|
PDF File
|
150MG ALISKIREN-CONTAINING AGENTS
|
TEKAMLO 150 MG-5 MG TABLET, TEKAMLO 150 MG-10 MG TABLET, TEKTURNA 150 MG TABLET, TEKTURNA HCT 150-12.5 MG TAB, TEKTURNA HCT 150-25 MG TABLET |
64 KB |
|
PDF File
|
300MG ALISKIREN-CONTAINING AGENTS
|
AMTURNIDE 300-5-25 MG TAB, TEKTURNA 300 MG TABLET, TEKTURNA HCT 300-12.5 MG TAB, TEKTURNA HCT 300-25 MG TABLET |
63 KB |
|
PDF File
|
ACCOLATE
|
zafirlukast (ACCOLATE) |
55 KB |
|
PDF File
|
ACTEMRA
|
tocilizumab (ACTEMRA) |
60 KB |
|
PDF File
|
ACTIQ
|
oral transmucosal fentanyl (ACTIQ) |
71 KB |
|
PDF File
|
ACTOS / DUETACT / OSENI
|
pioglitazone (ACTOS), pioglitazone/metformin (ACTOPLUS MET), pioglitazone/glimepiride (DUETACT), alogliptin/pioglitazone (OSENI) |
30 KB |
|
PDF File
|
AGENTS FOR GAUCHER’S DISEASE
|
CERDELGA, CEREZYME, ELELYSO, miglustat (ZAVESCA), VPRIV |
20 KB |
|
PDF File
|
ALDARA
|
imiquimod 5% cream (ALDARA) |
45 KB |
|
PDF File
|
AMITIZA
|
lubiprostone (AMITIZA) |
61 KB |
|
PDF File
|
ANTIEMETICS
|
AKYNZEO, ANZEMET, aprepitant (EMEND), GRANISETRON, SANCUSO |
26 KB |
|
PDF File
|
ANTIPSYCHOTICS
|
ABILIFY, ABILIFY DISCMELT, ABILIFY MAINTENA, ABILIFY MYCITE, AMITRIPTYLINE/PERPHENAZINE, ARIPIPRAZOLE, ARISTADA, CHLORPROMAZINE, CLOZAPINE, CLOZARIL, FANAPT, FAZACLO, FLUPHENAZINE, GEODON, HALOPERIDOL, INVEGA, INVEGA SUSTENNA, INVEGA TRINZA, LATUDA, LOXAPINE, LOXITANE, MOLINDONE, OLANZAPINE, OLANZAPINE/FLUOXETINE, ORAP, PALIPERIDONE, PERPHENAZINE, PERSERIS, PIMOZIDE, QUETIAPINE, REXULTI, RISPERDAL, RISPERDAL CONSTA, RISPERIDONE, SAPHRIS, SEROQUEL, SEROQUEL XR, SYMBYAX, THIORIDAZINE, THIOTHIXENE, TRIFLUOPERAZINE, VERSACLOZ, VRAYLAR, ZIPRASIDONE, ZYPREXA, ZYPREXA RELPREVV, ZYPREXA ZYDIS |
28 KB |
|
PDF File
|
ANXIOLYTICS (alprazolam)
|
alprazolam (XANAX) |
64 KB |
|
PDF File
|
ANXIOLYTICS (chlordiaz., meprobamate, oxazepam)
|
chlordiazepoxide, meprobamate, oxazepam |
69 KB |
|
PDF File
|
ANXIOLYTICS (clonazepam, diazepam)
|
clonazepam (KLONOPIN), diazepam |
73 KB |
|
PDF File
|
ANXIOLYTICS (clorazepate)
|
clorazepate (TRANXENE) |
71 KB |
|
PDF File
|
ANXIOLYTICS (lorazepam)
|
lorazepam |
67 KB |
|
PDF File
|
ARANESP
|
darbepoetin alfa (ARANESP) |
28 KB |
|
PDF File
|
ARIKAYCE
|
amikacin (ARIKAYCE) |
62 KB |
|
PDF File
|
ATTENTION DEFICIT MEDICATIONS (CLONIDINE ER)
|
clonidine ER |
57 KB |
|
PDF File
|
ATTENTION DEFICIT MEDICATIONS (ER FORMULATIONS)
|
amphetamine salts (MYDAYIS), amphetamine/dextroamphetamine salts (ADDERALL XR, DYANAVEL XR, ADZENYS ER, ADZENYS XR-ODT), dexmethylphenidate (FOCALIN XR), dextroamphetamine (DEXEDRINE SPANSULE), lisdexamfetamine (VYVANSE), lisdexamfetamine (VYVANSE) chewable tablet, methylphenidate (ADHANSIA XR, APTENSIO XR, CONCERTA, COTEMPLA XR-ODT, DAYTRANA TD, JORNAY PM, QUILLICHEW ER, QUILLIVANT XR, RITALIN LA) |
