About Prior Authorization
Certain medications require prior authorization to ensure safe and effective use. The drug policies and fax forms on this site are divided into tabs organized by drugs covered under the medical benefit or pharmacy benefit, and are subject to the terms of a member’s specific health plan.
Medical benefit:
Typically, medications covered under the medical benefit are administered in an outpatient hospital, home or office setting. For questions about a prior authorization covered under the medical benefit, please contact CVS Caremark at 888-877-0518.
Pharmacy benefit:
Typically, medications covered under the pharmacy benefit are oral, topical or inhaled products distributed by retail or mail pharmacies. For questions about a prior authorization covered under the pharmacy benefit, please contact CVS Caremark at 855-582-2038.
Specialty drugs may be covered either through the medical and/or pharmacy benefit. To view of a full list of drugs that have prior authorization and/or site of care requirements under the medical benefit, please check the Specialty Drug List.
For questions about FEP members and their prior authorization, please call 800-469-7556.
Pharmacy Benefit Policies
NOTE: Some policies may be indication specific. Where applicable, indications are noted in parentheses next to the policy name. In such case, indication-specific criteria take precedence.
Select the starting letter of the medication to find the desired form. Drug coverage is dependent on member’s formulary.
KEY: Brand names are in capital letters and generics are in lower case letters.
A
|
ABILIFY |
|---|
|
abiraterone |
|
ABRILADA |
|
ABRILADA (RHEUMATOID ARTHRITIS) |
|
ABSORICA |
|
acamprosate calcium |
|
ACANYA |
|
ACCUTANE |
|
ACIPHEX (Post Limit) |
|
ACIPHEX (QL) |
|
ACTEMRA |
|
ACTEMRA (RHEUMATOID ARTHRITIS) |
|
ACTHAR GEL |
|
ACTIMMUNE |
|
ACTIQ |
|
adalimumab |
|
adalimumab (RHEUMATOID ARTHRITIS) |
|
adalimumab-aacf |
|
adalimumab-aacf (RHEUMATOID ARTHRITIS) |
|
adalimumab-aaty |
|
adalimumab-aaty (RHEUMATOID ARTHRITIS) |
|
adalimumab-adaz |
|
adalimumab-adaz (RHEUMATOID ARTHRITIS) |
|
adalimumab-adbm |
|
adalimumab-adbm (RHEUMATOID ARTHRITIS) |
|
adalimumab-fkjp |
|
adalimumab-fkjp (RHEUMATOID ARTHRITIS) |
|
adalimumab-ryvk |
|
adalimumab-ryvk (RHEUMATOID ARTHRITIS) |
|
adapalene |
|
adapalene-benzoyl peroxide |
|
ADBRY |
|
ADBRY (ATOPIC DERMATITIS) |
|
ADCIRCA |
|
ADDERALL (Post Limit) |
|
ADDERALL (QL) |
|
ADEMPAS |
|
ADHANSIA (Post Limit) |
|
ADHANSIA (QL) |
|
ADLYXIN |
|
ADLYXIN (QL) |
|
ADVAIR |
|
ADZENYS (Post Limit) |
|
ADZENYS (QL) |
|
AFINITOR |
|
AGAMREE |
|
AIMOVIG |
|
AIRDUO |
|
AIRSUPRA |
|
AJOVY |
|
Akeega SGM 6118-A |
|
AKLIEF |
|
AKYNZEO (Post Limit) |
|
AKYNZEO (QL) |
|
albendazole (Post Limit) |
|
albendazole (QL) |
|
ALBENZA (Post Limit) |
|
ALBENZA (QL) |
|
albuterol |
|
alclometasone (topical) |
|
ALECENSA |
|
ALHEMO |
|
ALINIA |
|
almotriptan (Post Limit) |
|
almotriptan (QL) |
|
alogliptin |
|
alogliptin-pioglitazone |
|
alosetron |
|
alprazolam |
|
alprostadil (QL) |
|
ALTRENO |
|
ALUNBRIG |
|
ALVAIZ |
|
ALVESCO |
|
ALYFTREK |
|
ALYQ |
|
AMBIEN (Post Limit) |
|
AMBIEN (QL) |
|
AMBISOME (Post Limit) |
|
ambrisentan |
|
amcinonide (topical) |
|
amitriptyline (Age Limit) |
|
amitriptyline (Age Post Limit) |
|
amitriptyline (Post Limit, Age Limit) |
|
AMJEVITA |
|
AMJEVITA (RHEUMATOID ARTHRITIS) |
|
AMNESTEEM |
|
amoxapine (Age Limit) |
|
amoxapine (Age Post Limit) |
|
amoxapine (Post Limit, Age Limit) |
|
amphetamine (Post Limit) |
|
amphetamine (QL) |
|
amphetamine-dextroamphetamine (Post Limit) |
|
amphetamine-dextroamphetamine (QL) |
|
amphotericin (Post Limit) |
|
AMPYRA |
|
ANAFRANIL (Age Limit) |
|
ANAFRANIL (Age Post Limit) |
|
ANAFRANIL (Post Limit, Age Limit) |
|
ANDRODERM |
|
ANDROGEL |
|
ANORO ELLIPTA |
|
ANZEMET (Post Limit) |
|
ANZEMET (QL) |
|
APOKYN |
|
apomorphine |
|
aprepitant (Post Limit) |
|
aprepitant (QL) |
|
APTENSIO (Post Limit) |
|
APTENSIO (QL) |
|
APTIOM |
|
AQNEURSA |
|
ARANESP |
|
ARCALYST |
|
arformoterol |
|
ARIKAYCE |
|
armodafinil |
|
ARMONAIR |
|
ARNUITY ELLIPTA |
|
ASMANEX |
|
ATIVAN |
|
atomoxetine (Post Limit) |
|
atomoxetine (QL) |
|
ATRALIN |
|
ATROVENT |
|
ATTRUBY |
|
AUBAGIO |
|
AUGTYRO |
|
AUSTEDO |
|
AUVELITY |
|
AUVI-Q (CF) |
|
AVEED |
|
AVITA |
|
AVONEX |
|
AYVAKIT |
|
azacitidine |
|
azelaic acid (PA) |
|
azelastine (intranasal) |
|
AZSTARYS (Post Limit) |
|
AZSTARYS (QL) |
B
|
BAFIERTAM |
|---|
|
BALVERSA |
|
BANZEL |
|
BECONASE (intranasal) |
|
BELSOMRA |
|
BENLYSTA |
|
BENZAMYCIN |
|
benzphetamine |
|
BERINERT |
|
betaine |
|
betamethasone (topical) |
|
BETASERON |
|
BETHKIS |
|
BEVESPI AEROSPHERE |
|
bexarotene |
|
BILTRICIDE (Post Limit) |
|
BILTRICIDE (QL) |
|
BIMZELX |
|
bosentan |
|
BOSULIF |
|
BRAFTOVI |
|
BRENZAVVY |
|
BREO ELLIPTA |
|
BREXAFEMME |
|
BREZTRI |
|
brimonidine (PA) |
|
BROVANA |
|
BRUKINSA |
|
budesonide |
|
budesonide 1mg |
|
budesonide-formoterol |
|
BUPHENYL |
|
buprenorphine (PA) |
|
buprenorphine (Post Limit) |
|
buprenorphine-naloxone |
|
butalbital |
|
butorphanol |
|
BYDUREON BCISE |
|
BYDUREON BCISE (PA) |
|
BYDUREON BCISE (QL) |
|
BYETTA |
|
BYETTA (PA) |
|
BYETTA (QL) |
|
BYLVAY |
C
|
CABOMETYX |
|---|
|
calcipotriene (PA) |
|
calcipotriene (ST) |
|
CALCITRENE (PA) |
|
CALCITRENE (ST) |
|
CALQUENCE |
|
CAMZYOS |
|
CANCIDAS (Post Limit) |
|
CAPLYTA |
|
CAPRELSA |
|
CARAC |
|
CARBAGLU |
|
carglumic acid |
|
carisoprodol |
|
carisoprodol-aspirin-codeine |
|
caspofungin (Post Limit) |
|
CAVERJECT (QL) |
|
CAYSTON |
|
ceftriaxone (Post Limit) |
|
CENTANY |
|
CEQUA |
|
CERDELGA |
|
cetrorelix acetate |
|
CETROTIDE |
|
CHENODAL |
|
CHEWTADZY (PA) |
|
CHEWTADZY (QL) |
|
CHEWTADZY (ST) |
|
chlordiazepoxide |
|
chlordiazepoxide-amitriptyline (Age Limit) |
|
chlordiazepoxide-amitriptyline (Age Post Limit) |
|
chlordiazepoxide-amitriptyline (Post Limit, Age Limit) |
|
CHOLBAM |
|
chorionic-gonadotropin |
|
CIALIS (PA) |
|
CIALIS (QL) |
|
CIALIS (ST) |
|
CIBINQO |
|
ciclopirox (QL,Post Limit) |
|
ciclopirox (ST) |
|
CIMZIA |
|
CIMZIA (RHEUMATOID ARTHRITIS) |
|
cinacalcet |
|
CINBINQO (ATOPIC DERMATITIS) |
|
CINRYZE |
|
CINVANTI (Post Limit) |
|
CINVANTI (QL) |
|
CLARAVIS |
|
CLEOCIN-T |
|
CLINDAGEL |
|
clindamycin |
|
clindamycin-benzoyl peroxide |
|
clobazam |
|
clobetasol (topical) |
|
clocortolone (topical) |
|
clomipramine (Age Limit) |
|
clomipramine (Age Post Limit) |
|
clomipramine (Post Limit, Age Limit) |
|
clonazepam |
|
clonidine ER |
|
clorazepate |
|
clotrimazole (QL,Post Limit) |
|
clotrimazole betamethasone |
|
clotrimazole troches |
|
colchicine |
|
COLCRYS |
|
colistimethate (Post Limit) |
|
COLY-MYCIN (Post Limit) |
|
COMBIVENT |
|
COMETRIQ |
|
COMPOUNDED DRUGS |
|
CONCERTA (Post Limit) |
|
CONCERTA (QL) |
|
CONTRAVE |
|
COPAXONE |
|
COPIKTRA |
|
CORLANOR |
|
COSENTYX |
|
COTELLIC |
|
COTEMPLA (Post Limit) |
|
COTEMPLA (QL) |
|
CRENESSITY |
|
CREON |
|
cromolyn |
|
CUBICIN (Post Limit) |
|
cyanocobalamin injection |
|
cyclosporine |
|
CYLTEZO |
|
CYLTEZO (RHEUMATOID ARTHRITIS) |
|
CYSTADANE |
|
CYSTADROPS |
|
CYSTAGON |
|
CYSTARAN |
D
|
dalfampridine |
|---|
|
DALIRESP |
|
DALVANCE (Post Limit) |
|
DANZITEN |
|
daptomycin (Post Limit) |
|
DAPZURA (Post Limit) |
|
DARAPRIM |
|
dasatinib |
|
DAURISMO |
|
DAYBUE |
|
DAYTRANA (Post Limit) |
|
DAYTRANA (QL) |
|
DAYVIGO |
|
deferasirox |
|
deferiprone |
|
deflazacort |
|
DELATESTRYL |
|
DEMSER |
|
DEPO-TESTOSTERONE |
|
desipramine (Age Limit) |
|
desipramine (Age Post Limit) |
|
desipramine (Post Limit, Age Limit) |
|
desonide (topical) |
|
desoximetasone (topical) |
|
DESOXYN (Post Limit) |
|
DESOXYN (QL) |
|
desvenlafaxine |
|
DEXCOM (PA) |
|
DEXCOM (QL) |
|
