensive GUANABENZ Wytensin Hypertension       TABLET NONE NONE NONE NONE NONE Generic, Tier 3, Quantity Limit NONE NONE Generic, Tier 1 NONE NONE NONE
Beta Blocker PROPANOLOL HYDROCHLORIDE Humangeol Infantile Hemangioma Ventricular Tachycardia     ORAL SOLUTION NONE NONE NONE NONE NONE NONE NONE Preferred (covered 5 weeks-12weeks old) NONE NONE NONE Medicaid
Beta Blocker PROPANOLOL HYDROCHLORIDE Humangeol Infantile Hemangioma Ventricular Tachycardia     ORAL SOLUTION NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1, Gap Coverage NONE Generic, Tier 1 Generic, Tier 2 NONE NONE
Anticoagulant HEPARIN SODIUM Porcine Blood Clot       INJECTION NONE NONE NONE NONE Generic, Tier 4 Generic, Tier 1 Generic, Tier 1, Medicare Part B or Part D, Prior Authorization Generic, Preferred NONE Generic, Tier 4 NONE Medicaid
Anticoagulant HEPARIN SODIUM D5W Porcine (IV) Blood Clot       IV INJECTION NONE NONE NONE NONE NONE NONE Generic, Tier 1, Medicare Part B or Part D, Prior Authorization NONE NONE Generic, Tier 4, Medicare Part B or D, Prior Authorization NONE NONE
Beta Blocker PROPANOLOL HYDROCHLORIDE Innopran XL Hypertension     ER CAPSULE NONE NONE NONE NONE NONE NONE Tier 1 Not Preferred, Prior Authorization, Quantity Limit NONE Tier 4 Akrimax NONE
Beta Blocker PROPANOLOL HYDROCHLORIDE Innopran XL Hypertension     ER CAPSULE NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE NONE
Beta Blocker PROPANOLOL HYDROCHLORIDE Inderal Hypertension     10MG, 20MG, 40MG, 80MG TABLET NONE NONE NONE NONE Generic, Tier 1, Gap Coverage NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 Akrimax Cigna
Beta Blocker PROPANOLOL HYDROCHLORIDE Inderal Hypertension     60 MG TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 Akrimax NONE
Beta Blocker PROPANOLOL HYDROCHLORIDE Inderal Hypertension       INJECTION NONE NONE NONE NONE Generic, Tier 4 NONE Generic, Tier 1 NONE NONE Generic, Tier 4 Akrimax NONE
Angiotensin Receptor Blocker IRBESARTAN Avapro Hypertension       TABLET NONE NONE NONE NONE Generic, Tier 1, Gap Coverage Generic, Tier 1, Quanity Limit Generic, Tier 1, Quantity Limit Generic, Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Quantity Limit, Dose Optimization Required Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
Angiotensin Receptor Blocker & Diuretic IRBESARTAN-HCTZ Avalide Hypertension       TABLET NONE NONE NONE NONE Generic, Tier 1, Gap Coverage NONE Generic, Tier 1, Quantity Limit Generic, Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Quantity Limit, Dose Optimization Required Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
Nitrate ISOSORBIDE DINITRATE Isordil Titradose Angina     40 MG TABLET NONE NONE NONE NONE NONE NONE Tier 1 NONE NONE Tier 4 NONE NONE
Nitrate ISOSORBIDE DINITRATE Isordil Angina     ER TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 NONE NONE Generic, Tier 2 NONE NONE
Vasodilator ISOXSUPRINE Vasodilan Arteriosclerosis Circulation Problems Reynaud's Syndrome   TABLET NONE NONE NONE NONE NONE NONE NONE NONE Generic, Tier 1 NONE NONE NONE
Antihyperlipidemic LOMITAPIDE Juxtapid Hypercholesterolemia Hyperlipidemia     CAPSULE NONE NONE NONE NONE NONE NONE Tier 1, Prior Authorization Not Preferred, Prior Authorization, Quantity Limit NONE Tier 5, Prior Authorization NONE NONE