191 KB |
|
PDF File
|
ATTENTION DEFICIT MEDICATIONS (IR FORMULATIONS)
|
amphetamine/dextroamphetamine salts (ADDERALL), amphetamine sulfate (EVEKEO, EVEKEO ODT), dexmethylphenidate (FOCALIN), dextroamphetamine (DEXEDRINE, PROCENTRA, ZENZEDI), methamphetamine (DESOXYN), methylphenidate (METHYLIN, RITALIN) |
195 KB |
|
PDF File
|
ATTENTION DEFICIT MEDICATIONS (NON-STIMULANTS)
|
guanfacine SR (INTUNIV), atomoxetine (STRATTERA) |
57 KB |
|
PDF File
|
AUSTEDO & XENAZINE
|
deutetrabenazine (AUSTEDO), tetrabenazine (XENAZINE) |
69 KB |
|
PDF File
|
AVANDIA
|
rosiglitazone (AVANDIA) |
27 KB |
|
PDF File
|
Blood Glucose Monitors with Special Features
|
|
22 KB |
|
PDF File
|
BONJESTA & DICLEGIS
|
doxylamine/pyridoxine (BONJESTA, DICLEGIS) |
57 KB |
|
PDF File
|
BUNAVAIL / SUBOXONE / ZUBSOLV
|
buprenorphine/naloxone (BUNAVAIL, SUBOXONE, ZUBSOLV) |
62 KB |
|
PDF File
|
BUPRENORPHINE
|
buprenorphine |
54 KB |
|
PDF File
|
CARISOPRODOL-CONTAINING AGENTS
|
CARISOPRODOL, CARISOPRODOL COMPOUND TAB, CARISOPRODOL ASPIRIN AND CODEINE PHOSPHATE, CARISOPRODOL-ASPIRIN, SOMA |
65 KB |
|
PDF File
|
CGRP ANTAGONISTS
|
erenumab (AIMOVIG), fremanezumab (AJOVY), galcanezumab (EMGALITY) |
98 KB |
|
PDF File
|
CIMZIA
|
certolizumab pegol (CIMZIA) |
70 KB |
|
PDF File
|
COMPOUND DRUGS
|
|
30 KB |
|
PDF File
|
CONTRACEPTIVES - CHIP PLANS ONLY
|
|
18 KB |
|
PDF File
|
CONTRACEPTIVES - DELL CHILDREN HEALTH PLAN (SETON)
|
|
18 KB |
|
PDF File
|
COSENTYX
|
secukinumab (COSENTYX) |
62 KB |
|
PDF File
|
COUGH & COLD
|
ALAHIST, ALA-HIST DM LIQUID, ALLFEN DM TABLET, AP-HIST DM LIQUID, BROMFED DM COUGH SYRUP, BROMPHENIR-PSEUDOEPHED-DM SYR, BROTAPP DM LIQUID, CHILD DELSYM, CHILD MUCINEX, CHILDREN COLD & COUGH DM ELIXI, COUGH DM 30 MG/5 ML SUSPENSION,
DALLERGY, DECONEX DMX TABLET, DELSYM 30 MG/5 ML SUSPENSION, DEXTROMETHORPHAN ER 30 MG/5 ML, DIMAPHEN DM ELIXIR, ED A-HIST, ENDACOF-DM LIQUID, EXTRA ACTION COUGH SYRUP, HISTEX-DM SYRUP, IOPHEN DM-NR LIQUID, KIDKARE COUGH & COLD LIQUID,
LOHIST, LORTUSS DM LIQUID, MAXIPHEN DM TABLET, M-END DMX LIQUID, M-HIST DM LIQUID, MUCINEX, NASAL DECONGESTANT 0.05% SPRAY, NASOPEN PE LIQUID, NINJACOF LIQUID, NOHIST, PEDIATRIC COUGH-COLD LIQUID, PHENYLEPHRINE-PYRILAMINE 10-25, POLY HIST, POLYTUSSIN DM SYRUP, POLY-VENT DM TABLET, PROMETHAZINE-DM SYRUP, Q-TUSSIN DM SYRUP, RESCON-DM LIQUID, ROBAFEN, RYMED TABLET, RYNEX DM LIQUID, SILTUSSIN, SM NASAL SPRAY 0.05%, SM TUSSIN, TUSSIN, VANACOF, VANATAB |
110 KB |
|
PDF File
|
COUGH & COLD
|