DEXEDRINE (Post Limit) |
|
DEXEDRINE (QL) |
|
DEXILANT (Post Limit) |
|
DEXILANT (QL) |
|
dexlansoprazole (Post Limit) |
|
dexlansoprazole (QL) |
|
dexmethylphenidate (Post Limit) |
|
dexmethylphenidate (QL) |
|
dextroamphetamine (Post Limit) |
|
dextroamphetamine (QL) |
|
DIABETIC TEST STRIPS (Post Limit) |
|
DIABETIC TEST STRIPS (QL) |
|
DIACOMIT |
|
diazepam |
|
diazepam spray |
|
DIBENZYLINE |
|
dichlorphenamide |
|
diclofenac 1% |
|
diclofenac 3% |
|
diclofenac gel (Post Limit) |
|
diclofenac solution |
|
diethylpropion |
|
DIFFERIN |
|
DIFICID (PA) |
|
DIFICID (REG) |
|
diflorasone (topical) |
|
dimethyl fumarate |
|
dofetilide |
|
DOJOLVI |
|
DOPTELET |
|
DORAL (Post Limit) |
|
DORAL (QL) |
|
doxepin (Age Limit) |
|
doxepin (Age Post Limit) |
|
doxepin (Post Limit, Age Limit) |
|
doxepin (ST) |
|
dronabinol (Post Limit) |
|
dronabinol (QL) |
|
droxidopa |
|
DUAKLIR |
|
DULERA |
|
DUPIXENT |
|
DUPIXENT (ATOPIC) |
|
DUVYZAT |
|
DYANAVEL (Post Limit) |
|
DYANAVEL (QL) |
|
DYMISTA (intranasal) |
E
|
EBGLYSS |
|---|
|
EBGLYSS (ATOPIC DERMATITIS) |
|
econazole (QL,Post Limit) |
|
econazole (ST) |
|
ECOZA (QL,Post Limit) |
|
ECOZA (ST) |
|
EDEX (QL) |
|
EGATEN (Post Limit) |
|
EGATEN (QL) |
|
EGRIFTA |
|
eletriptan (Post Limit) |
|
eletriptan (QL) |
|
ELIDEL |
|
EMEND (Post Limit) |
|
EMEND (QL) |
|
EMFLAZA |
|
EMGALITY |
|
EMSAM |
|
EMVERM (Post Limit) |
|
EMVERM (QL) |
|
ENBREL |
|
ENBREL (RHEUMATOID ARTHRITIS) |
|
ENDARI |
|
ENSPRYNG |
|
ENSTILAR (PA) |
|
ENSTILAR (ST) |
|
EOHILIA |
|
EPCLUSA |
|
EPIDIOLEX |
|
EPIDUO |
|
epinephrine (CF) |
|
EPIPEN (CF) |
|
EPOGEN |
|
ERIVEDGE |
|
ERLEADA |
|
erlotinib |
|
ERTACZO (QL,Post Limit) |
|
ERTACZO (ST) |
|
ertapenem (Post Limit) |
|
ERYGEL |
|
erythromycin |
|
erythromycin-benzoyl peroxide |
|
ESBRIET |
|
esomeprazole (Post Limit) |
|
esomeprazole (QL) |
|
estazolam (Post Limit) |
|
estazolam (QL) |
|
estradiol injection |
|
estrogen injection |
|
eszopiclone (Post Limit) |
|
eszopiclone (QL) |
|
EVEKEO (Post Limit) |
|
EVEKEO (QL) |
|
everolimus |
|
EVERSENSE (PA) |
|
EVERSENSE (QL) |
|
EVRYSDI |
|
EXELDERM (QL,Post Limit) |
|
EXELDERM (ST) |
|
EXJADE |
|
EXKIVITY |
|
EXTAVIA |
|
EXTINA (QL,Post Limit) |
|
EXTINA (ST) |
|
EYSUVIS |
|
ezetimibe-simvastatin 10/80mg |
F
|
FABHALTA |
|---|
|
FABIOR |
|
FANAPT |
|
FARXIGA |
|
FASENRA PEN |
|
febuxostat |
|
FEMALE CONDOMS |
|
fentanyl OT lozenge |
|
FENTORA |
|
FERRIPROX |
|
FETZIMA |
|
FILSPARI |
|
FILSUVEZ |
|
FINACEA (PA) |
|
finasteride |
|
fingolimod |
|
FINTEPLA |
|
FIRAZYR |
|
FIRDAPSE |
|
FIRVANQ (QL) |
|
FLOVENT |
|
flunisolide (intranasal) |
|
fluocinolone (topical) |
|
fluocinonide (topical) |
|
FLUOROPLEX |
|
fluorouracil |
|
flurandrenolide (topical) |
|
flurazepam (Post Limit) |
|
flurazepam (QL) |
|
fluticasone |
|
fluticasone (intranasal) |
|
fluticasone (topical) |
|
fluticasone-salmeterol |
|
fluticasone-vilanterol |
|
FOCALIN (Post Limit) |
|
FOCALIN (QL) |
|
FOCINVEZ (Post Limit) |
|
FOCINVEZ (QL) |
|
FOLLISTIM AQ |
|
formoterol |
|
FORTEO |
|
FORTESTA |
|
FOTIVDA |
|
FREESTYLE LIBRE (PA) |
|
FREESTYLE LIBRE (QL) |
|
FROVA (Post Limit) |
|
FROVA (QL) |
|
frovatriptan (Post Limit) |
|
frovatriptan (QL) |
|
FRUZAQLA |
|
FULPHILA |
|
FUZEON |
|
FYLNETRA |
|
FYREMADEL |
G
|
gabapentin |
|---|
|
gabapentin (ST) |
|
gabapentin IR (Post Limit) |
|
GABARONE (Post Limit) |
|
GALAFOLD |
|
ganirelix acetate |
|
GATTEX |
|
GAVRETO |
|
gefitinib |
|
GENOTROPIN |
|
GEODON |
|
GILENYA |
|
GILOTRIF |
|
glatiramer |
|
GLATOPA |
|
GLEEVEC |
|
GLOPERBA |
|
GLUMETZA |
|
glycopyrrolate |
|
GLYXAMBI |
|
GONAL-F |
|
GRALISE |
|
GRALISE (ST) |
|
granisetron (Post Limit) |
|
granisetron (QL) |
|
GRANIX |
|
guanfacine ER |
|
GUARDIAN (PA) |
|
GUARDIAN (QL) |
H
|
HADLIMA |
|---|
|
HADLIMA (RHEUMATOID ARTHRITIS) |
|
HAEGARDA |
|
halcinonide (topical) |
|
HALCION (Post Limit) |
|
HALCION (QL) |
|
halobetasol (topical) |
|
HARVONI |
|
HEMLIBRA |
|
heparin injection |
|
HETLIOZ |
|
HIGH RISK |
|
HORIZANT |
|
HORIZANT (ST) |
|
HULIO |
|
HULIO (RHEUMATOID ARTHRITIS) |
|
HUMATROPE |
|
HUMIRA |
|
HUMIRA (RHEUMATOID ARTHRITIS) |
|
HYCAMTIN |
|
hydrocortisone (topical) |
|
HYMPAVZI |
|
HYRIMOZ |
|
HYRIMOZ (RHEUMATOID ARTHRITIS) |
I
|
IBRANCE |
|---|
|
icatibant |
|
ICLUSIG |
|
icosapent |
|
IDACIO |
|
IDACIO (RHEUMATOID ARTHRITIS) |
|
IDHIFA |
|
imatinib |
|
IMBRUVICA |
|
imipramine (Age Limit) |
|
imipramine (Age Post Limit) |
|
imipramine (Post Limit, Age Limit) |
|
imiquimod |
|
imiquimod 5% |
|
IMITREX (Post Limit) |
|
IMITREX (QL) |
|
IMKELDI |
|
INBRIJA |
|
INCRELEX |
|
INCRUSE-ELLIPTA |
|
INGREZZA |
|
INLYTA |
|
INQOVI |
|
INREBIC |
|
INTRON A |
|
INTUNIV |
|
INVANZ (Post Limit) |
|
INVEGA |
|
INVOKAMET |
|
INVOKANA |
|
ipratropium |
|
IRESSA |
|
isotretinoin |
|
ISTURISA |
|
ITOVEBI |
|
itraconazole |
|
itraconazole caps |
|
ivermectin (PA) |
|
IWILFIN |
J
|
JADENU |
|---|
|
JAKAFI |
|
JANUMET |
|
JANUVIA |
|
JARDIANCE |
|
JATENZO |
|
JAVYGTOR |
|
JAYPIRCA |
|
JENTADUETO |
|
JESDUVROQ |
|
JOENJA |
|
JORNAY (Post Limit) |
|
JORNAY (QL) |
|
JOURNAVX (Post Limit) |
|
JUBLIA (Post Limit) |
|
JUXTAPID |
|
JYNARQUE |
K
|
KALBITOR |
|---|
|
KALYDECO |
|
KAPVAY |
|
KAZANO |
|
KERENDIA |
|
KERYDIN |
|
KERYDIN (topical) |
|
KESIMPTA |
|
ketoconazole (QL,Post Limit) |
|
ketoconazole (ST) |
|
ketorolac |
|
KEVEYIS |
|
KEVZARA |
|
KEVZARA (RHEUMATOID ARTHRITIS) |
|
KIMYRSA (Post Limit) |
|
KINERET |
|
KINERET (RHEUMATOID ARTHRITIS) |
|
KISQALI |
|
KISQALI FEMARA CO-PACK |
|
KITABIS PAK |
|
KLONOPIN |
|
KLOXXADO (PA) |
|
KLOXXADO (Post Limit) |
|
KOMBIGLYZE XR |
|
KONVOMEP (PA) |
|
KONVOMEP (Post Limit) |
|
KONVOMEP (QL) |
|
KORLYM |
|
KOSELUGO |
|
KRAZATI |
|
KUVAN |
|
KYNMOBI |
|
KYZATREX |
L
|
LAGEVRIO |
|---|
|
lansoprazole (Post Limit) |
|
lansoprazole (QL) |
|
lapatinib |
|
LATUDA |
|
LAZCLUZE |
|
ledipasvir-sofosbuvir |
|
lenalidomide |
|
LENVIMA |
|
LETAIRIS |
|
LEUKINE |
|
leuprolide acetate |
|
levalbuterol |
|
levofloxacin (Post Limit) |
|
LIBERVANT |
|
lidocaine |
|
lidocaine patch |
|
lidocaine patch (Limit) |
|
lidocaine topical (QL) |
|
lidocaine-prilocaine (Post Limit) |
|
lidocaine-prilocaine (QL) |
|
lidocaine-tetracaine (Post Limit) |
|
lidocaine-tetracaine (QL) |
|
lidocaine-topical (Post Limit) |
|
LIDODERM (Limit) |
|
LIDODERM PATCH |
|
LIDODERM PATCH (QL) |
|
linezolid |
|
LIQREV |
|
lisdexamfetamine (Post Limit) |
|
lisdexamfetamine (QL) |
|
LITFULO |
|
LIVDELZI |
|
LIVMARLI |
|
LODOCO |
|
LONHALA |
|
LONSURF |
|
LOPROX (QL,Post Limit) |
|
LOPROX (ST) |
|
lorazepam |
|
LORBRENA |
|
LOREEV XR |
|
loteprednol |
|
LOTRONEX |
|
LOVAZA |
|
luliconazole (QL,Post Limit) |
|
luliconazole (ST) |
|
LUMAKRAS |
|
LUMRYZ |
|
LUNESTA (Post Limit) |
|
LUNESTA (QL) |
|
LUPKYNIS |
|
LUZU (QL,Post Limit) |
|
LUZU (ST) |
|
LYBALVI |
|
LYNPARZA |
|
LYRICA (QL) |
|
LYRICA (ST) |
|
LYTGOBI |
M
|
MALE CONDOMS |
|---|
|
MARINOL (Post Limit) |
|
MARINOL (QL) |
|
MAVENCLAD |
|
MAVYRET |
|
MAXALT (Post Limit) |
|
MAXALT (QL) |
|
MAYZENT |
|
mebendazole (Post Limit) |
|
mebendazole (QL) |
|
medroxyprogesterone injection |
|
MEKINIST |
|
MEKTOVI |
|
MENOPUR |
|
MENTAX (QL,Post Limit) |
|
MENTAX (ST) |
|
meropenem (Post Limit) |
|
metformin ER |
|
methadone |
|
METHADOSE |
|
methamphetamine (Post Limit) |
|
methamphetamine (QL) |
|
METHITEST |
|
METHYLIN (Post Limit) |
|
METHYLIN (QL) |
|
methylphenidate (Post Limit) |
|
methylphenidate (QL) |
|
methyltestosterone |
|
METROCREAM (Post Limit) |
|
METROGEL (Post Limit) |
|
METROLOTION (Post Limit) |
|
metronidazole (PA) |
|
metronidazole (Post Limit) |
|
metyrosine |
|
micafungin (Post Limit) |
|
miconazole |
|
miconazole-zinc oxide-white petrolatum (QL,Post Limit) |
|
miconazole-zinc oxide-white petrolatum (ST) |