Antihyperlipidemic MIPOMERSEN SODIUM Kynamro Hypercholesterolemia Hyperlipidemia     INJECTION NONE NONE NONE NONE NONE NONE Tier 1, Prior Authorization Not Preferred, Prior Authorization, Quantity Limit NONE Tier 5, Prior Authorization NONE NONE
Beta Blocker LABETALOL Trandate Hypertension       INJECTION NONE NONE NONE NONE Generic, Tier 4 Generic, Tier 1 Generic, Tier 1 NONE NONE Generic, Tier 4 NONE NONE
Beta Blocker LABETALOL Trandate Hypertension       TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE NONE
Leukocyte Growth Factor SARGRAMOSTIM Leukine Neutropenia       INJECTION NONE NONE NONE NONE NONE Tier 4, Prior Authorization Tier 1, Prior Authorization NONE NONE NONE Sanofi NONE
Beta Blocker PENBUTOLOL SULFATE Levatol Hypertension       TABLET NONE NONE NONE NONE NONE Tier 3 NONE Preferred, Quantity Limit NONE NONE NONE Medicaid
Anesthetic LIDOCAINE HYDROCHLORIDE Xylocaine Pain       INJECTION NONE NONE NONE NONE Tier 4 NONE NONE NONE NONE NONE NONE NONE
Peroxisome Proliferator Receptor Alpha Agonist FENOFIBRATE Lipofen Hypercholesterolemia Hyperlipidemia     CAPSULE NONE NONE NONE NONE Tier 3 NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE Cigna
Cholesterol Absorption Inhibitor & HMG-CoA Reductase Inhibitor EZETIMIBE-ATORVASTATIN Liptruzet Hypercholesterolemia Hyperlipidemia     TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE
HMG-CoA Reductase Inhibitor PITAVASTATIN Livalo Hypercholesterolemia Hyperlipidemia     TABLET NONE NONE NONE NONE NONE Tier 3, Quantity Limit NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE Kowa NONE
Angiotensin Receptor Blocker LOSARTAN Cozaar Hypertension Kidney Disease     TABLET NONE NONE NONE NONE Generic, Tier 1, Gap Coverage, Quantity Limit Generic, Tier 1, Quanity Limit Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1, Quantity Limit, Dose Optimization Required Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
Angiotensin Receptor Blocker & Diuretic LOSARTAN HCTZ Hyzaar Hypertension Kidney Disease     TABLET NONE NONE NONE NONE Generic, Tier 1, Gap Coverage, Quantity Limit Generic, Tier 1, Quanity Limit Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1, Quantity Limit, Dose Optimization Required Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
Antilipemic OMEGA-3-ACID ETHYL ESTERS Lovaza Hypercholesterolemia Hyperlipidemia     CAPSULE NONE NONE NONE NONE NONE Tier 2 NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE GlaxoSmithKline Ambetter
Antilipemic OMEGA-3-ACID ETHYL ESTERS Lovaza Hypercholesterolemia Hyperlipidemia     CAPSULE NONE NONE NONE NONE Generic, Tier 2, Gap Coverage, Quantity Limit NONE Generic, Tier 1 Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Step Therapy Generic, Tier 4 GlaxoSmithKline NONE
Calcium Channel Blocker MATZIM LA Cardizem LA Hypertension Angina Arrythmias   TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE NONE Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Quantity Limit, Dose Optimization Required NONE NONE NONE
Calcium Channel Blocker MATZIM LA ER Cardizem LA ER Hypertension Angina Arrythmias 180MG,240MG,300 MG TABLET NONE NONE NONE NONE NONE NONE Generic, Tier 1 NONE NONE Generic, Tier 3 NONE CIP
