| ABELCET |
3 |
n/a
|
Prior authorization required
|
| ABILIFY |
2 |
n/a
|
|
| ABILIFY DISCMELT |
2 |
n/a
|
|
| ABRAXANE |
3 |
n/a
|
|
| ACCOLATE |
2 |
n/a
|
|
| ACCUNEB |
2 |
albuterol sulfate
|
Prior authorization required Generic substitution allowed
|
| ACCUPRIL |
2 |
quinapril hcl
|
Generic substitution allowed
|
| ACCURETIC |
2 |
quinapril/hydrochlor
|
Generic substitution allowed
|
| ACCUTANE |
3 |
isotretinoin
|
Generic substitution allowed
|
| acebutolol hcl |
1 |
n/a
|
|
| ACEON |
2 |
n/a
|
|
| ACETADOTE |
2 |
n/a
|
Prior authorization required
|
| acetaminophen w/codeine |
1 |
n/a
|
|
| acetazolamide |
1 |
n/a
|
|
| acetazolamide sodium |
1 |
n/a
|
|
| acetic acid |
1 |
n/a
|
|
| acetic acid/hydrocortisone |
1 |
n/a
|
|
| acetylcysteine |
1 |
n/a
|
Prior authorization required
|
| ACIPHEX |
2 |
n/a
|
|
| ACLOVATE |
2 |
alclometasone diprop
|
Generic substitution allowed
|
| ACTHIB |
2 |
n/a
|
|
| acticin |
1 |
n/a
|
|
| ACTIGALL |
2 |
ursodiol
|
Generic substitution allowed
|
| ACTIMMUNE |
3 |
n/a
|
|
| ACTIQ |
3 |
n/a
|
|
| ACTIVELLA |
2 |
n/a
|
|
| ACTONEL |
2 |
n/a
|
|
| ACTONEL WITH CALCIUM |
2 |
n/a
|
|
| ACTOPLUS MET |
2 |
n/a
|
|
| ACTOS |
2 |
n/a
|
|
| ACULAR |
2 |
n/a
|
|
| ACULAR LS |
2 |
n/a
|
|
| ACULAR PF |
2 |
n/a
|
|
| acyclovir |
1 |
n/a
|
|
| acyclovir sodium |
1 |
n/a
|
Prior authorization required
|
| ADACEL |
2 |
n/a
|
|
| ADAGEN |
3 |
n/a
|
|
| ADALAT CC |
2 |
nifedipine
|
Generic substitution allowed
|
| ADDERALL |
2 |
amphet asp/amphet/d-
|
Generic substitution allowed
|
| ADDERALL XR |
2 |
n/a
|
|
| ADOXA |
2 |
doxycycline monohydr
|
Generic substitution allowed
|
| ADOXA PAK |
2 |
doxycycline monohydr
|
Generic substitution allowed
|
| adrenalin chloride 1mg/ml vial |
1 |
n/a
|
|
| ADRENALIN CHLORIDE SOL, NON-ORAL |
2 |
n/a
|
Prior authorization required
|
| adriamycin 10mg vial |
1 |
n/a
|
Prior authorization required
|
| ADRIAMYCIN 20MG VIAL |
2 |
n/a
|
Prior authorization required
|
| adriamycin 2mg/ml |
1 |
n/a
|
Prior authorization required
|
| adriamycin 50 mg vial |
1 |
n/a
|
Prior authorization required
|
| ADVAIR DISKUS |
2 |
n/a
|
|
| ADVAIR HFA |
2 |
n/a
|
|
| ADVICOR |
2 |
n/a
|
|
| AEROBID |
2 |
n/a
|
|
| AEROBID-M |
2 |
n/a
|
|
| afeditab cr |
1 |
n/a
|
|
| AGENERASE |
2 |
n/a
|
|
| AGGRENOX |
2 |
n/a
|
|
| AGRYLIN |
3 |
anagrelide hcl
|
Generic substitution allowed
|
| a-hydrocort |
1 |
n/a
|
|
| AIRET |
2 |
albuterol sulfate
|
Prior authorization required Generic substitution allowed
|
| ak-con |
1 |
n/a
|
|
| AKINETON |
2 |
n/a
|
|
| AKNE-MYCIN |