|
midazolam (PA) |
|
midazolam (QL) |
|
MIEBO |
|
mifepristone |
|
miglustat |
|
MIGRANAL NASAL SPRAY |
|
minoxidil |
|
MIPLYFFA |
|
MIRCERA |
|
MIRVASO (PA) |
|
MITIGARE |
|
modafinil |
|
mometasone |
|
mometasone (intranasal) |
|
mometasone (topical) |
|
MOUNJARO |
|
MOUNJARO (PA) |
|
MOUNJARO (QL) |
|
MOVANTIK |
|
MULPLETA |
|
MULTAQ |
|
mupirocin |
|
MUSE (QL) |
|
MYALEPT |
|
MYCAMINE (Post Limit) |
|
MYCAPSSA |
|
MYDAYIS (Post Limit) |
|
MYDAYIS (QL) |
|
MYFEMBREE |
|
MYORISAN |
N
|
naftifine (QL,Post Limit) |
|---|
|
naftifine (ST) |
|
NAFTIN (QL,Post Limit) |
|
NAFTIN (ST) |
|
Nail Antifungal Topical Aligned PA 1325-A UDR 10-2023a |
|
naloxone (PA) |
|
naloxone (Post Limit) |
|
naratriptan (Post Limit) |
|
naratriptan (QL) |
|
NARCAN (PA) |
|
NARCAN (Post Limit) |
|
NATESTO |
|
NAYZILAM (PA) |
|
NAYZILAM (QL) |
|
NEMLUVIO |
|
NERLYNX |
|
NESINA |
|
NEULASTA |
|
NEUPOGEN |
|
NEURONTIN (Post Limit) |
|
NEXAVAR |
|
NEXIUM (Post Limit) |
|
NEXIUM (QL) |
|
NEXLETOL |
|
NEXLIZET |
|
NGENLA |
|
NINLARO |
|
nitazoxanide |
|
nitisinone |
|
NITYR |
|
NIVESTYM |
|
NORDITROPIN |
|
NORITATE (PA) |
|
NORITATE (Post Limit) |
|
NORPRAMIN (Age Limit) |
|
NORPRAMIN (Age Post Limit) |
|
NORPRAMIN (Post Limit, Age Limit) |
|
NORTHERA |
|
nortriptyline (Age Limit) |
|
nortriptyline (Age Post Limit) |
|
nortriptyline (Post Limit, Age Limit) |
|
NOVAREL |
|
NOXAFIL |
|
NUBEQA |
|
NUEDEXTA |
|
NUPLAZID |
|
NURTEC |
|
NUTROPIN AQ |
|
NUVIGIL |
|
NYPOZI |
|
nystatin ointment (QL,Post Limit) |
|
nystatin triamcinolone |
|
NYVEPRIA |
O
|
OCALIVA |
|---|
|
octreotide |
|
ODOMZO |
|
OFEV |
|
OGSIVEO |
|
OHTUVAYRE |
|
OJJAARA |
|
olopatadine (intranasal) |
|
OLPRUVA |
|
OLUMIANT |
|
omega-3-acid |
|
omeprazole (Post Limit) |
|
omeprazole (QL) |
|
omeprazole-sodium bicarbonate (PA) |
|
omeprazole-sodium bicarbonate (Post Limit) |
|
omeprazole-sodium bicarbonate (QL) |
|
OMNARIS (intranasal) |
|
OMNIPOD |
|
OMNITROPE |
|
OMVOH |
|
ONEXTON |
|
ONFI |
|
ONGENTYS |
|
ONGLYZA |
|
ONUREG |
|
ONYDA XR |
|
ONZETRA XSAIL (Post Limit) |
|
ONZETRA XSAIL (QL) |
|
OPFOLDA |
|
Opioid Containing Cough and Cold Products |
|
OPIOIDS-ER |
|
OPIOIDS-IR (3Day Post Limit) |
|
OPIOIDS-IR (3Day) |
|
OPIOIDS-IR (7Day Post Limit) |
|
OPIOIDS-IR (7Day) |
|
OPIOIDS-IR (Combo Products) |
|
OPIPZA |
|
OPSUMIT |
|
OPSYNVI |
|
OPVEE (PA) |
|
OPVEE (Post Limit) |
|
OPZELURA |
|
ORAVIG |
|
ORBACTIV (Post Limit) |
|
ORENCIA |
|
ORENCIA (RHEUMATOID ARTHRITIS) |
|
ORENITRAM |
|
ORFADIN |
|
ORGOVYX |
|
ORIAHNN |
|
ORILISSA |
|
ORKAMBI |
|
ORLADEYO |
|
orlistat |
|
ORMALVI |
|
ORSERDU |
|
oseltamivir (Post Limit) |
|
OSENI |
|
OSPHENA |
|
OTEZLA |
|
OTREXUP |
|
OTULFI |
|
OVIDREL |
|
oxazepam |
|
OXBRYTA |
|
OXERVATE |
|
oxiconazole (QL,Post Limit) |
|
oxiconazole (ST) |
|
OXISTAT (QL,Post Limit) |
|
OXISTAT (ST) |
|
OZEMPIC |
|
OZEMPIC (PA) |
|
OZEMPIC (QL) |
P
|
palonosetron (Post Limit) |
|---|
|
PALYNZIQ |
|
PAMELOR (Age Limit) |
|
PAMELOR (Age Post Limit) |
|
PAMELOR (Post Limit, Age Limit) |
|
PANCREAZE |
|
pancrelipase |
|
pantoprazole (Post Limit) |
|
pantoprazole (QL) |
|
PATANASE (intranasal) |
|
PAXLOVID |
|
pazopanib |
|
PEGASYS |
|
PEMAZYRE |
|
PENNSAID |
|
PERFOROMIST |
|
perphenazine-amitriptyline (Age Limit) |
|
perphenazine-amitriptyline (Age Post Limit) |
|
perphenazine-amitriptyline (Post Limit, Age Limit) |
|
PERTZYE |
|
PHEBURANE |
|
phendimetrazine |
|
phenoxybenzamine |
|
PHYRAGO |
|
pilocarpine |
|
pimecrolimus |
|
PIQRAY |
|
pirfenidone |
|
PLEGRIDY |
|
PLIAGLIS |
|
PLIAGLIS (Post Limit) |
|
POMALYST |
|
PONVORY |
|
posaconazole |
|
POSFREA (Post Limit) |
|
PRALUENT |
|
praziquantel (Post Limit) |
|
praziquantel (QL) |
|
prednicarbate (topical) |
|
pregabalin (QL) |
|
pregabalin (ST) |
|
PREGNYL |
|
PREVACID (Post Limit) |
|
PREVACID (QL) |
|
PREVYMIS |
|
PRILOSEC (Post Limit) |
|
PRILOSEC (QL) |
|
PRISTIQ |
|
PROAIR |
|
PROCENTRA (Post Limit) |
|
PROCENTRA (QL) |
|
PROCRIT |
|
PROCYSBI |
|
PROMACTA |
|
PROPECIA |
|
PROTONIX (Post Limit) |
|
PROTONIX (QL) |
|
protriptyline (Age Limit) |
|
protriptyline (Age Post Limit) |
|
protriptyline (Post Limit, Age Limit) |
|
PROVENTIL |
|
PROVIGIL |
|
PRUDOXIN (ST) |
|
PULMICORT |
|
PULMICORT 1MG |
|
PULMOZYME |
|
Purified Cortrophin Gel |
|
PURIXAN |
|
pyrimethamine |
|
PYRUKYND |
Q
|
QELBREE (Post Limit) |
|---|
|
QELBREE (QL) |
|
QFITLIA |
|
QINLOCK |
|
QLOSI |
|
QNASL (intranasal) |
|
QSYMIA |
|
QTERN |
|
quazepam (Post Limit) |
|
quazepam (QL) |
|
QUILLICHEW (Post Limit) |
|
QUILLICHEW (QL) |
|
QUILLIVANT (Post Limit) |
|
QUILLIVANT (QL) |
|
QULIPTA |
|
QUVIVIQ |
|
QVAR |
R
|
rabeprazole (Post Limit) |
|---|
|
rabeprazole (QL) |
|
ramelteon (Post Limit) |
|
ramelteon (QL) |
|
RANEXA |
|
ranolazine ER |
|
RASUVO |
|
RAVICTI |
|
REBIF |
|
REDITREX |
|
REGRANEX |
|
RELENZA (Post Limit) |
|
RELENZA (QL) |
|
RELEUKO |
|
RELEXXII (Post Limit) |
|
RELEXXII (QL) |
|
RELISTOR |
|
RELPAX (Post Limit) |
|
RELPAX (QL) |
|
RELYVRIO |
|
REPATHA |
|
RESTASIS |
|
RESTORIL (Post Limit) |
|
RESTORIL (QL) |
|
RETACRIT |
|
RETEVMO |
|
RETIN-A |
|
REVCOVI |
|
REVLIMID |
|
REVUFORJ |
|
REXTOVY (PA) |
|
REXTOVY (Post Limit) |
|
REXULTI |
|
REYVOW |
|
REZDIFFRA |
|
REZENOPY (PA) |
|
REZENOPY (Post Limit) |
|
REZLIDHIA |
|
REZUROCK |
|
RHOFADE (PA) |
|
ribavirin |
|
RINVOQ |
|
RINVOQ (ATOPIC DERMATITIS) |
|
RISPERDAL |
|
RITALIN (Post Limit) |
|
RITALIN (QL) |
|
RIVFLOZA |
|
RIVIVE (PA) |
|
RIVIVE (Post Limit) |
|
RIZAFILM (Post Limit) |
|
RIZAFILM (QL) |
|
rizatriptan (Post Limit) |
|
rizatriptan (QL) |
|
ROGAINE |
|
ROMVIMZA |
|
ROZEREM (Post Limit) |
|
ROZEREM (QL) |
|
ROZLYTREK |
|
RUBRACA |
|
RUCONEST |
|
RYALTRIS (intranasal) |
|
RYBELSUS |
|
RYBELSUS (PA) |
|
RYBELSUS (QL) |
|
RYDAPT |
S
|
SABRIL |
|---|
|
SAIZEN |
|
SAJAZIR |
|
SAMSCA |
|
SANCUSO (Post Limit) |
|
SANCUSO (QL) |
|
SANDOSTATIN |
|
SANTYL COLLAGENASE |
|
SAPHRIS |
|
sapropterin dihydrochloride |
|
SAVELLA |
|
saxagliptin |
|
SAXENDA |
|
SCEMBLIX |
|
SECUADO |
|
SEGLUROMET |
|
SELARSDI |
|
selegiline |
|
SENSIPAR |
|
SEREVENT |
|
SEROQUEL |
|
SEROSTIM |
|
SIGNIFOR |
|
sildenafil (QL) |
|
sildenafil (Specialty) |
|
SILENOR (Age Limit) |
|
SILENOR (Age Post Limit) |
|
SILENOR (Post Limit, Age Limit) |
|
SILIQ |
|
SIMLANDI |
|
SIMLANDI (RHEUMATOID ARTHRITIS) |
|
SIMPONI |
|
SIMPONI (RHEUMATOID ARTHRITIS) |
|
simvastatin 80mg |
|
SKYCLARYS |
|
SKYRIZI |
|
SKYTROFA |
|
sodium oxybate |
|
sodium phenylbutyrate |
|
sofosbuvir-velpatasvir |
|
SOGROYA |
|
SOHONOS |
|
SOLIQUA |
|
SOLU-CORTEF |
|
SOMA |
|
SOMAVERT |
|
SOOLANTRA (PA) |
|
sorafenib |
|
SORILUX (PA) |
|
SORILUX (ST) |
|
SOTYKTU |
|
SOVALDI |
|
SPIRIVA |
|
SPORANOX |
|
SPORANOX CAPS |
|
SPRAVATO |
|
SPRIX |
|
SPRYCEL |
|
STEGLATRO |
|
STEGLUJAN |
|
STELARA |
|
STENDRA (QL) |
|
STIMATE |
|
STIMUFEND |
|
STIOLTO |
|
STIVARGA |
|
STRATTERA (Post Limit) |
|
STRATTERA (QL) |
|
STRENSIQ |
|
streptomycin (Post Limit) |
|
STRIVERDI |
|
SUBOXONE |
|
SUCRAID |
|
sulconazole (QL,Post Limit) |
|
sulconazole (ST) |
|
sumatriptan (Post Limit) |
|
sumatriptan (QL) |
|
sumatriptan-naproxen (ST) |
|
sunitinib |
|
SUNOSI |
|
SUSTOL (Post Limit) |
|
SUSTOL (QL) |
|
SUTENT |
|
SYMBICORT |
|
SYMBRAVO (QL) |
|
SYMBRAVO (ST) |
|
SYMDEKO |
|
SYMJEPI (CF) |
|
SYMLINPEN |
|
SYMPAZAN |
|
SYMPROIC |
|
SYNDROS (Post Limit) |
|
SYNDROS (QL) |
|
SYNERA |
|
SYNERA (Post Limit) |
|
SYNJARDY |
T
|
TABRECTA |
|---|
|
TACLONEX (PA) |
|
TACLONEX (ST) |
|
tacrolimus |
|
tadalafil (PA) |
|
tadalafil (QL) |
|
tadalafil (Specialty) |
|
tadalafil (ST) |
|
TADLIQ |
|
TAFINLAR |
|
TAGRISSO |
|
TAKHZYRO |
|
TALTZ |
|
TALZENNA |
|
TAMIFLU (Limit) |
|
TAMIFLU (Post Limit) |
|
TARGRETIN |
|
TARPEYO |
|
TASCENSO ODT |
|
TASIGNA |
|
tasimelteon |