Calcium Channel Blocker MATZIM LA ER Cardizem LA ER Hypertension Angina Arrythmias 360MG, 420MG TABLET NONE NONE NONE NONE NONE NONE Generic, Tier 1, Quantity Limit NONE NONE Generic, Tier 3, Quantity Limit NONE CIP
Synthetic Vitamin K PHYTONADIONE Mephyton Coagulation Disorders       TABLET NONE NONE NONE NONE NONE NONE NONE Preferred NONE NONE NONE Medicaid
Carbonic Anhydrase Inhibitor METHAZOLAMIDE Neptazane Ocular Hypertension Glaucoma     TABLET NONE NONE NONE NONE NONE Generic, Tier 1, Quanity Limit NONE NONE NONE NONE NONE NONE
Diuretic METHYCLOTHIAZIDE Aquatensen Hypertension Edema     TABLET NONE NONE NONE NONE NONE Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 3 NONE CIP
Antihypertensive METHYLDOPATE HYDROCHLORIDE   Hypertension       INJECTION NONE NONE NONE NONE Generic, Tier 2, Gap Coverage, Prior Authorization Generic, Tier 3 Generic, Tier 1 NONE NONE Generic, Tier 4 NONE NONE
Diuretic METHYLDOPA HCTZ Aldoril Hypertension Edema     TABLET NONE NONE NONE NONE NONE NONE NONE NONE Generic, Tier 1 NONE NONE NONE
Diuretic METOLAZONE Mykrox Hypertension Edema     TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1, Quanity Limit Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 3 NONE CIP
Beta Blocker METOPROLOL-SUCCINATE Toprol-XL Angina Hypertension Heart Failure ER TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1 NONE Medicaid
Beta Blocker METOPROLOL-SUCCINATE Toprol-XL Angina Hypertension Heart Failure ER TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Quantity Limit NONE NONE NONE NONE
Beta Blocker METOPROLOL-TARTRATE Lopressor Angina Myocardial Infarct (MI) Hypertension   INJECTION NONE NONE NONE NONE Generic, Tier 4 NONE Generic, Tier 1 NONE NONE Generic, Tier 4 NONE NONE
Antiarrhythmic MEXILETINE Mexitil Arrhythmias       CAPSULE NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE NONE
Angiotensin Receptor Blocker TELMISARTAN Micardis Hypertension       TABLET NONE NONE NONE NONE NONE Tier 3, Quanity Limit, Step Therapy NONE Preferred, Prior Authorization, Quantity Limit NONE NONE NONE Medicaid
Angiotensin Receptor Blocker TELMISARTAN Micardis Hypertension       TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage, Quantity Limit NONE Generic, Tier 1, Quantity Limit Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Quantity Limit, Dose Optimization Required Generic, Tier 1, Quantity Limit NONE NONE
Angiotensin Receptor Blocker & Diuretic TELMISARTAN-HYDROCHLOROTHIAZIDE Micardis HCT Hypertension       TABLET NONE NONE NONE NONE NONE NONE NONE Preferred, Prior Authorization, Quantity Limit NONE NONE NONE Medicaid
Angiotensin Receptor Blocker & Diuretic TELMISARTAN-HYDROCHLOROTHIAZIDE Micardis HCT Hypertension       TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage, Quantity Limit NONE Generic, Tier 1, Quantity Limit Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Quantity Limit Generic, Tier 1, Quantity Limit NONE NONE
Vasopressor MIDRODINE HYDROCHLORIDE ProAmatine Orthostatic Hypotension       TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 3 NONE CIP
Vasopressor MIDRODINE HYDROCHLORIDE ProAmatine Orthostatic Hypotension       TABLET NONE NONE NONE NONE NONE NONE NONE Preferred NONE NONE NONE Medicaid