2 |
n/a
|
|
| ak-poly-bac |
1 |
n/a
|
|
| aktob |
1 |
n/a
|
|
| ala-cort |
1 |
n/a
|
|
| ALAMAST |
2 |
n/a
|
|
| ALA-SCALP HP |
2 |
n/a
|
|
| ALBALON |
2 |
naphazoline hcl
|
Generic substitution allowed
|
| ALBENZA |
2 |
n/a
|
|
| albuterol aerosol |
1 |
n/a
|
|
| albuterol sulfate er tab |
1 |
n/a
|
|
| albuterol sulfate sol |
1 |
n/a
|
Prior authorization required
|
| albuterol sulfate syrup |
1 |
n/a
|
|
| albuterol sulfate tab |
1 |
n/a
|
|
| ALCAINE |
2 |
proparacaine hcl
|
Generic substitution allowed
|
| alclometasone dipropionate |
1 |
n/a
|
|
| alcohol in dextrose |
1 |
n/a
|
Prior authorization required
|
| ALCOHOL PREP |
2 |
n/a
|
|
| ALDACTAZIDE 25-25MG |
2 |
spironolact/hydrochl
|
Generic substitution allowed
|
| ALDACTAZIDE 50-50MG |
2 |
n/a
|
|
| ALDACTONE |
2 |
spironolactone
|
Generic substitution allowed
|
| ALDARA |
2 |
n/a
|
|
| ALDURAZYME |
3 |
n/a
|
|
| alendronate sodium tab |
1 |
n/a
|
|
| ALESSE |
2 |
levonorgestrel-eth e
|
Generic substitution allowed
|
| ALFERON N |
3 |
n/a
|
|
| ALIMTA |
3 |
n/a
|
|
| ALINIA |
2 |
n/a
|
|
| ALKERAN VIAL |
3 |
n/a
|
Prior authorization required
|
| ALLEGRA SUSP |
2 |
n/a
|
|
| ALLEGRA TAB |
2 |
fexofenadine hcl
|
Generic substitution allowed
|
| ALLEGRA-D |
2 |
n/a
|
|
| allopurinol |
1 |
n/a
|
|
| ALLOPURINOL SODIUM |
2 |
n/a
|
|
| ALOCRIL |
2 |
n/a
|
|
| ALOMIDE |
2 |
n/a
|
|
| ALOPRIM |
2 |
n/a
|
|
| ALORA |
2 |
n/a
|
|
| ALOXI |
2 |
n/a
|
|
| ALPHAGAN P |
2 |
n/a
|
|
| alphatrex |
1 |
n/a
|
|
| ALREX |
2 |
n/a
|
|
| ALTABAX |
2 |
n/a
|
|
| ALTACE CAP |
2 |
ramipril
|
Generic substitution allowed
|
| ALTOPREV |
2 |
n/a
|
|
| ALUPENT |
2 |
n/a
|
|
| amantadine hcl |
1 |
n/a
|
|
| AMARYL |
2 |
glimepiride
|
Generic substitution allowed
|
| AMBIEN |
2 |
zolpidem tartrate
|
Generic substitution allowed
|
| AMBIEN CR |
2 |
n/a
|
|
| AMBISOME |
3 |
n/a
|
Prior authorization required
|
| amcinonide |
1 |
n/a
|
|
| AMERGE |
2 |
n/a
|
Quantity limitations apply
|
| a-methapred |
1 |
n/a
|
|
| AMEVIVE |
3 |
n/a
|
|
| amikacin sulfate |
1 |
n/a
|
|
| amikin |
1 |
n/a
|
|
| AMIKIN PEDIATRIC |
2 |
amikacin sulfate
|
Generic substitution allowed
|
| amiloride hcl |
1 |
n/a
|
|
| amiloride hcl w/hctz |
1 |
n/a
|
|
| aminophylline |
1 |
n/a
|
|
| AMINOSYN 10% |
2 |
n/a
|
Prior authorization required
|
| AMINOSYN 3.5% |
2 |
n/a
|
Prior authorization required
|
| AMINOSYN 5% |
2 |
n/a
|
Prior authorization required
|
| AMINOSYN 7% |
2 |
n/a
|
Prior authorization required
|
| AMINOSYN 8.5% |
2 |
n/a
|
Prior authorization required
|
| AMINOSYN II 10% |