|
tavaborole |
|
tavaborole (topical) |
|
TAVALISSE |
|
TAVNEOS |
|
tazarotene |
|
tazarotene foam |
|
TAZORAC |
|
TAZVERIK |
|
TECFIDERA |
|
TEGSEDI |
|
temazepam (Post Limit) |
|
temazepam (QL) |
|
TEMODAR |
|
temozolomide |
|
TEPMETKO |
|
teriflunomide |
|
teriparatide |
|
TEST STRIPS |
|
TEST STRIPS (Preferred) |
|
TESTIM |
|
TESTOPEL |
|
testosterone |
|
tetrabenazine |
|
tetracycline |
|
THALOMID |
|
THIOLA |
|
TIBSOVO |
|
tigecycline (Post Limit) |
|
TIKOSYN |
|
tiopronin |
|
tiotropium |
|
TLANDO |
|
TOBI PODHALER |
|
tobramycin (Post Limit) |
|
tobramycin inhalation solution |
|
TOFIDENCE |
|
TOLAK |
|
tolvaptan |
|
TORPENZ |
|
TOSYMRA (Post Limit) |
|
TOSYMRA (QL) |
|
TRACLEER |
|
TRADJENTA |
|
TRANXENE |
|
TRELEGY |
|
TREMFYA |
|
tretinoin |
|
TREXIMET (Post Limit) |
|
TREXIMET (QL) |
|
TREXIMET (ST) |
|
triamcinolone (topical) |
|
triazolam (Post Limit) |
|
triazolam (QL) |
|
TRIJARDY XR |
|
TRIKAFTA |
|
trimipramine (Age Limit) |
|
trimipramine (Age Post Limit) |
|
trimipramine (Post Limit, Age Limit) |
|
TRUDHESA NASAL SPRAY |
|
TRULICITY |
|
TRULICITY (PA) |
|
TRULICITY (QL) |
|
TRUQAP |
|
TRYNGOLZA |
|
TRYPTYR |
|
TUDORZA |
|
TUKYSA |
|
TURALIO |
|
TWYNEO |
|
TYENNE |
|
TYENNE (RHEUMATOID ARTHRITIS) |
|
TYGACIL (Post Limit) |
|
TYKERB |
|
TYMLOS |
|
TYRVAYA |
|
TYVASO |
U
|
UBRELVY |
|---|
|
UDENYCA |
|
ULORIC |
|
UNDECATREX |
|
UPTRAVI |
V
|
V-GO |
|---|
|
VAFSEO |
|
VALCHLOR |
|
VALIUM |
|
VALTOCO |
|
VANCOCIN (QL) |
|
vancomycin (Post Limit) |
|
vancomycin (QL) |
|
VANFLYTA |
|
vardenafil (QL) |
|
varenicline |
|
VARUBI (Post Limit) |
|
VARUBI (QL) |
|
VASCEPA |
|
VECTICAL (PA) |
|
VECTICAL (ST) |
|
VELSIPITY |
|
VELTI |
|
VENCLEXTA |
|
VENTAVIS |
|
VENTOLIN |
|
VEOZAH |
|
VERQUVO |
|
VERZENIO |
|
VEVYE |
|
VFEND IV (Post Limit) |
|
VIAGRA (QL) |
|
VIBERZI |
|
VICTOZA |
|
VICTOZA (PA) |
|
VICTOZA (QL) |
|
VIDAZA |
|
VIEKIRA PAK |
|
vigabatrin |
|
VIGADRONE |
|
VIGAFYDE |
|
VIGPODER |
|
VIJOICE |
|
VIOKACE |
|
VITRAKVI |
|
VIZIMPRO |
|
VOGELXO |
|
VOLTAREN (Post Limit) |
|
VOLTAREN (QL) |
|
VONJO |
|
VOQUEZNA |
|
VORANIGO |
|
voriconazole (Post Limit) |
|
VOSEVI |
|
VOTRIENT |
|
VOWST |
|
VOXZOGO |
|
VOYDEYA |
|
VRAYLAR |
|
VTAMA |
|
VUITY |
|
VUMERITY |
|
VUSION (QL,Post Limit) |
|
VUSION (ST) |
|
VYALEV |
|
VYKAT XR |
|
VYLEESI |
|
VYNDAMAX |
|
VYNDAQEL |
|
VYTORIN 10/80MG |
|
VYVANSE (Post Limit) |
|
VYVANSE (QL) |
W
|
WAINUA |
|---|
|
WAKIX |
|
WEGOVY |
|
WELIREG |
|
WEZLANA |
|
WINLEVI |
|
WYNZORA (PA) |
|
WYNZORA (ST) |
X
|
XALKORI |
|---|
|
XANAX |
|
XELJANZ |
|
XELODA |
|
XELSTRYM (Post Limit) |
|
XELSTRYM (QL) |
|
XENAZINE |
|
XENICAL |
|
XEPI (PA) |
|
XEPI_(REG) |
|
XERMELO |
|
XHANCE |
|
XHANCE (intranasal) |
|
XIFAXAN 200MG |
|
XIFAXAN 550MG |
|
XIGDUO XR |
|
XIIDRA |
|
XOFLUZA (Post Limit) |
|
XOFLUZA (QL) |
|
XOLEGEL (QL,Post Limit) |
|
XOLEGEL (ST) |
|
XOLREMDI |
|
XOPENEX |
|
XOSPATA |
|
XPHOZAH |
|
XPOVIO |
|
XTANDI |
|
XULTOPHY |
|
XYREM |
|
XYWAV |
Y
|
Yargesa |
|---|
|
YONSA |
|
YORVIPATH |
|
YUFLYMA |
|
YUFLYMA (RHEUMATOID ARTHRITIS) |
|
YUPELRI |
|
YUSIMRY |
|
YUSIMRY (RHEUMATOID ARTHRITIS) |
Z
|
zaleplon (Post Limit) |
|---|
|
zaleplon (QL) |
|
ZARXIO |
|
ZAVESCA |
|
ZAVZPRET |
|
ZEGERID (PA) |
|
ZEGERID (Post Limit) |
|
ZEGERID (QL) |
|
ZEJULA |
|
ZELBORAF |
|
ZEMBRACE (Post Limit) |
|
ZEMBRACE (QL) |
|
ZENATANE |
|
ZENPEP |
|
ZENZEDI (Post Limit) |
|
ZENZEDI (QL) |
|
ZEPATIER |
|
ZEPBOUND |
|
ZEPOSIA |
|
ZETONNA (intranasal) |
|
ZIANA |
|
ZIEXTENZO |
|
ZILBRYSQ |
|
zileuton |
|
ZIMHI (PA) |
|
ZIMHI (Post Limit) |
|
ZITUVIMET |
|
ZITUVIO |
|
ZOCOR 80MG |
|
ZOKINVY |
|
ZOLINZA |
|
zolmitriptan (Post Limit) |
|
zolmitriptan (QL) |
|
zolpidem (Post Limit) |
|
zolpidem (QL) |
|
ZOMACTON |
|
ZOMIG (Post Limit) |
|
ZONALON (ST) |
|
ZORBTIVE |
|
ZORYVE |
|
ZTALMY |
|
ZTLIDO |
|
ZTLIDO (Limit) |
|
ZUBSOLV |
|
ZUPLENZ (Post Limit) |
|
ZURNAI (PA) |
|
ZURNAI (Post Limit) |
|
ZURZUVAE |
|
ZYCLARA |
|
ZYDELIG |
|
ZYFLO |
|
ZYKADIA |
|
ZYPREXA |
|
ZYTIGA |
|
ZYVOX |
Pharmacy Fax Forms
Select the starting letter of the medication to find the desired form. Drug coverage is dependent on member’s formulary.
KEY: Brand names are in capital letters and generics are in lower case letters.
A
|
ABELCET (Post Limit) |
|---|
|
ABILIFY |
|
abiraterone |
|
ABRILADA |
|
ABSORICA |
|
acamprosate calcium |
|
ACANYA |
|
ACCUTANE |
|
ACIPHEX (Post Limit) |
|
ACTEMRA |
|
ACTHAR GEL |
|
ACTIMMUNE |
|
ACTIQ |
|
adalimumab |
|
adalimumab-aacf |
|
adalimumab-aaty |
|
adalimumab-adaz |
|
adalimumab-adbm |
|
adalimumab-fkjp |
|
adalimumab-ryvk |
|
adapalene |
|
adapalene-benzoyl peroxide |
|
ADBRY |
|
ADCIRCA |
|
ADDERALL (Post Limit) |
|
ADEMPAS |
|
ADHANSIA (Post Limit) |
|
ADLYXIN |
|
ADZENYS (Post Limit) |
|
AFINITOR |
|
AGAMREE |
|
AIMOVIG |
|
AJOVY |
|
AKEEGA |
|
AKLIEF |
|
AKYNZEO (Post Limit) |
|
albendazole (Post Limit) |
|
ALBENZA (Post Limit) |
|
alclometasone (topical) |
|
ALECENSA |
|
ALHEMO |
|
almotriptan (Post Limit) |
|
alogliptin |
|
alogliptin-pioglitazone |
|
alosetron |
|
ALTRENO |
|
ALUNBRIG |
|
ALVAIZ |
|
ALYFTREK |
|
ALYQ |
|
AMBIEN (Post Limit) |
|
AMBISOME (Post Limit) |
|
ambrisentan |
|
amcinonide (topical) |
|
amitriptyline (Post Limit REG) |
|
amitriptyline (Post Limit) |
|
AMJEVITA |
|
AMNESTEEM |
|
amoxapine (Post Limit REG) |
|
amphetamine (Post Limit) |
|
amphetamine-dextroamphetamine (Post Limit) |
|
amphotericin (Post Limit) |
|
AMPYRA |
|
ANAFRANIL (Post Limit REG) |
|
ANAFRANIL (Post Limit) |
|
ANDRODERM |
|
ANDROGEL |
|
ANZEMET (Post Limit) |
|
APOKYN |
|
apomorphine |
|
aprepitant (Post Limit) |
|
APTENSIO (Post Limit) |
|
AQNEURSA |
|
ARANESP |
|
ARCALYST |
|
ARIKAYCE |
|
armodafinil |
|
atomoxetine (Post Limit) |
|
ATRALIN |
|
AUBAGIO |
|
AUGTYRO |
|
AUSTEDO |
|
AUVELITY |
|
AUVI-Q (CF) |
|
AVEED |
|
AVITA |
|
AVONEX |
|
AYVAKIT |
|
azacitidine |
|
azelaic acid |
|
AZSTARYS (Post Limit) |
B
|
BAFIERTAM |
|---|
|
BALVERSA |
|
BANZEL |
|
BELSOMRA |
|
BENLYSTA |
|
BENZAMYCIN |
|
benzphetamine |
|
BERINERT |
|
betaine |
|
betamethasone (topical) |
|
BETASERON |
|
BETHKIS |
|
bexarotene |
|
BILTRICIDE (Post Limit) |
|
BIMZELX |
|
bosentan |
|
BOSULIF |
|
BRAFTOVI |
|
BRENZAVVY |
|
BREXAFEMME |
|
brimonidine |
|
BRUKINSA |
|
budesonide 1mg |
|
BUPHENYL |
|
buprenorphine (PA) |
|
buprenorphine (Post Limit) |
|
buprenorphine sublingual |
|
BYDUREON BCISE |
|
BYDUREON BCISE (PA) |
|
BYETTA |
|
BYETTA (PA) |
|
BYLVAY |
C
|
CABOMETYX |
|---|
|
calcipotriene (PA) |
|
CALCITRENE (PA) |
|
CALQUENCE |
|
CAMZYOS |
|
CANCIDAS (Post Limit) |
|
CAPLYTA |
|
CAPRELSA |
|
CARAC |
|
CARBAGLU |
|
carglumic acid |
|
caspofungin (Post Limit) |
|
CAYSTON |
|
ceftriaxone (Post Limit) |
|
CENTANY |
|
CEQUA |
|
CERDELGA |
|
cetrorelix acetate |
|
CETROTIDE |
|
CHENODAL |
|
chlordiazepoxide-amitriptyline (Post Limit REG) |
|
chlordiazepoxide-amitriptyline (Post Limit) |
|
CHOLBAM |
|
chorionic gonadotropin |
|
CIALIS (PA) |
|
CIALIS (ST) |
|
CIALIS 5mg (ST) |
|
CIBINQO |
|
ciclopirox (Post Limit) |
|
CIMZIA |
|
cinacalcet |
|
CINRYZE |
|
CINVANTI (Post Limit) |
|
CLARAVIS |
|
CLEOCIN-T |
|
CLINDAGEL |
|
clindamycin |
|
clindamycin-benzoyl peroxide |
|
clobazam |
|
clobetasol (topical) |
|
clocortolone (topical) |
|
clomipramine (Post Limit REG) |
|
clomipramine (Post Limit) |
|
clonidine ER |
|
clotrimazole (Post Limit) |
|
clotrimazole troches |
|
colistimethate (Post Limit) |
|
COLY-MYCIN (Post Limit) |
|
COMETRIQ |
|
COMPOUNDED DRUGS |
|
CONCERTA (Post Limit) |
|
CONTRAVE |
|
COPAXONE |
|
COPIKTRA |
|
CORLANOR |
|
COSENTYX |
|
COTELLIC |
|
COTEMPLA (Post Limit) |
|
CRENESSITY |
|
CREON |
|
CUBICIN (Post Limit) |
|
cyanocobalamin injection |
|
cyclosporine |
|
CYLTEZO |
|
CYSTADANE |
|
CYSTADROPS |