Phosphodiesterase 3 Inhibitor MILRINONE Primacor Congestive Heart Failure       INJECTION NONE NONE NONE NONE NONE NONE NONE Generic, Preferred, Prior Authorization NONE NONE NONE Medicaid
Nitrate NITROGLYCERIN Minitran Angina Congestive Heart Failure Heart Attack   PATCH NONE NONE NONE NONE Tier 2, Gap Coverage NONE Tier 1 NONE NONE Tier 2 NONE NONE
Nitrate NITROGLYCERIN Minitran Angina Congestive Heart Failure Heart Attack   PATCH NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 2 NONE Medicaid
Vasodilator MINOXIDIL Loniten Hypertension       TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE NONE
ACE Inhibitor MOEXIPRIL Univasc Hypertension Congestive Heart Failure     TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE NONE
ACE Inhibitor & Diuretic MOEXIPRIL HCTZ Uniretic Hypertension       TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE NONE
Immunostimulant PLERIXAFOR Mozobil Stem Cell Transplant       INJECTION NONE NONE NONE NONE NONE NONE Tier 1, Prior Authorization NONE NONE NONE Sanofi NONE
Antiarrhythmic DRONEDARONE Multaq Arrhythmias Atrial Fibrillation     TABLET NONE NONE NONE NONE Tier 3, Quantity Limit Tier 4 Tier 1 Not Preferred, Prior Authorization, Quantity Limit NONE Tier 3 Sanofi Cigna, CIP
Leukocyte Growth Factor PEGFILGRASTIM Neulasta Neutropenia       INJECTION NONE NONE NONE NONE NONE Tier 4, Prior Authorization Tier 1, Prior Authorization NONE NONE NONE NONE NONE
Thrombopoetic Growth Factor OPRELVEKIN Neumega Thrombocytopenia       INJECTION NONE NONE NONE NONE NONE NONE Tier 1, Prior Authorization NONE Tier 3, Prior Authorization NONE NONE NONE
Leukocyte Growth Factor FILGRASTIM Neupogen Neutropenia       INJECTION NONE NONE NONE NONE NONE Tier 4, Quantity Limit, Prior Authorization Tier 1, Prior Authorization NONE Tier 3, Prior Authorization NONE NONE NONE
Antihyperlipidemic NIACIN Niacor, Niaspan Hypercholesterolemia Hyperlipidemia     TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage, Quantity Limit NONE Generic, Tier 1 Generic, Preferred, Quantity Limit Generic, Tier 1, Quantity Limit Generic, Tier 3 NONE Medicaid, CIP
Antihyperlipidemic NIACIN Niacor Hypercholesterolemia Hyperlipidemia     TABLET NONE NONE NONE NONE Tier 2, Gap Coverage NONE Tier 1 Not Preferred, Prior Authorization NONE Tier 2 NONE NONE
Antihyperlipidemic NIACIN Niaspan Hypercholesterolemia Hyperlipidemia     TABLET NONE NONE NONE NONE NONE Tier 2 NONE NONE NONE NONE NONE Ambetter
Calcium Channel Blocker NIMODIPINE Nimotop Subarachnoid Hemorrhage       CAPSULE NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 5 NONE NONE
Calcium Channel Blocker NISOLDIPINE Sular Hypertension       TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Quantity Limit, Dose Optimization Required Generic, Tier 4 NONE NONE
Nitrate NITROGLYCERIN Nitro-Bid Angina       OINTMENT NONE NONE NONE NONE NONE Tier 3 Tier 1 NONE Tier 1 Tier 4 NONE NONE
Nitrate NITROGLYCERIN Nitro-Time Angina     ER CAPSULE NONE NONE NONE NONE NONE Generic, Tier 1 NONE NONE Generic, Tier 1 NONE NONE NONE
Nitrate NITROGLYCERIN Nitro-Time Angina     ER CAPSULE NONE NONE NONE NONE NONE NONE NONE NONE Tier 1 NONE NONE NONE
Nitrate NITROGLYCERIN   Angina       INJECTION NONE NONE NONE NONE Generic, Tier 4 NONE Generic, Tier 1 NONE NONE Generic, Tier 4 NONE NONE