2 |
n/a
|
Prior authorization required
|
| aminosyn ii 15% |
1 |
n/a
|
Prior authorization required
|
| AMINOSYN II 3.5% M/DEXTROSE 5% |
2 |
n/a
|
Prior authorization required
|
| AMINOSYN II 3.5%/DEXTROSE 25% |
2 |
n/a
|
Prior authorization required
|
| AMINOSYN II 3.5%/DEXTROSE 5% |
2 |
n/a
|
Prior authorization required
|
| aminosyn ii 4.25% m/dext 10% |
1 |
n/a
|
Prior authorization required
|
| aminosyn ii 4.25%/dextrose 25% |
1 |
n/a
|
Prior authorization required
|
| AMINOSYN II 5% IN 25% DEXTROSE |
2 |
n/a
|
Prior authorization required
|
| AMINOSYN II 7% |
2 |
n/a
|
Prior authorization required
|
| AMINOSYN II 8.5% |
2 |
n/a
|
Prior authorization required
|
| AMINOSYN II IN DEXTROSE 4.25% |
2 |
n/a
|
Prior authorization required
|
| AMINOSYN II W/ELEC IN DEX W/CA 3.5% |
2 |
n/a
|
Prior authorization required
|
| AMINOSYN II W/ELEC IN DEX W/CA 4.25% |
2 |
n/a
|
Prior authorization required
|
| AMINOSYN M 3.5% |
2 |
n/a
|
Prior authorization required
|
| AMINOSYN W/ELECTROLYTES 7% |
2 |
n/a
|
Prior authorization required
|
| AMINOSYN-HF 8% |
2 |
n/a
|
Prior authorization required
|
| amiodarone hcl |
1 |
n/a
|
|
| AMITIZA |
2 |
n/a
|
|
| amitriptyline hcl |
1 |
n/a
|
|
| amitriptyline w/perphenazine |
1 |
n/a
|
|
| amitriptyline w/perphenazine |
1 |
n/a
|
|
| amitriptyline/chlordiazepoxide |
1 |
n/a
|
|
| amlodipine besylate |
1 |
n/a
|
|
| amlodipine besylate-benazepril |
1 |
n/a
|
|
| AMMONIUM CHLORIDE |
2 |
n/a
|
|
| ammonium lactate |
1 |
n/a
|
|
| amnesteem |
1 |
n/a
|
|
| amoclan |
1 |
n/a
|
|
| amox tr/potassium clavulanate |
1 |
n/a
|
|
| amoxapine 100mg |
1 |
n/a
|
|
| amoxapine 150mg |
1 |
n/a
|
|
| AMOXAPINE 25MG |
2 |
n/a
|
|
| amoxapine 50mg |
1 |
n/a
|
|
| amoxicillin |
1 |
n/a
|
|
| AMOXIL 200MG/5ML |
2 |
amoxicillin trihydra
|
Generic substitution allowed
|
| amoxil 250mg/5ml |
1 |
n/a
|
|
| AMOXIL 400MG/5ML |
2 |
amoxicillin trihydra
|
Generic substitution allowed
|
| amoxil cap |
1 |
n/a
|
|
| AMOXIL CHEW TAB |
2 |
amoxicillin trihydra
|
Generic substitution allowed
|
| amoxil drops |
1 |
n/a
|
|
| AMOXIL TAB |
2 |
amoxicillin trihydra
|
Generic substitution allowed
|
| amphetamine salt combo |
1 |
n/a
|
|
| amphocin |
1 |
n/a
|
Prior authorization required
|
| AMPHOTEC |
3 |
n/a
|
Prior authorization required
|
| amphotericin b |
1 |
n/a
|
Prior authorization required
|
| ampicillin sodium 1 g vial |
1 |
n/a
|
|
| ampicillin sodium 10g vial |
1 |
n/a
|
|
| AMPICILLIN SODIUM 125MG VIAL |
2 |
n/a
|
|
| ampicillin sodium 250mg vial |
1 |
n/a
|
|
| ampicillin sodium 2g vial |