|
CYSTAGON |
|
CYSTARAN |
D
|
dalfampridine |
|---|
|
DALIRESP |
|
DALVANCE (Post Limit) |
|
DANZITEN |
|
daptomycin (Post Limit) |
|
DAPZURA (Post Limit) |
|
DARAPRIM |
|
dasatinib |
|
DAURISMO |
|
DAYBUE |
|
DAYTRANA (Post Limit) |
|
DAYVIGO |
|
deferasirox |
|
deferiprone |
|
DELATESTRYL |
|
DEMSER |
|
DEPO-TESTOSTERONE |
|
desipramine (Post Limit REG) |
|
desipramine (Post Limit) |
|
desonide (topical) |
|
desoximetasone (topical) |
|
DESOXYN (Post Limit) |
|
desvenlafaxine ER |
|
DEXCOM (PA) |
|
DEXEDRINE (Post Limit) |
|
DEXILANT (Post Limit) |
|
dexlansoprazole (Post Limit) |
|
dexmethylphenidate (Post Limit) |
|
dextroamphetamine (Post Limit) |
|
DIABETIC TEST STRIPS (Post Limit) |
|
DIACOMIT |
|
diazepam spray |
|
DIBENZYLINE |
|
dichlorphenamide |
|
diclofenac 3% |
|
diclofenac gel (Post Limit) |
|
diclofenac solution |
|
diethylpropion |
|
DIFFERIN |
|
DIFICID (PA) |
|
DIFICID (REG) |
|
diflorasone (topical) |
|
dimethyl fumarate |
|
dofetilide |
|
DOJOLVI |
|
DOPTELET |
|
DORAL (Post Limit) |
|
doxepin (Post Limit REG) |
|
doxepin (Post Limit) |
|
doxepin cream (ST) |
|
dronabinol (Post Limit) |
|
droxidopa |
|
DUPIXENT |
|
DUPIXENT (ATOPIC) |
|
DUVYZAT |
|
DYANAVEL (Post Limit) |
E
|
EBGLYSS |
|---|
|
econazole (Post Limit) |
|
ECOZA (Post Limit) |
|
EGATEN (Post Limit) |
|
EGRIFTA |
|
eletriptan (Post Limit) |
|
ELIDEL |
|
EMEND (Post Limit) |
|
EMFLAZA |
|
EMGALITY |
|
EMSAM |
|
EMVERM (Post Limit) |
|
ENBREL |
|
ENDARI |
|
ENSPRYNG |
|
ENSTILAR (PA) |
|
EOHILIA |
|
EPCLUSA |
|
EPIDIOLEX |
|
EPIDUO |
|
epinephrine (CF) |
|
EPIPEN (CF) |
|
EPOGEN |
|
ERIVEDGE |
|
ERLEADA |
|
erlotinib |
|
ERTACZO (Post Limit) |
|
ertapenem (Post Limit) |
|
ERYGEL |
|
erythromycin |
|
erythromycin-benzoyl peroxide |
|
ESBRIET |
|
esomeprazole (Post Limit) |
|
estazolam (Post Limit) |
|
estradiol injection |
|
estrogen injection |
|
eszopiclone (Post Limit) |
|
EVEKEO (Post Limit) |
|
everolimus |
|
EVERSENSE (PA) |
|
EVRYSDI |
|
EXELDERM |
|
EXELDERM (Post Limit) |
|
EXJADE |
|
EXKIVITY |
|
EXTAVIA |
|
EXTINA |
|
EYSUVIS |
|
ezetimibe-simvastatin 10/80mg |
F
|
FABHALTA |
|---|
|
FABIOR |
|
FANAPT |
|
FARXIGA |
|
FASENRA PEN |
|
febuxostat |
|
FEMALE CONDOMS |
|
fentanyl OT lozenge |
|
FENTORA |
|
FERRIPROX |
|
FETZIMA |
|
FILSPARI |
|
FILSUVEZ |
|
FINACEA |
|
finasteride |
|
fingolimod |
|
FINTEPLA |
|
FIRAZYR |
|
FIRDAPSE |
|
fluocinolone (topical) |
|
fluocinonide (topical) |
|
FLUOROPLEX |
|
fluorouracil |
|
flurandrenolide (topical) |
|
flurazepam (Post Limit) |
|
fluticasone (topical) |
|
FOCALIN (Post Limit) |
|
FOCINVEZ (Post Limit) |
|
FOLLISTIM AQ |
|
FORTAMET |
|
FORTEO |
|
FORTESTA |
|
FOTIVDA |
|
FREESTYLE LIBRE (PA) |
|
FROVA (Post Limit) |
|
frovatriptan (Post Limit) |
|
FRUZAQLA |
|
FULPHILA |
|
FUZEON |
|
FYLNETRA |
|
FYREMADEL |
G
|
gabapentin (ST) |
|---|
|
gabapentin IR (Post Limit) |
|
GABARONE (Post Limit) |
|
GALAFOLD |
|
ganirelix |
|
ganirelix acetate |
|
GATTEX |
|
GAVRETO |
|
gefitinib |
|
GENOTROPIN |
|
GEODON |
|
GILENYA |
|
GILOTRIF |
|
glatiramer |
|
GLATOPA |
|
GLEEVEC |
|
GLUMETZA |
|
GLYXAMBI |
|
GONAL-F |
|
GRALISE (ST) |
|
granisetron (Post Limit) |
|
GRANIX |
|
guanfacine ER |
|
GUARDIAN (PA) |
H
|
HADLIMA |
|---|
|
HAEGARDA |
|
halcinonide (topical) |
|
HALCION (Post Limit) |
|
halobetasol (topical) |
|
HARVONI |
|
HEMLIBRA |
|
heparin injection |
|
HETLIOZ |
|
HORIZANT (ST) |
|
HULIO |
|
HUMATROPE |
|
HUMIRA |
|
HYCAMTIN |
|
hydrocortisone (topical) |
|
HYMPAVZI |
|
HYRIMOZ |
I
|
IBRANCE |
|---|
|
icatibant |
|
ICLUSIG |
|
icosapent ethyl |
|
IDACIO |
|
IDHIFA |
|
imatinib |
|
IMBRUVICA |
|
imipramine (Post Limit REG) |
|
imipramine (Post Limit) |
|
imiquimod |
|
IMITREX (Post Limit) |
|
INBRIJA |
|
INCRELEX |
|
INGREZZA |
|
INLYTA |
|
INQOVI |
|
INREBIC |
|
INTRON A |
|
INTUNIV |
|
INVANZ (Post Limit) |
|
INVEGA |
|
INVOKAMET |
|
INVOKANA |
|
IRESSA |
|
isotretinoin |
|
ISTURISA |
|
ITOVEBI |
|
itraconazole caps |
|
itraconazole sol |
|
ivermectin (topical) |
|
IWILFIN |
J
|
JADENU |
|---|
|
JAKAFI |
|
JANUMET |
|
JANUVIA |
|
JARDIANCE |
|
JATENZO |
|
JAVYGTOR |
|
JAYPIRCA |
|
JENTADUETO |
|
JESDUVROQ |
|
JOENJA |
|
JORNAY (Post Limit) |
|
JUBLIA (PA) |
|
JUBLIA (Post Limit) |
|
JUXTAPID |
|
JYNARQUE |
K
|
KALBITOR |
|---|
|
KALYDECO |
|
KAPVAY |
|
KAZANO |
|
KERENDIA |
|
KERYDIN |
|
KESIMPTA |
|
ketoconazole |
|
ketoconazole (Post Limit) |
|
KEVEYIS |
|
KEVZARA |
|
KIMYRSA (Post Limit) |
|
KINERET |
|
KISQALI |
|
KISQALI FEMARA CO-PACK |
|
KITABIS PAK |
|
KLISYRI |
|
KLOXXADO (PA) |
|
KLOXXADO (Post Limit) |
|
KOMBIGLYZE XR |
|
KONVOMEP |
|
KONVOMEP (Post Limit) |
|
KORLYM |
|
KOSELUGO |
|
KRAZATI |
|
KUVAN |
|
KYNMOBI |
|
KYZATREX |
L
|
lansoprazole (Post Limit) |
|---|
|
lapatinib |
|
LATUDA |
|
LAZCLUZE |
|
ledipasvir-sofosbuvir |
|
lenalidomide |
|
LENVIMA |
|
LETAIRIS |
|
LEUKINE |
|
leuprolide acetate |
|
levofloxacin (Post Limit) |
|
LIBERVANT |
|
lidocaine patch (PA) |
|
lidocaine topical (Post Limit) |
|
lidocaine-prilocaine (Post Limit) |
|
lidocaine-tetracaine (Post Limit) |
|
LIDODERM PATCH (PA) |
|
linezolid |
|
LIQREV |
|
lisdexamfetamine (Post Limit) |
|
LITFULO |
|
LIVDELZI |
|
LIVMARLI |
|
LODOCO |
|
LONSURF |
|
LOPROX (Post Limit) |
|
LORBRENA |
|
loteprednol |
|
LOTRONEX |
|
LOVAZA |
|
luliconazole (Post Limit) |
|
LUMAKRAS |
|
LUMRYZ |
|
LUNESTA (Post Limit) |
|
LUPKYNIS |
|
LUZU (Post Limit) |
|
LYBALVI |
|
LYNPARZA |
|
LYRICA (ST) |
|
LYTGOBI |
M
|
Male Condoms (Post Limit) |
|---|
|
MARINOL (Post Limit) |
|
MAVENCLAD |
|
MAVYRET |
|
MAXALT (Post Limit) |
|
MAYZENT |
|
mebendazole (Post Limit) |
|
medroxyprogesterone injection |
|
MEKINIST |
|
MEKTOVI |
|
MENOPUR |
|
MENTAX (Post Limit) |
|
meropenem (Post Limit) |
|
metformin ER |
|
methamphetamine (Post Limit) |
|
METHITEST |
|
METHYLIN (Post Limit) |
|
methylphenidate (Post Limit) |
|
methyltestosterone |
|
METROCREAM |
|
METROGEL |
|
METROLOTION |
|
metronidazole (PA) |
|
metronidazole (Post Limit) |
|
metyrosine |
|
micafungin (Post Limit) |
|
miconazole-zinc oxide-white petrolatum (Post Limit) |
|
midazolam nasal spray |
|
MIEBO |
|
mifepristone |
|
miglustat |
|
minoxidil |
|
MIPLYFFA |
|
MIRCERA |
|
MIRVASO |
|
modafinil |
|
mometasone (topical) |
|
MOUNJARO |
|
MOUNJARO (PA) |
|
MOVANTIK |
|
MULPLETA |
|
MULTAQ |
|
mupirocin |
|
MYALEPT |
|
MYCAMINE (Post Limit) |
|
MYCAPSSA |
|
MYDAYIS (Post Limit) |
|
MYFEMBREE |
|
MYORISAN |
N
|
naftifine (Post Limit) |
|---|
|
NAFTIN (Post Limit) |
|
naloxone (PA) |
|
naloxone (Post Limit) |
|
naratriptan (Post Limit) |
|
NARCAN (PA) |
|
NARCAN (Post Limit) |
|
NATESTO |
|
NAYZILAM |
|
NEMLUVIO |
|
NERLYNX |
|
NESINA |
|
NEULASTA |
|
NEUPOGEN |
|
NEURONTIN (Post Limit) |
|
NEXAVAR |
|
NEXIUM (Post Limit) |
|
NEXLETOL |
|
NEXLIZET |
|
NGENLA |
|
NINLARO |
|
nitisinone |
|
NITYR |
|
NIVESTYM |
|
NORDITROPIN |
|
NORITATE |
|
NORITATE (Post Limit) |
|
NORPRAMIN (Post Limit REG) |
|
NORPRAMIN (Post Limit) |
|
NORTHERA |
|
nortriptyline (Post Limit REG) |
|
nortriptyline (Post Limit) |
|
NOVAREL |
|
NOXAFIL |
|
NUBEQA |
|
NUEDEXTA |
|
NUPLAZID |
|
NURTEC |
|
NUTROPIN AQ |
|
NUVIGIL |
|
NYPOZI |
|
nystatin ointment (Post Limit) |
|
NYVEPRIA |
O
|
OCALIVA |
|---|
|
octreotide |
|
ODOMZO |
|
OFEV |
|
OGSIVEO |
|
OJJAARA |
|
OLPRUVA |
|
OLUMIANT |
|
omega-3-acid ethyl esters |
|
omeprazole (Post Limit) |
|
omeprazole-sodium bicarbonate |
|
omeprazole-sodium bicarbonate (Post Limit) |
|
OMNIPOD |
|
OMNITROPE |
|
OMVOH |
|
ONEXTON |
|
ONFI |
|
ONGENTYS |
|
ONGLYZA |
|
ONUREG |
|
ONYDA XR |
|
ONZETRA XSAIL (Post Limit) |
|
OPFOLDA |
|
Opioid Containing Cough and Cold Products |
|
Opioids ER - Step Therapy with MME Limit and Post Limit |
|