Nitrate NITROGLYCERIN Nitromist Angina       LINGUAL SPRAY AEROSOL NONE NONE NONE NONE NONE NONE NONE Generic, Not Preferred, Prior Authorization, Quantity Limit NONE NONE Akrimax NONE
Nitrate NITROGLYCERIN Nitromist Angina       LINGUAL SPRAY AEROSOL NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE Akrimax Medicaid
Nitrate NITROGLYCERIN Nitrolingual Angina       LINGUAL SPRAY SOLUTION NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 Generic, Not Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1 NONE NONE
Nitrate NITROGLYCERIN Nitrolingual Angina       LINGUAL SPRAY SOLUTION NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit Generic, Tier 1 NONE NONE Medicaid
Nitrate NITROGLYCERIN Nitrostat Angina       SUBLINGUAL TABLET NONE NONE NONE NONE Tier 3, Gap Coverage Tier 2 Tier 1 NONE NONE Tier 3 Pfizer Cigna, Ambetter, CIP
Nitrate NITROGLYCERIN Rectiv Angina Chronic Anal Fissure     OINTMENT NONE NONE NONE NONE NONE Tier 3 NONE NONE NONE NONE Actavis Allergan NONE
Vasopressor DROXIDOPA Northera Orthostatic Hypotension Hypotension     CAPSULE NONE NONE NONE NONE NONE NONE Tier 1, Prior Authorization, Quantity Limit Not Preferred, Prior Authorization, Quantity Limit NONE Tier 5, Prior Authorization, Quantity Limit NONE NONE
Thrombopoietin Receptor Agonists ROMIPLOSTIM Nplate Idiopathic Thrombocytopenic Purpura (ITP) Thrombocytopenia     INJECTION NONE NONE NONE NONE NONE Tier 4, Prior Authorization NONE NONE NONE NONE NONE NONE
Vasodilator PAPAVERINE   Angina Smooth Muscle Spasms     CAPSULE NONE NONE NONE NONE NONE NONE NONE NONE Generic, Tier 1 NONE NONE NONE
Hemorrheologic Agents PENTOXIFYLLINE ER Trentol Peripheral Artery Disease       TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1, Quanity Limit Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE NONE
ACE Inhibitor PERINDOPRIL Aceon Hypertension Coronary Artery Disease     TABLET NONE NONE NONE NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Not Preferred, Prior Authorization, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna
Anticoagulant DABIGATRAN Pradaxa Atrial Fibrillation       TABLET NONE NONE NONE NONE Tier 3, Prior Authorization, Quantity Limit Tier 2, Prior Authorization, Quantity Limit Tier 1, Prior Authorization, Quantity Limit Not Preferred, Prior Authorization, Quantity Limit NONE Tier 3, Prior Authorization, Quantity Limit Boehringer Cigna, Ambetter, CIP
Bile Acid Sequestrant CHOLESTYRAMINE-ASPARTAME Prevalite Hypercholesterolemia Partial Biliary Obstruction     POWDER NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 Generic, Preferred Generic, Tier 1 Generic, Tier 4 NONE Medicaid
Antiarrhythmic PROCAINAMIDE Pronestyl Arrhythmias       INJECTION NONE NONE NONE NONE NONE Generic, Tier 1, Quanity Limit Generic, Tier 1 NONE NONE Generic, Tier 4 NONE NONE
Antiarrhythmic PROPAFENONE Rythmol Arrhythmias Atrial Fibrillation     TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1, Quanity Limit Generic, Tier 1 NONE Generic, Tier 1 NONE NONE NONE
Antiarrhythmic PROPAFENONE Rythmol Arrhythmias Atrial Fibrillation   ER TABLET NONE NONE NONE NONE NONE NONE NONE Generic, Not Preferred, Prior Authorization NONE Generic, Tier 4 NONE NONE
Antiarrhythmic PROPAFENONE Rythmol Arrhythmias Atrial Fibrillation   SR TABLET NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE NONE Medicaid