ALA-HIST PE TABLET, APRODINE TABLET, BROTAPP LIQUID, CHEST CONGESTION RELIEF PE, CHEST CONGESTION RELIEF TABLET, CHL MUCINEX CHEST CONGEST LIQ, CHLD MUCINEX STUFFY NOSE-COLD, CHLO TUSS LIQUID, COUGH SYRUP 200 MG/10 ML, DECONEX IR TABLET, DIMAPHEN ELIXIR, ED BRON GP LIQUID, ED CHLORPED D PEDIATRIC DROPS, ED-A-HIST PSE TABLET, GUAIFENESIN 100 MG/5 ML SYRUP, HISTEX-PE SYRUP, IOPHEN NR LIQUID, KID'S MUCINEX MINI-MELTS PACK, LODRANE D CAPSULE, LORTUSS LQ LIQUID, MAXIPHEN TABLET, MUCUS RELIEF 400 MG TABLET, MUCUS RELIEF SINUS TABLET, NOSE DROPS, ORGAN-I NR 200 MG TABLET, POLY-HIST PD LIQUID, POLY-VENT IR TABLET, PROMETHAZINE VC SYRUP, Q-TUSSIN 100 MG/5 ML SOLUTION, RESCON-GG LIQUID, RESPAIRE-30 CAPSULE, ROBAFEN 100 MG/5 ML SYRUP, RU-HIST D 10-4 MG TABLET, RYNEX PE LIQUID, RYNEX PSE LIQUID, SILTUSSIN SA 100 MG/5 ML SYR, STAHIST AD LIQUID, STAHIST AD TABLET, TUSSIN 100 MG/5 ML SYRUP |
121 KB |
|
PDF File
|
COUGH & COLD
|
DELSYM COUGH + CHEST CONGST DM LQ, GUAIFENESIN ER 1,200 MG TABLET, GUAIFENESIN/PSE ER 600-60 MG, MUCINEX D ER 1,200-120 MG TABLET, MUCINEX D ER 600-60 MG TABLET, MUCINEX DM ER 1,200-60 MG TAB, MUCINEX DM ER 600-30 MG TABLET, MUCINEX ER 1,200 MG TABLET, MUCINEX ER 600 MG TABLET, MUCINEX FAST-MAX CONGEST-COUGH, MUCINEX FAST-MAX DM MAX LIQUID, RESCON TABLET, ROBAFEN COUGH 15 MG LIQUIDGEL, SUDOGEST SINUS & ALLERGY TAB |
104 KB |
|
PDF File
|
COUGH & COLD
|
BENZONATATE |
98 KB |
|
PDF File
|
COX-2 INHIBITORS (CELEBREX)
|
celecoxib (CELEBREX) |
33 KB |
|
PDF File
|
COX-2 INHIBITORS (MOBIC)
|
meloxicam (MOBIC) |
63 KB |
|
PDF File
|
CYCLOBENZAPRINE
|
cyclobenzaprine (FLEXERIL / AMRIX) |
27 KB |
|
PDF File
|
DDAVP INJECTABLE
|
desmopressin injectable (DDAVP) |
21 KB |
|
PDF File
|
DDAVP ORAL
|
desmopressin oral (DDAVP) |
87 KB |
|
PDF File
|
DIABETIC SUPPLIES
|
|
19 KB |
|
PDF File
|
DIACOMIT
|
stiripentol (DIACOMIT) |
49 KB |
|
PDF File
|
DICLOFENAC 1.5% & 2% SOLUTION
|
diclofenac 1.5% topical solution, diclofenac 2% topical solution (PENNSAID 2% PUMP) |
56 KB |
|
PDF File
|
DICLOFENAC 3% GEL
|
diclofenac 3% gel (SOLARAZE 3% GEL) |
47 KB |
|
PDF File
|
DPP-4 INHIBITORS: CRITERIA A
|
alogliptin 6.25 mg (NESINA 6.25 MG), JANUVIA 25 MG, ONGLYZA 2.5 MG, TRADJENTA 5 MG |
58 KB |
|
PDF File
|
DPP-4 INHIBITORS: CRITERIA B
|
alogliptin 12.5 mg (NESINA 12.5 MG), JANUVIA 50 MG |
58 KB |
|
PDF File
|
DPP-4 INHIBITORS: CRITERIA C
|
alogliptin 25 mg (NESINA 25 MG), JANUVIA 100 MG, ONGLYZA 5 MG |
60 KB |
|
PDF File
|
DPP-4 INHIBITORS: CRITERIA D
|
alogliptin-metformin (KAZANO), alogliptin-pioglitazone (OSENI), GLYXAMBI, JANUMET (XR), JENTADUETO (XR), KOMBIGLYZE XR, QTERN, STEGLUJAN |
56 KB |
|
PDF File
|
DRUG REGIMEN OPTIMIZATION - ALTACE / DIOVAN
|
ramipril (ALTACE), valsartan (DIOVAN) |
58 KB |
|
PDF File
|
DUPIXENT - INITIAL REQUESTS
|
dupilumab (DUPIXENT) |