Opioids IR - 7-Day Acute Pain Duration Limit with MME Limit and Post Limit |
|
Opioids IR - Combo Products - Acute Pain Duration Limit |
|
OPIOIDS-ER |
|
OPIOIDS-IR (3Day Post Limit) |
|
OPIOIDS-IR (3Day) |
|
OPIOIDS-IR (7Day Post Limit) |
|
OPIOIDS-IR (7Day) |
|
OPIOIDS-IR (Combo Products) |
|
OPIPZA |
|
OPSUMIT |
|
OPSYNVI |
|
OPVEE (PA) |
|
OPVEE (Post Limit) |
|
OPZELURA |
|
ORBACTIV (Post Limit) |
|
ORENCIA |
|
ORENITRAM |
|
ORFADIN |
|
ORGOVYX |
|
ORIAHNN |
|
ORILISSA |
|
ORKAMBI |
|
ORLADEYO |
|
orlistat |
|
ORMALVI |
|
ORSERDU |
|
oseltamivir (Post Limit) |
|
OSENI |
|
OSPHENA |
|
OTEZLA |
|
OTREXUP |
|
OVIDREL |
|
OXBRYTA |
|
OXERVATE |
|
oxiconazole (Post Limit) |
|
OXISTAT (Post Limit) |
|
OZEMPIC |
|
OZEMPIC (PA) |
P
|
palonosetron (Post Limit) |
|---|
|
PALYNZIQ |
|
PAMELOR (Post Limit REG) |
|
PAMELOR (Post Limit) |
|
PANCREAZE |
|
pancrelipase |
|
pantoprazole (Post Limit) |
|
pazopanib |
|
PEGASYS |
|
PEMAZYRE |
|
PENNSAID |
|
perphenazine-amitriptyline (Post Limit REG) |
|
perphenazine-amitriptyline (Post Limit) |
|
PERTZYE |
|
PHEBURANE |
|
phendimetrazine |
|
phenoxybenzamine |
|
PHYRAGO |
|
pimecrolimus |
|
PIQRAY |
|
pirfenidone |
|
PLEGRIDY |
|
PLIAGLIS (Post Limit) |
|
POMALYST |
|
PONVORY |
|
posaconazole |
|
POSFREA (Post Limit) |
|
PRALUENT |
|
PRALUENT ENHANCED SGM |
|
praziquantel (Post Limit) |
|
prednicarbate (topical) |
|
pregabalin (ST) |
|
PREGNYL |
|
PREVACID (Post Limit) |
|
PREVYMIS |
|
PRILOSEC (Post Limit) |
|
PRISTIQ |
|
PROCENTRA (Post Limit) |
|
PROCRIT |
|
PROCYSBI |
|
PROMACTA |
|
PROPECIA |
|
PROTONIX (Post Limit) |
|
protriptyline (Post Limit REG) |
|
protriptyline (Post Limit) |
|
PROVIGIL |
|
PRUDOXIN (ST) |
|
PULMICORT 1mg |
|
PULMOZYME |
|
Purified Cortrophin Gel |
|
PURIXAN |
|
pyrimethamine |
|
PYRUKYND |
Q
|
QELBREE (Post Limit) |
|---|
|
QFITLIA |
|
QINLOCK |
|
QSYMIA |
|
QTERN |
|
quazepam (Post Limit) |
|
QUILLICHEW (Post Limit) |
|
QUILLIVANT (Post Limit) |
|
QULIPTA |
|
QUVIVIQ |
R
|
rabeprazole (Post Limit) |
|---|
|
ramelteon (Post Limit) |
|
RANEXA |
|
ranolazine ER |
|
RASUVO |
|
RAVICTI |
|
REBIF |
|
REDITREX |
|
REGRANEX |
|
RELENZA (Post Limit) |
|
RELEUKO |
|
RELEXXII (Post Limit) |
|
RELISTOR |
|
RELPAX (Post Limit) |
|
RELYVRIO |
|
REPATHA |
|
REPATHA ENHANCED SGM |
|
RESTASIS |
|
RESTORIL (Post Limit) |
|
RETACRIT |
|
RETEVMO |
|
RETIN-A |
|
REVATIO |
|
REVCOVI |
|
REVLIMID |
|
REXTOVY (PA) |
|
REXTOVY (Post Limit) |
|
REXULTI |
|
REYVOW |
|
REZDIFFRA |
|
REZENOPY (PA) |
|
REZENOPY (Post Limit) |
|
REZLIDHIA |
|
REZUROCK |
|
RHOFADE |
|
ribavirin |
|
RINVOQ |
|
RISPERDAL |
|
RITALIN (Post Limit) |
|
RIVFLOZA |
|
RIVIVE (PA) |
|
RIVIVE (Post Limit) |
|
RIZAFILM (Post Limit) |
|
rizatriptan (Post Limit) |
|
roflumilast |
|
ROGAINE |
|
ROMVIMZA |
|
ROZEREM (Post Limit) |
|
ROZLYTREK |
|
RUBRACA |
|
RUCONEST |
|
RYBELSUS |
|
RYBELSUS (PA) |
|
RYDAPT |
S
|
SABRIL |
|---|
|
SAIZEN |
|
SAJAZIR |
|
SAMSCA |
|
SANCUSO (Post Limit) |
|
SANDOSTATIN |
|
SANTYL COLLAGENASE |
|
SAPHRIS |
|
sapropterin dihydrochloride |
|
SAVELLA |
|
saxagliptin |
|
SAXENDA |
|
SCEMBLIX |
|
SECUADO |
|
SEGLUROMET |
|
SELARSDI |
|
selegiline |
|
SENSIPAR |
|
SEROQUEL |
|
SEROSTIM |
|
SIGNIFOR |
|
sildenafil (Specialty) |
|
SILENOR (Post Limit REG) |
|
SILENOR (Post Limit) |
|
SILIQ |
|
SIMLANDI |
|
SIMPONI |
|
simvastatin 80mg |
|
SKYCLARYS |
|
SKYRIZI |
|
SKYTROFA |
|
sodium oxybate |
|
sodium phenylbutyrate |
|
sofosbuvir-velpatasvir |
|
SOGROYA |
|
SOHONOS |
|
SOLARAZE |
|
SOLIQUA |
|
SOLU-CORTEF |
|
SOMAVERT |
|
SOOLANTRA |
|
sorafenib |
|
SORILUX (PA) |
|
SOTYKTU |
|
SOVALDI |
|
SPORANOX CAPS |
|
SPORANOX SOL |
|
SPRAVATO |
|
SPRYCEL |
|
STEGLATRO |
|
STEGLUJAN |
|
STELARA |
|
STIMATE |
|
STIMUFEND |
|
STIVARGA |
|
STRATTERA (Post Limit) |
|
STRENSIQ |
|
streptomycin (Post Limit) |
|
SUBSYS |
|
SUCRAID |
|
sulconazole |
|
sulconazole (Post Limit) |
|
sumatriptan (Post Limit) |
|
sumatriptan-naproxen_(ST) |
|
sunitinib |
|
SUNOSI |
|
SUSTOL (Post Limit) |
|
SUTENT |
|
SYMBRAVO_(ST) |
|
SYMDEKO |
|
SYMJEPI (CF) |
|
SYMLINPEN |
|
SYMPAZAN |
|
SYMPROIC |
|
SYNDROS (Post Limit) |
|
SYNERA (Post Limit) |
|
SYNJARDY |
T
|
TABRECTA |
|---|
|
TACLONEX (PA) |
|
tacrolimus |
|
tadalafil (PA) |
|
tadalafil (Specialty) |
|
tadalafil (ST) |
|
tadalafil 5mg (ST) |
|
TADLIQ |
|
TAFINLAR |
|
TAGRISSO |
|
TAKHZYRO |
|
TALTZ |
|
TALZENNA |
|
TAMIFLU (Post Limit) |
|
TARGRETIN |
|
TARPEYO |
|
TASCENSO ODT |
|
TASIGNA |
|
tasimelteon |
|
tavaborole |
|
TAVALISSE |
|
TAVNEOS |
|
tazarotene |
|
tazarotene foam |
|
TAZORAC |
|
TAZVERIK |
|
TECFIDERA |
|
TEGSEDI |
|
temazepam (Post Limit) |
|
TEMODAR |
|
temozolomide |
|
TEPMETKO |
|
teriflunomide |
|
teriparatide |
|
TEST STRIPS |
|
TESTIM |
|
TESTOPEL |
|
testosterone |
|
tetrabenazine |
|
tetracycline caps (Post Limit) |
|
THALOMID |
|
THIOLA |
|
TIBSOVO |
|
tigecycline (Post Limit) |
|
TIKOSYN |
|
tiopronin |
|
TLANDO |
|
TOBI PODHALER |
|
tobramycin (Post Limit) |
|
tobramycin inhalation solution |
|
TOFIDENCE |
|
TOLAK |
|
tolvaptan |
|
TORPENZ |
|
TOSYMRA (Post Limit) |
|
TRACLEER |
|
TRADJENTA |
|
TREMFYA |
|
tretinoin |
|
TREXIMET |
|
TREXIMET (Post Limit) |
|
triamcinolone (topical) |
|
triazolam (Post Limit) |
|
TRIJARDY XR |
|
TRIKAFTA |
|
trimipramine (Post Limit REG) |
|
trimipramine (Post Limit) |
|
TRULICITY |
|
TRULICITY (PA) |
|
TRUQAP |
|
TRUSELTIQ |
|
TRYNGOLZA |
|
TUKYSA |
|
TURALIO |
|
TWYNEO |
|
TYENNE |
|
TYGACIL (Post Limit) |
|
TYKERB |
|
TYMLOS |
|
TYRVAYA |
|
TYVASO |
U
|
UBRELVY |
|---|
|
UDENYCA |
|
ULORIC |
|
UPTRAVI |
V
|
V-GO |
|---|
|
VALCHLOR |
|
VALTOCO |
|
vancomycin (Post Limit) |
|
VANFLYTA |
|
varenicline |
|
VARUBI (Post Limit) |
|
VASCEPA |
|
VECTICAL (PA) |
|
VELSIPITY |
|
VELTI |
|
VENCLEXTA |
|
VENTAVIS |
|
VEOZAH |
|
VERQUVO |
|
VERZENIO |
|
VEVYE |
|
VFEND IV (Post Limit) |
|
VICTOZA |
|
VICTOZA (PA) |
|
VIDAZA |
|
VIEKIRA PAK |
|
vigabatrin |
|
VIGADRONE |
|
VIGAFYDE |
|
VIGPODER |
|
VIJOICE |
|
VIOKACE |
|
VITRAKVI |
|
VIZIMPRO |
|
VOGELXO |
|
VOLTAREN (Post Limit) |
|
VONJO |
|
VOQUEZNA |
|
VORANIGO |
|
voriconazole (Post Limit) |
|
VOSEVI |
|
VOTRIENT |
|
VOWST |
|
VOXZOGO |
|
VOYDEYA |
|
VRAYLAR |
|
Vtama |
|
VUMERITY |
|
VUSION |
|
VYLEESI |
|
VYNDAMAX |
|
VYNDAQEL |
|
VYTORIN 10/80MG |
|
VYVANSE (Post Limit) |
W
|
WAINUA |
|---|
|
WAKIX |
|
WEGOVY |
|
WELIREG |
|
WEZLANA |
|
WINLEVI |
|
WYNZORA (PA) |
X
|
XALKORI |
|---|
|
XELJANZ |
|
XELODA |
|
XELSTRYM (Post Limit) |
|
XENAZINE |
|
XENICAL |
|
XEPI (PA) |
|
XERMELO |
|
XHANCE |
|
XIFAXAN 200MG (Post Limit) |
|
XIFAXAN 550MG |
|
XIGDUO XR |
|
XIIDRA |
|
XOFLUZA (Post Limit) |
|
XOLEGEL (Post Limit) |
|
XOLREMDI |
|
XOSPATA |
|
XPHOZAH |
|
XPOVIO |
|
XTANDI |
|
XULTOPHY |
|
XYOSTED |
|
XYREM |
|
XYWAV |
Y
|
Yargesa |
|---|
|
YONSA |
|
YORVIPATH |
|
YUFLYMA |
|
YUSIMRY |
Z
|
zaleplon (Post Limit) |
|---|
|
ZARXIO |
|
ZAVESCA |
|
ZAVZPRET |
|
ZEGERID |
|
ZEGERID (Post Limit) |
|
ZEJULA |
|
ZELBORAF |
|
ZEMBRACE (Post Limit) |
|
ZENATANE |
|
ZENPEP |
|
ZENZEDI (Post Limit) |
|
ZEPATIER |
|
ZEPBOUND |
|
ZEPOSIA |
|
ZIANA |
|
ZIEXTENZO |
|
ZILBRYSQ |
|
zileuto |
|
ZIMHI (PA) |
|
ZIMHI (Post Limit) |
|
ZITUVIMET |
|
ZITUVIO |
|
ZOCOR 80MG |
|
ZOKINVY |
|
ZOLINZA |
|
zolmitriptan (Post Limit) |
|
zolpidem (Post Limit) |
|
ZOMACTON |
|
ZOMIG (Post Limit) |
|
ZONALON (ST) |
|
ZORBTIVE |
|
ZORYVE |
|
ZTALMY |
|
ZTLIDO (PA) |
|
ZUPLENZ (Post Limit) |
|
ZURNAI (PA) |
|
ZURNAI (Post Limit) |
|
ZURZUVAE |
|
ZYCLARA |
|
ZYDELIG |
|
ZYFLO |
|
ZYKADIA |
|
ZYPREXA |
|
ZYTIGA |
|
ZYVOX |
Medical Benefit Policies
NOTE: Some policies may be indication specific. Where applicable, indications are noted in parentheses next to the policy name. In such case, indication-specific criteria take precedence.