Thrombopoetic Growth Factor ELTROMBOPAG Promacta Thrombocytopenia Chronic Idiopathic Thrombocytopenic Purpura (ITP) Hepatitis C   TABLET NONE NONE NONE NONE NONE Tier 4, Prior Authorization Tier 1, Prior Authorization NONE NONE NONE NONE NONE
Beta Blocker & Diuretic PROPANOLOL HYDROCHLOROTHIAZIDE Inderide Hypertension     25MG-40MG TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1, Quantity Limit NONE Generic, Tier 1 Generic, Tier 2, Quantity Limit NONE NONE
Beta Blocker & Diuretic PROPANOLOL HYDROCHLOROTHIAZIDE Inderide Hypertension     25MG-80MG TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE NONE
ACE Inhibitor QUINAPRIL Accupril Hypertension Heart Failure     TABLET NONE NONE NONE NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
ACE Inhibitor & Diuretic QUINAPRIL HYDROCHLOROTHIAZIDE Accuretic Hypertension Heart Failure     TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit Pfizer Medicaid
Antiarrhythmic QUINIDINE GLUCONATE Quinidex Arrythmias       TABLET NONE NONE NONE NONE NONE Generic, Tier 1, Quanity Limit Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 4 NONE NONE
Antiarrhythmic QUINIDINE GLUCONATE N/A Arrythmias     CR TABLET NONE NONE NONE NONE NONE NONE Generic, Tier 1 NONE NONE Generic, Tier 4 NONE NONE
Antiarrhythmic QUINIDINE SULFATE   Arrythmias       TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage NONE Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 4 NONE NONE
Antiarrhythmic QUINIDINE SULFATE   Arrythmias     ER TABLET NONE NONE NONE NONE NONE NONE Generic, Tier 1 NONE NONE Generic, Tier 4 NONE NONE
Glucocorticoid BECLOMETHASONE DIPROPIONATE HFA Qvar Asthma Hay Fever     INHALATION AEROSOL NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE TevaCares Medicaid
ACE Inhibitor RAMIPRIL Altace Hypertension Heart Failure     CAPSULE NONE NONE NONE NONE Generic, Tier 1, Gap Coverage Generic, Tier 1 Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1 Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
Antianginal RANOLAZINE Ranexa Angina       TABLET NONE NONE NONE NONE Tier 3, Quantity Limit, Step Therapy Tier 2, Quantity Limit Tier 1, Quantity Limit Not Preferred, Prior Authorization NONE Tier 3, Quantity Limit Gilead Cigna, Ambetter, CIP
Platelet Aggregation Inhibitor ABCIXIMAB Reopro Cardiac Ischemic Complications (Preventative)       IV INJECTION NONE NONE NONE NONE NONE Tier 3 NONE NONE NONE NONE LillyCares NONE
Rauwolfia Alkaloid RESERPINE Raudixin, Serpalan, Serpasil Hypertension       TABLET NONE NONE NONE NONE NONE NONE NONE NONE Generic, Tier 1 NONE NONE NONE
Anticoagulant EDOXABAN Savaysa Atrial Fibrillation       TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE DaiichiSankyo NONE
Vitamin B3 & HMG-CoA Reductase Inhibitor NIACIN-SIMVASTATIN Simcor Hypercholesterolemia Hyperlipidemia     TABLET NONE NONE NONE NONE NONE Tier 2 NONE Preferred, Quantity Limit NONE NONE NONE Ambetter, Medicaid
HMG-CoA Reductase Inhibitor SIMVASTATIN Zocor Hypercholesterolemia Hyperlipidemia   5MG, 10MG, 20MG, 40MG TABLET NONE NONE NONE NONE Generic, Tier 1, Gap Coverage, Quantity Limit Generic, Tier 1, Quanity Limit Generic, Tier 1, Quantity Limit Generic, Preferred, Quantity Limit Generic, Tier 1, Quantity Limit, Dose Optimization Required Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