1 |
n/a
|
|
| ampicillin sodium 500mg vial |
1 |
n/a
|
|
| ampicillin trihydrate |
1 |
n/a
|
|
| ampicillin/sulbactam |
1 |
n/a
|
|
| AMRIX |
2 |
n/a
|
|
| ANADROL-50 |
3 |
n/a
|
|
| ANAFRANIL |
2 |
clomipramine hcl
|
Generic substitution allowed
|
| anagrelide hydrochloride |
1 |
n/a
|
|
| ANAPROX |
2 |
naproxen sodium
|
Generic substitution allowed
|
| ANAPROX DS |
2 |
naproxen sodium
|
Generic substitution allowed
|
| ANCOBON |
2 |
n/a
|
|
| ANDRODERM |
2 |
n/a
|
|
| ANDROGEL |
2 |
n/a
|
|
| ANDROID |
2 |
n/a
|
|
| androxy |
1 |
n/a
|
|
| ANEXSIA |
2 |
hydrocodone bit/acet
|
Generic substitution allowed
|
| ANGELIQ |
2 |
n/a
|
|
| ANSAID |
2 |
flurbiprofen
|
Generic substitution allowed
|
| ANTABUSE |
2 |
n/a
|
|
| ANTARA |
2 |
n/a
|
|
| antibiotic ear solution |
1 |
n/a
|
|
| antibiotic ear suspension |
1 |
n/a
|
|
| ANTIVERT |
2 |
meclizine hcl
|
Generic substitution allowed
|
| ANTIZOL |
3 |
n/a
|
|
| ANUSOL-HC |
2 |
hydrocortisone
|
Generic substitution allowed
|
| ANZEMET |
2 |
n/a
|
Prior authorization required
|
| ANZEMET VIAL |
2 |
n/a
|
|
| APHTHASOL |
2 |
n/a
|
|
| APIDRA |
2 |
n/a
|
|
| APOKYN |
2 |
n/a
|
|
| apri |
1 |
n/a
|
|
| APTIVUS |
3 |
n/a
|
|
| ARALAST |
3 |
n/a
|
|
| ARALEN PHOSPHATE |
2 |
chloroquine phosphat
|
Generic substitution allowed
|
| aranelle |
1 |
n/a
|
|
| ARANESP 100MCG |
3 |
n/a
|
Prior authorization required
|
| ARANESP 150MCG |
3 |
n/a
|
Prior authorization required
|
| ARANESP 200MCG |
3 |
n/a
|
Prior authorization required
|
| ARANESP 25MCG |
2 |
n/a
|
Prior authorization required
|
| ARANESP 300MCG |
3 |
n/a
|
Prior authorization required
|
| ARANESP 40MCG |
3 |
n/a
|
Prior authorization required
|
| ARANESP 500MCG |
3 |
n/a
|
Prior authorization required
|
| ARANESP 60MCG |
3 |
n/a
|
Prior authorization required
|
| ARAVA |
2 |
leflunomide
|
Generic substitution allowed
|
| AREDIA |
3 |
n/a
|
Prior authorization required
|
| ARESTIN |
2 |
n/a
|
|
| ARICEPT |
2 |
n/a
|
|
| ARICEPT ODT |
2 |
n/a
|
|
| ARIMIDEX |
2 |
n/a
|
|
| ARISTOSPAN |
2 |
n/a
|
|
| ARIXTRA |
3 |
n/a
|
|
| AROMASIN |
2 |
n/a
|
|
| ARRANON |
3 |
n/a
|
|
| ARTHROTEC |
2 |
n/a
|
|
| ASACOL |
2 |
n/a
|
|
| ascomp w/codeine |
1 |
n/a
|
|
| ASMANEX |
2 |
n/a
|
|
| aspirin w/codeine |
1 |
n/a
|
|
| ASTELIN |
2 |
n/a
|
|
| ASTRAMORPH-PF |
2 |
morphine sulfate/pf
|
Prior authorization required Generic substitution allowed
|
| ATACAND |
2 |
n/a
|
|
| ATACAND HCT |
2 |
n/a
|
|
| atenolol |
1 |
n/a
|
|
| atenolol w/chlorthalidone |
1 |
n/a
|
|
| ATGAM |
3 |
n/a
|
Prior authorization required
|