Select the starting letter of the medication to find the desired form. Drug coverage is dependent on member’s formulary.
KEY: Brand names are in capital letters and generics are in lower case letters.
A
|
ABECMA |
|---|
|
ABRAXANE |
|
ACTEMRA |
|
ACTHAR GEL |
|
ACTIMMUNE |
|
ADAKVEO |
|
ADCETRIS |
|
ADSTILADRIN |
|
ADVATE |
|
ADYNOVATE |
|
ADZYNMA |
|
AFSTYLA |
|
AHZANTIVE |
|
ALDURAZYME |
|
ALIMTA |
|
ALPHANATE |
|
ALPHANINE SD |
|
ALPROLIX |
|
ALTUVIIIO |
|
ALYGLO |
|
ALYMSYS |
|
ALYMSYS (Ocular) |
|
AMONDYS 45 |
|
AMTAGVI |
|
AMVUTTRA |
|
APOKYN |
|
apomorphine |
|
ARALAST-NP |
|
ARANESP |
|
ARZERRA |
|
ASCENIV |
|
ASPARLAS |
|
AUCATZYL |
|
AVASTIN |
|
AVASTIN (Ocular) |
|
AVEED |
|
AVSOLA |
|
AVSOLA (PSORIASIS) |
|
AVZIVI |
|
AVZIVI (Ocular) |
|
azacitidine |
B
|
BAVENCIO |
|---|
|
BELEODAQ |
|
BELRAPZO |
|
bendamustine |
|
BENDEKA |
|
BENEFIX |
|
BENLYSTA |
|
BEOVU |
|
BEQVEX |
|
BERINERT |
|
BESPONSA |
|
BESREMI |
|
BIVIGAM |
|
BKEMV |
|
BLINCYTO |
|
bortezomib |
|
BORUZU |
|
BOTOX |
|
BREYANZI |
|
BRINEURA |
|
BRIUMVI |
|
BYNFEZIA |
|
BYOOVIZ |
C
|
cabazitaxel |
|---|
|
CABENUVA |
|
CABLIVI |
|
CAMCEVI |
|
CARVYKTI |
|
CASGEVY |
|
CERDELGA |
|
CEREZYME |
|
cetrorelix acetate |
|
CETROTIDE |
|
chorionic gonadotropin |
|
CIMERLI |
|
CIMZIA |
|
CIMZIA (PSORIASIS) |
|
CINQAIR |
|
CINRYZE |
|
COAGADEX |
|
COLUMVI |
|
CORIFACT |
|
COSELA |
|
COSENTYX |
|
COSENTYX (PSORIASIS) |
|
CRYSVITA |
|
CUTAQUIG |
|
CUVITRU |
|
CYRAMZA |
D
|
DACOGEN |
|---|
|
DARZALEX |
|
DARZALEX FASPRO |
|
DATROWAY |
|
DAXXIFY |
|
decitabine |
|
deferoxamine |
|
DESFERAL |
|
docetaxel |
|
DOCIVYX |
|
DUOPA |
|
DUROLANE |
|
DYSPORT |
E
|
ELAHERE |
|---|
|
ELAPRASE |
|
ELELYSO |
|
ELFABRIO |
|
ELIGARD |
|
ELOCTATE |
|
ELOXATIN |
|
ELREXFIO |
|
ELZONRIS |
|
EMPAVELI |
|
EMPLICITI |
|
ENHERTU |
|
ENJAYMO |
|
ENSPRYNG |
|
ENTYVIO |
|
ENZEEVU |
|
EPKINLY |
|
EPOGEN |
|
epoprostenol |
|
EPYSQLI |
|
ERBITUX |
|
eribulin |
|
ESPEROCT |
|
EUFLEXXA |
|
EVENITY |
|
EVKEEZA |
|
EXONDYS 51 |
|
EYLEA |
F
|
FABRAZYME |
|---|
|
FASENRA SYRINGE |
|
FASLODEX |
|
FEIBA |
|
FENSOLVI |
|
FIBRYGA |
|
FIRAZYR |
|
FIRMAGON |
|
FLEBOGAMMA |
|
FLOLAN |
|
FOLLISTIM AQ |
|
FOLOTYN |
|
FULPHILA |
|
fulvestrant |
|
FUSILEV |
|
FYARRO |
|
FYLNETRA |
|
FYREMADEL |
G
|
GAMASTAN |
|---|
|
GAMIFANT |
|
GAMMAGARD |
|
GAMMAKED |
|
GAMMAPLEX |
|
GAMUNEX |
|
ganirelix |
|
GAZYVA |
|
GEL-ONE |
|
GELSYN-3 |
|
gemcitabine |
|
GEMZAR |
|
GENOTROPIN |
|
GENVISC-850 |
|
GIVLAARI |
|
GLASSIA |
|
GONAL-F |
|
GRANIX |
H
|
HAEGARDA |
|---|
|
HALAVEN |
|
HEMGENIX |
|
HEMLIBRA |
|
HEMOFIL-M |
|
HERCEPTIN |
|
HERCEPTIN HYLECTA |
|
HERCESSI |
|
HERZUMA |
|
HIZENTRA |
|
HUMATE-P |
|
HUMATROPE |
|
HYALGAN |
|
HYMOVIS |
|
HYMPAVZI |
|
HYQVIA |
I
|
icatibant |
|---|
|
IDELVION |
|
ILARIS |
|
ILUMYA |
|
ILUMYA (PSORIASIS) |
|
IMFINZI |
|
IMJUDO |
|
IMLYGIC |
|
IMULDOSA |
|
INCRELEX |
|
INFLECTRA |
|
INFLECTRA (PSORIASIS) |
|
infliximab |
|
infliximab (PSORIASIS) |
|
INFUGEM |
|
ISTODAX |
|
IXEMPRA |
|
IXINITY |
J
|
JELMYTO |
|---|
|
JEMPERLI |
|
JEVTANA |
|
JIVI |
K
|
KADCYLA |
|---|
|
KALBITOR |
|
KANJINTI |
|
KANUMA |
|
KEBILIDI |
|
KEYTRUDA |
|
KHAPZORY |
|
KIMMTRAK |
|
KOATE-DVI |
|
KOGENATE FS |
|
KOVALTRY |
|
KRYSTEXXA |
|
KYMRIAH |
|
KYNMOBI |
|
KYPROLIS |
L
|
LAMZEDE |
|---|
|
lanreotide injection |
|
LEMTRADA |
|
LENMELDY |
|
LEQVIO |
|
LEUKINE |
|
leuprolide acetate (Endometriosis) |
|
leuprolide acetate (PED) |
|
leuprolide acetate (Prostate CA) |
|
levoleucovorin |
|
LIBTAYO |
|
LUCENTIS |
|
LUMIZYME |
|
LUNSUMIO |
|
LUPRON DEPOT (Endometriosis) |
|
LUPRON DEPOT (PED) |
|
LUPRON DEPOT (Prostate CA) |
|
LUTATHERA |
|
LUXTURNA |
|
LYFGENIA |
M
|
MACUGEN |
|---|
|
MARGENZA |
|
MEPSEVII |
|
MIRCERA |
|
MONJUVI |
|
MONOVISC |
|
MOZOBIL |
|
MVASI |
|
MVASI (Ocular) |
|
MYALEPT |
|
MYCAPSSA |
|
MYLOTARG |
|
MYOBLOC |
N
|
NAGLAZYME |
|---|
|
NEULASTA |
|
NEUPOGEN |
|
NEXVIAZYME |
|
NIKTIMVO |
|
NIVESTYM |
|
NORDITROPIN |
|
NOVAREL |
|
NOVOEIGHT |
|
NOVOSEVEN |
|
NPLATE |
|
NUCALA |
|
NULIBRY |
|
NUTROPIN AQ |
|
NUWIQ |
|
NYPOZI |
|
NYVEPRIA |
O
|
Obizur |
|---|
|
OCREVUS |
|
OCREVUS ZUNOVO |
|
OCTAGAM |
|
octreotide |
|
OGIVRI |
|
OMISIRGE |
|
OMNITROPE |
|
OMVOH |
|
ONCASPAR |
|
ONPATTRO |
|
ONTRUZANT |
|
OPDIVO |
|
OPDIVO QVANTIG |
|
OPDUALAG |
|
OPUVIZ |
|
ORENCIA |
|
ORTHOVISC |
|
OTULFI |
|
OVIDREL |
|
oxaliplatin |
|
OXERVATE |
|
OXLUMO |
P
|
paclitaxel |
|---|
|
PADCEV |
|
PANZYGA |
|
PARSABIV |
|
PAVBLU |
|
pemetrexed |
|
PEMFEXY |
|
PEMRYDI RTU |
|
PERJETA |
|
PHESGO |
|
PIASKY |
|
plerixafor |
|
PLUVICTO |
|
POLIVY |
|
POMBILITI |
|
POTELIGEO |
|
pralatrexate |
|
PREGNYL |
|
PRIVIGEN |
|
PROCRIT |
|
PROFILNINE |
|
PROLASTIN-C |
|
PROLEUKIN |
|
PROLIA |
|
Purified Cortrophin Gel |
|
PYZCHIVA |
R
|
RADICAVA |
|---|
|
REBINYN |
|
REBLOZYL |
|
RECLAST |
|
RECOMBINATE |
|
RELEUKO |
|
REMICADE |
|
REMICADE (PSORIASIS) |
|
REMODULIN |
|
RENFLEXIS |
|
RENFLEXIS (PSORIASIS) |
|
RETACRIT |
|
RIABNI |
|
RIASTAP |
|
RITUXAN |
|
RITUXAN HYCELA |
|
RIXUBIS |
|
ROCTAVIAN |
|
ROLVEDON |
|
romidepsin |
|
RUCONEST |
|
RUXIENCE |
|
RYBREVANT |
|
RYLAZE |
|
RYPLAZIM |
|
RYSTIGGO |
S
|
SAIZEN |
|---|
|
SAJAZIR |
|
SANDOSTATIN |
|
SANDOSTATIN LAR DEPOT |
|
SAPHNELO |
|
SARCLISA |
|
SCENESSE |
|
SELARSDI |
|
SEVENFACT |
|
SIGNIFOR LAR |
|
SIMPONI ARIA |
|
SKYRIZI |
|
SKYRIZI (PSORIASIS) |
|
SKYSONA Skysona SGM 5628-A |
|
sodium hyaluronate 1% |
|
SOLIRIS |
|
SOMATULINE DEPOT |
|
SOMAVERT |
|
SPEVIGO |
|
SPINRAZA |
|
SPRAVATO |
|
STELARA |
|
STELARA (PSORIASIS) |
|
STEQEYMA |
|
STIMATE |
|
STIMUFEND |
|
SUPARTZ |
|
SUPPRELIN LA |
|
SUSVIMO |
|
SYFOVRE |
|
SYLVANT |
|
SYNAGIS |
|
SYNOJOYNT |
|
SYNRIBO |
|
SYNVISC |
T
|
TAKHZYRO |
|---|
|
TALVEY |
|
TAXOTERE |
|
TECARTUS |
|
TECELRA |
|
TECENTRIQ |
|
TECENTRIQ HYBREZA |
|
TECVAYLI |
|
TEGSEDI |
|
TEMODAR |
|
temozolomide |
|
temsirolimus |
|
TEPEZZA |
|
TEVIMBRA |
|
TEZSPIRE |
|
TIVDAK |
|
TOBI |
|
Tobramycin inhalation solution |
|
TOFIDENCE |
|
TORISEL |
|
TRAZIMERA |
|
TREANDA |
|
TRELSTAR |
|
TREMFYA |
|
treprostinil |
|
TRETTEN |
|
TRILURON |
|
TRIPTODUR |
|
TRIVISC |
|
TRODELVY |
|
TRUXIMA |
|
TYENNE |
|
TYRUKO |
|
TYSABRI |
|
TYVASO |
|
TZIELD |
U
|
UDENYCA |
|---|
|
ULTOMIRIS |
|
UPLIZNA |
|
UPTRAVI |
|
ustekinumab-aekn |
V
|
VABYSMO |
|---|
|
VECTIBIX |
|
VEGZELMA |
|
VEGZELMA (Ocular) |
|
VELCADE |
|
VELETRI |
|
VIDAZA |
|
VILTEPSO |
|
VIMIZIM |
|
VISCO-3 |
|
VISUDYNE |
|
VIVIMUSTA |
|
VONVENDI |
|
VPRIV |
|
VYEPTI |
|
VYJUVEK |
|
VYLOY |
|
VYONDYS 53 |
|
VYVGART |
|
VYVGART HYTRULO |
W
|
WAINUA |
|---|
|
WEZLANA |
|
WILATE |
|
WINREVAIR |
X
|
XEMBIFY |
|---|
|
XENPOZYME |
|
XEOMIN |
|
XGEVA |
|
XIAFLEX |
|
XIPERE |
|
XOFIGO |
|
XOLAIR |
|
XYNTHA |
Y
|
YERVOY |
|---|
|
YESAFILI |
|
YESCARTA |
|
YESINTEK |
Z
|
ZALTRAP |
|---|
|
ZARXIO |
|
ZEMAIRA |
|
ZEPZELCA |
|
ZIEXTENZO |
|
ZIIHERA |
|
ZIRABEV |
|
ZIRABEV (Ocular) |
|
ZOLADEX |
|
zoledronic acid (RECLAST) |
|
zoledronic acid (ZOMETA) |
|
ZOLGENSMA |
|
ZOMACTON |
|
ZOMETA zoledronic acid-Zometa SGM 2382-A |
|
ZULRESSO |
|
ZYMFENTRA |
|
ZYNLONTA |
|
ZYNTEGLO |
|
ZYNYZ |
Medical Fax Forms
Select the starting letter of the medication to find the desired form. Drug coverage is dependent on member’s formulary.