HMG-CoA Reductase Inhibitor SIMVASTATIN Zocor Hypercholesterolemia Hyperlipidemia   80MG TABLET NONE NONE NONE NONE Generic, Tier 1, Gap Coverage, Quantity Limit Generic, Tier 1, Quanity Limit Generic, Tier 1, Quantity Limit Generic, Preferred, Prior Authorization, Quantity Limit Generic, Tier 1, Quantity Limit, Dose Optimization Required Generic, Tier 1, Quantity Limit NONE Cigna, Medicaid
HMG-CoA Reductase Inhibitor SIMVASTATIN Zocor Hypercholesterolemia Hyperlipidemia   ALL TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Quantity Limit NONE NONE NONE NONE
Diuretic SODIUM-EDECRIN Edecrin Edema Ascites     IV INJECTION NONE NONE NONE NONE Generic, Tier 4 NONE NONE NONE NONE NONE NONE NONE
Phosphate Binder SEVELAMER CARBONATE Renvela Chronic Kidney Disease       TABLET NONE NONE NONE NONE NONE NONE NONE NONE Generic, Tier 1 NONE NONE NONE
Bronchodilator TIOTROPIUM BROMIDE Spiriva Respimat Emphysema Chronic Bronchitis Chronic Obstructive Pulmonary Disease (COPD)   INHALATION SPRAY NONE NONE NONE NONE NONE NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE Boehringer NONE
Bronchodilator TIOTROPIUM BROMIDE Spiriva HandiHaler Emphysema Chronic Bronchitis Chronic Obstructive Pulmonary Disease (COPD)   INHALATION POWDER NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE Boehringer Medicaid
Corticosteroid & Bronchiodilator BUDESONIDE-FORMOTEROL Symbicort Asthma Chronic Obstructive Pulmonary Disease (COPD)     INHALATION AEROSOL NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE Astrazeneca Medicaid
ACE Inhibitor & Calcium Channel Blocker TRANDOLAPRIL-VERAPAMIL HCL ER Tarka Hypertension       TABLET NONE NONE NONE NONE NONE NONE NONE Preferred, Quantity Limit NONE NONE Abbot Abbvie Medicaid
ACE Inhibitor & Calcium Channel Blocker TRANDOLAPRIL-VERAPAMIL HCL ER Tarka Hypertension       TABLET NONE NONE NONE NONE NONE NONE NONE NONE Generic, Tier 1 NONE Abbot Abbvie NONE
Renin Inhibitor ALISKIREN Tekturna Hypertension       TABLET NONE NONE NONE NONE Tier 3, Step Therapy Tier 2, Quantity Limit, Step Therapy NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE Novartis Cigna, Ambetter
Renin Inhibitor & Diuretic ALISKIREN HCTZ Tekturna HCT Hypertension       TABLET NONE NONE NONE NONE Tier 3, Step Therapy NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE Novartis Cigna
Anticoagulant TICLOPIDINE Ticlid Blood Clot       TABLET NONE NONE NONE NONE NONE Generic, Tier 1 NONE Generic, Preferred Generic, Tier 1 NONE NONE Medicaid
Antiarrhythmic DOFETILIDE Tikosyn Arrythmias       CAPSULE NONE NONE NONE NONE Tier 3 Tier 2 Tier 1 NONE NONE Tier 4 NONE Cigna, Ambetter
Antiarrhythmic TOCAINIDE HCL Tonocard Arrythmias       TABLET NONE NONE NONE NONE NONE NONE NONE Preferred NONE NONE NONE Medicaid
Diuretic TORSEMIDE Demadex Edema Hypertension     TABLET NONE NONE NONE NONE Generic, Tier 2, Gap Coverage Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 Generic, Tier 2 NONE NONE
Diuretic TORSEMIDE Demadex Edema Hypertension     INJECTION NONE NONE NONE NONE NONE NONE Generic, Tier 1 NONE NONE Generic, Tier 4 NONE NONE