KEY: Brand names are in capital letters and generics are in lower case letters.
A
|
ABECMA |
|---|
|
ABRAXANE |
|
ACTEMRA |
|
ACTHAR GEL |
|
ACTIMMUNE |
|
ADAKVEO |
|
ADCETRIS |
|
ADSTILADRIN |
|
ADVATE |
|
ADYNOVATE |
|
AFSTYLA |
|
AHZANTIVE |
|
ALDURAZYME |
|
ALIMTA |
|
ALPHANATE |
|
ALPHANINE SD |
|
ALPROLIX |
|
ALTUVIIIO |
|
ALYGLO |
|
ALYMSYS |
|
AMONDYS 45 |
|
AMTAGVI |
|
AMVUTTRA |
|
APOKYN |
|
apomorphine |
|
ARALAST-NP |
|
ARANESP |
|
ARZERRA |
|
ASCENIV |
|
ASPARLAS |
|
AVASTIN |
|
AVEED |
|
AVSOLA |
|
AVZIVI |
|
azacitidine |
B
|
BAVENCIO |
|---|
|
BELRAPZO |
|
bendamustine |
|
BENDEKA |
|
BENEFIX |
|
BENLYSTA |
|
BEOVU |
|
BEQVEX |
|
BERINERT |
|
BESPONSA |
|
BESREMI |
|
BIVIGAM |
|
BLINCYTO |
|
bortezomib |
|
BOTOX |
|
BREYANZI |
|
brimonidine (PA) |
|
BRINEURA |
|
BRIUMVI |
|
BYNFEZIA |
|
BYOOVIZ |
C
|
cabazitaxel |
|---|
|
CABLIVI |
|
CAMCEVI |
|
CARVYKTI |
|
CASGEVY |
|
CERDELGA |
|
CEREZYME |
|
cetrorelix acetate |
|
CETROTIDE |
|
chorionic gonadotropin |
|
CIMERLI |
|
CIMZIA |
|
CINQAIR |
|
CINRYZE |
|
COAGADEX |
|
CORIFACT |
|
COSELA |
|
COSENTYX |
|
CRYSVITA |
|
CUTAQUIG |
|
CUVITRU |
|
CYRAMZA |
D
|
DACOGEN |
|---|
|
DARZALEX |
|
DARZALEX FASPRO |
|
DAXXIFY |
|
decitabine |
|
deferoxamine |
|
DESFERAL |
|
docetaxel |
|
DOCIVYX |
|
DUOPA |
|
DUROLANE |
|
DYSPORT |
E
|
ELAHERE |
|---|
|
ELAPRASE |
|
ELELYSO |
|
ELFABRIO |
|
ELIGARD |
|
ELOCTATE |
|
ELOXATIN |
|
ELOXATIN |
|
ELREXFIO |
|
ELZONRIS |
|
EMPAVELI |
|
EMPLICITI |
|
ENHERTU |
|
ENJAYMO |
|
ENSPRYNG |
|
ENTYVIO |
|
ENZEEVU |
|
EPKINLY |
|
EPOGEN |
|
epoprostenol |
|
ERBITUX |
|
eribulin |
|
ESPEROCT |
|
EUFLEXXA |
|
EVENITY |
|
EVKEEZA |
|
EXONDYS 51 |
|
EYLEA |
F
|
FABRAZYME |
|---|
|
FASENRA SYRINGE |
|
FASLODEX |
|
FEIBA |
|
FENSOLVI |
|
FIBRYGA |
|
FIRAZYR |
|
FIRMAGON |
|
FLEBOGAMMA |
|
FLOLAN |
|
FOLLISTIM AQ |
|
FOLOTYN |
|
FULPHILA |
|
fulvestrant |
|
FUSILEV |
|
FYARRO |
|
FYLNETRA |
|
FYREMADEL |
G
|
GAMASTAN |
|---|
|
GAMIFANT |
|
GAMMAGARD |
|
GAMMAKED |
|
GAMMAPLEX |
|
GAMUNEX |
|
ganirelix |
|
GAZYVA |
|
GEL-ONE |
|
GELSYN-3 |
|
gemcitabine |
|
GEMZAR |
|
GENOTROPIN |
|
GENVISC-850 |
|
GIVLAARI |
|
GLASSIA |
|
GONAL-F |
|
GRANIX |
H
|
HAEGARDA |
|---|
|
HALAVEN |
|
HEMGENIX |
|
HEMLIBRA |
|
HEMOFIL-M |
|
HERCEPTIN |
|
HERCEPTIN HYLECTA |
|
HERZUMA |
|
HIZENTRA |
|
HUMATE-P |
|
HUMATROPE |
|
HYALGAN |
|
HYMOVIS |
|
HYQVIA |
I
|
icatibant |
|---|
|
IDELVION |
|
ILARIS |
|
ILUMYA |
|
IMFINZI |
|
IMJUDO |
|
IMLYGIC |
|
INCRELEX |
|
INFLECTRA |
|
infliximab |
|
INFUGEM |
|
ISTODAX |
|
IXEMPRA |
|
IXINITY |
J
|
JELMYTO |
|---|
|
JEMPERLI |
|
JEVTANA |
|
JIVI |
K
|
KADCYLA |
|---|
|
KALBITOR |
|
KANJINTI |
|
KANUMA |
|
KEYTRUDA |
|
KHAPZORY |
|
KIMMTRAK |
|
KOATE-DVI |
|
KOGENATE FS |
|
KOVALTRY |
|
KRYSTEXXA |
|
KYMRIAH |
|
KYNMOBI |
|
KYPROLIS |
L
|
LAMZEDE |
|---|
|
lanreotide injection |
|
LEMTRADA |
|
LENMELDY |
|
LEQVIO |
|
LEUKINE |
|
leuprolide acetate (Endometriosis) |
|
leuprolide acetate (PED) |
|
leuprolide acetate (Prostate CA) |
|
levoleucovorin |
|
LIBTAYO |
|
LUCENTIS |
|
LUMIZYME |
|
LUMOXITI |
|
LUNSUMIO |
|
LUPRON DEPOT (Endometriosis) |
|
LUPRON DEPOT (PED) |
|
LUPRON DEPOT (Prostate CA) |
|
LUTATHERA |
|
LUXTURNA |
|
LYFGENIA |
M
|
MACUGEN |
|---|
|
MARGENZA |
|
MEPSEVII |
|
MIRCERA |
|
MONJUVI |
|
MONONINE |
|
MONOVISC |
|
MOZOBIL |
|
MVASI |
|
MYALEPT |
|
MYLOTARG |
|
MYOBLOC |
N
|
NAGLAZYME |
|---|
|
NEULASTA |
|
NEUPOGEN |
|
NEXVIAZYME |
|
NIVESTYM |
|
NORDITROPIN |
|
NOVAREL |
|
NOVOEIGHT |
|
NOVOSEVEN |
|
NPLATE |
|
NUCALA |
|
NULIBRY |
|
NUTROPIN AQ |
|
NUWIQ |
|
NYVEPRIA |
O
|
OBIZUR |
|---|
|
OCREVUS |
|
OCREVUS-ZUNOVO |
|
OCTAGAM |
|
octreotide |
|
OGIVRI |
|
OMISIRGE |
|
OMNITROPE |
|
ONCASPAR |
|
ONPATTRO |
|
ONTRUZANT |
|
OPDIVO |
|
OPDUALAG |
|
OPUVIZ |
|
ORENCIA |
|
ORTHOVISC |
|
OVIDREL |
|
oxaliplatin |
|
OXERVATE |
|
OXLUMO |
P
|
paclitaxel |
|---|
|
PADCEV |
|
PANZYGA |
|
PARSABIV |
|
PAVBLU |
|
pemetrexed |
|
PEMFEXY |
|
PEMRYDI-RTU |
|
PERJETA |
|
PHESGO |
|
PIASKY |
|
plerixafor |
|
PLUVICTO |
|
POLIVY |
|
POTELIGEO |
|
pralatrexate |
|
PREGNYL |
|
PRIVIGEN |
|
PROCRIT |
|
PROFILNINE |
|
PROLASTIN-C |
|
PROLEUKIN |
|
PROLIA |
|
Purified Cortrophin Gel |
R
|
RADICAVA |
|---|
|
REBINYN |
|
REBLOZYL |
|
RECLAST |
|
RECOMBINATE |
|
RELEUKO |
|
REMICADE |
|
REMODULIN |
|
RENFLEXIS |
|
RETACRIT |
|
RIABNI |
|
RIASTAP |
|
RITUXAN |
|
RITUXAN HYCELA |
|
RIXUBIS |
|
ROCTAVIAN |
|
ROLVEDON |
|
romidepsin |
|
RUCONEST |
|
RUXIENCE |
|
RYBREVANT |
|
RYLAZE |
|
RYPLAZIM |
|
RYSTIGGO |
S
|
SAIZEN |
|---|
|
SAJAZIR |
|
SANDOSTATIN |
|
SANDOSTATIN LAR DEPOT |
|
SAPHNELO |
|
SARCLISA |
|
SCENESSE |
|
SEVENFACT |
|
SIGNIFOR LAR |
|
SIMPONI ARIA |
|
SKYRIZI |
|
SKYSONA |
|
sodium hyaluronate 1% |
|
SOLIRIS |
|
SOMATULINE DEPOT |
|
SOMAVERT |
|
SPEVIGO |
|
SPINRAZA |
|
SPRAVATO |
|
STELARA |
|
STIMATE |
|
STIMUFEND |
|
SUPARTZ |
|
SUPPRELIN LA |
|
SUSVIMO |
|
SYFOVRE |
|
SYLVANT |
|
SYNAGIS |
|
SYNOJOYNT |
|
SYNRIBO |
|
SYNVISC |
T
|
TAKHZYRO |
|---|
|
TALVEY |
|
TAXOTERE |
|
TECARTUS |
|
TECENTRIQ |
|
TECVAYLI |
|
TEGSEDI |
|
TEMODAR |
|
temozolomide |
|
temsirolimus |
|
TEPEZZA |
|
TEZSPIRE |
|
TIVDAK |
|
TOBI |
|
Tobramycin inhalation solution |
|
TOFIDENCE |
|
TORISEL |
|
TRAZIMERA |
|
TREANDA |
|
TRELSTAR |
|
TREMFYA IV |
|
treprostinil |
|
TRETTEN |
|
TRILURON |
|
TRIPTODUR |
|
TRIVISC |
|
TRODELVY |
|
TRUXIMA |
|
TYENNE |
|
TYRUKO |
|
TYSABRI |
|
TYVASO |
|
TZIELD |
U
|
UDENYCA |
|---|
|
ULTOMIRIS |
|
UPLIZNA |
|
UPTRAVI |
V
|
VABYSMO |
|---|
|
VECTIBIX |
|
VEGZELMA |
|
VELCADE |
|
VELETRI |
|
VIDAZA |
|
VILTEPSO |
|
VIMIZIM |
|
VISCO-3 |
|
VISUDYNE |
|
VIVIMUSTA |
|
VONVENDI |
|
VPRIV |
|
VYEPTI |
|
VYJUVEK |
|
VYONDYS 53 |
|
VYVGART |
|
VYVGART HYTRULO |
W
|
WAINUA |
|---|
|
WEZLANA |
|
WILATE |
|
WINREVAIR |
X
|
XEMBIFY |
|---|
|
XENPOZYME |
|
XEOMIN |
|
XGEVA |
|
XIAFLEX |
|
XIPERE |
|
XOFIGO |
|
XOLAIR |
|
XYNTHA |
Y
|
YERVOY |
|---|
|
YESAFILI |
|
YESCARTA |
Z
|
ZALTRAP |
|---|
|
ZARXIO |
|
ZEMAIRA |
|
ZEPZELCA |
|
ZIEXTENZO |
|
ZIRABEV |
|
ZOLADEX |
|
zoledronic acid (RECLAST) |
|
zoledronic acid (ZOMETA) |
|
ZOLGENSMA |
|
ZOMACTON |
|
ZOMETA |
|
ZULRESSO |
|
ZYMFENTRA |
|
ZYNLONTA |
|
ZYNTEGLO |
|
ZYNYZ |