Antifibrinolytic TRANEXAMIC ACID Lysteda Hemophilia       TABLET NONE NONE NONE NONE NONE Generic, Tier 1 Generic, Tier 1 NONE Generic, Tier 1 NONE NONE NONE
Antifibrinolytic TRANEXAMIC ACID Cyklokapron Hemophilia       INJECTION NONE NONE NONE NONE NONE NONE Generic, Tier 1 NONE NONE NONE NONE NONE
Angiotensin Receptor Blocker, Calcium Channel Blocker, & Diuretic OLMESARTAN-AMLODIPINE-HYDROCHLOROTHIAZIDE Tribenzor Hypertension       TABLET NONE NONE NONE NONE NONE NONE Tier 1, Quantity Limit Not Preferred, Prior Authorization, Quantity Limit NONE Tier 3, Quantity Limit DaiichiSankyo CIP
Anticholinergic ACLIDINIUM BROMIDE Tudorza Chronic Obstructive Pulmonary Disease (COPD) Chronic Bronchitis Emphysema   INHALATION POWDER NONE NONE NONE NONE NONE NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE Actavis Allergan NONE
Angiotensin Receptor Blocker & Calcium Channel Blocker TELMISARTAN-AMLODIPINE Twynsta Hypertension       TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE
Lipid Regulating Agent ICOSAPENT ETHYL Vascepa Hyperlipidemia       CAPSULE NONE NONE NONE NONE NONE NONE Tier 1 Not Preferred, Prior Authorization, Quantity Limit NONE Tier 4 NONE NONE
Ganglion Blocker MECAMYLAMINE Vecamyl Hypertension       TABLET NONE NONE NONE NONE NONE NONE Tier 1, Prior Authorization Not Preferred, Prior Authorization, Quantity Limit NONE Tier 5, Prior Authorization NONE NONE
Cholesterol Absorption Inhibitor & HMG-CoA Reductase Inhibitor EZETIMIBE-SIMVASTATIN Vytorin Hypercholesterolemia Hyperlipidemia     TABLET NONE NONE NONE NONE NONE Tier 2, Step Therapy Tier 1, Quantity Limit Not Preferred, Prior Authorization, Quantity Limit NONE Tier 4, Quantity Limit Merck Ambetter
Bile Acid Sequestrant COLESEVELAM HYDROCHLORIDE Welchol Hypercholesterolemia Type II Diabetes     ORAL SUSPENSION NONE NONE NONE NONE Generic, Tier 3 NONE Generic, Tier 1 Not Preferred, Prior Authorization, Quantity Limit NONE Generic, Tier 3 DaiichiSankyo Cigna, CIP
Anticoagulant RIVAROXABAN Xarelto Blood Clot (Preventative)       TABLET NONE NONE NONE NONE Tier 3, Prior Authorization, Quantity Limit Tier 2, Prior Authorization Tier 1, Prior Authorization, Quantity Limit Not Preferred, Prior Authorization, Quantity Limit NONE Tier 3, Prior Authorization, Quantity Limit Johnson & Johnson Cigna, Ambetter, CIP
Anticoagulant RIVAROXABAN Xarelto Starter Pack Blood Clot (Preventative)       TABLET NONE NONE NONE NONE NONE NONE Tier 1, Prior Authorization, Quantity Limit NONE NONE Tier 3, Prior Authorization, Quantity Limit Johnson & Johnson CIP
Gastrointenstinal Lipase Inhibitor ORLISTAT Xenical Obesity       CAPSULE NONE NONE NONE NONE NONE NONE NONE Preferred, Prior Authorization, Under 21 years of age NONE NONE NONE Medicaid
Cholesterol Absorption Inhibitor EZETIMIBE Zetia Hypercholesterolemia       TABLET NONE NONE NONE NONE Tier 3, Quantity Limit Tier 2, Step Therapy Tier 1, Quantity Limit Not Preferred, Prior Authorization, Quantity Limit NONE Tier 3 Merck Cigna, Ambetter, CIP
Platelet Aggregation Inhibitor VORAPAXAR Zontivity Thrombotic Cardiovasular Events (Preventative) Myocardial Infarction Peripheral Artery Disease   TABLET NONE NONE NONE NONE NONE NONE NONE Not Preferred, Prior Authorization, Quantity Limit NONE NONE NONE NONE

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