66 KB |
|
PDF File
|
DUPIXENT - RENEWAL REQUESTS
|
dupilumab (DUPIXENT) |
23 KB |
|
PDF File
|
DURAGESIC
|
transdermal fentanyl (DURAGESIC) |
67 KB |
|
PDF File
|
ELIDEL & PROTOPIC 0.03%
|
pimecrolimus (ELIDEL), tacrolimus (PROTOPIC 0.03%) |
66 KB |
|
PDF File
|
EMFLAZA - INITIAL REQUESTS
|
deflazacort (EMFLAZA) |
75 KB |
|
PDF File
|
EMFLAZA - RENEWAL REQUESTS
|
deflazacort (EMFLAZA) |
25 KB |
|
PDF File
|
ENBREL
|
etanercept (ENBREL) |
55 KB |
|
PDF File
|
ENZYMES
|
ALDURAZYME, ADAGEN, CEPROTIN, ELAPRASE, FABRAZYME, LUMIZYME, NAGLAZYME, NITYR, ORFADIN, REVCOVI, VIMIZIM |
60 KB |
|
PDF File
|
ENZYMES - COOK
|
ALDURAZYME, ADAGEN, CEPROTIN, ELAPRASE, FABRAZYME, LUMIZYME, NAGLAZYME, NITYR, ORFADIN, REVCOVI, VIMIZIM |
60 KB |
|
PDF File
|
EPIDIOLEX
|
cannabidiol (EPIDIOLEX) |
49 KB |
|
PDF File
|
EPOGEN / PROCRIT
|
epoetin alfa (EPOGEN / PROCRIT) |
28 KB |
|
PDF File
|
EUCRISA
|
crisaborole (EUCRISA) |
19 KB |
|
PDF File
|
EXCEPTION TO COVERAGE REQUEST
|
|
39 KB |
|
PDF File
|
FENTORA
|
buccal fentanyl (FENTORA) |
68 KB |
|
PDF File
|
GABAPENTIN
|
gabapentin (NEURONTIN) |
60 KB |
|
PDF File
|
GLP-1 RECEPTOR AGONISTS
|
ADLYXIN, BYDUREON, BYDUREON BCISE, BYETTA, OZEMPIC, SOLIQUA, TRULICITY, VICTOZA, XULTOPHY |
74 KB |
|
PDF File
|
GRALISE
|
gabapentin extended release (GRALISE) |
58 KB |
|
PDF File
|
GROWTH HORMONE - SEROSTIM
|
somatropin (SEROSTIM) |
63 KB |
|
PDF File
|
GROWTH HORMONE - ZORBTIVE
|
somatropin (ZORBITIVE) |
56 KB |
|
PDF File
|
GROWTH HORMONES - GENOTROPIN & NORDITROPIN
|
GENOTROPIN, NORDITROPIN |
120 KB |
|
PDF File
|
GROWTH HORMONES - GENOTROPIN & NORDITROPIN - COOK
|
GENOTROPIN, NORDITROPIN |
121 KB |
|
PDF File
|
GROWTH HORMONES - GENOTROPIN & NORDITROPIN - TCHP
|
GENOTROPIN, NORDITROPIN |
121 KB |
|
PDF File
|
GROWTH HORMONES - OTHER PRODUCTS
|
HUMATROPE, NUTROPIN AQ, OMNITROPE, SAIZEN |
120 KB |
|
PDF File
|
HEPATITIS C - INITIAL REQUEST
|
sofosbuvir/velpatasvir (EPCLUSA), daclatasvir (DAKLINZA), ledipasvir/sofosbuvir (HARVONI), glecaprevir/pibrentasvir (MAVYRET), simeprevir (OLYSIO), sofosbuvir (SOVALDI), ombitasvir/paritaprevir/ritonavir (TECHNIVIE), ombitasvir/paritaprevir/ritonavir and dasabuvir (VIEKIRA PAK), ombitasvir/paritaprevir/ritonavir and dasabuvir (VIEKIRA XR), sofosbuvir/velpatasvir/voxilaprevir (VOSEVI), elbasvir/grazoprevir (ZEPATIER) |
102 KB |
|
PDF File
|
HEPATITIS C - REFILL REQUEST
|
sofosbuvir/velpatasvir (EPCLUSA), daclatasvir (DAKLINZA), ledipasvir/sofosbuvir (HARVONI), glecaprevir/pibrentasvir (MAVYRET), simeprevir (OLYSIO), sofosbuvir (SOVALDI), ombitasvir/paritaprevir/ritonavir (TECHNIVIE), ombitasvir/paritaprevir/ritonavir and dasabuvir (VIEKIRA PAK), ombitasvir/paritaprevir/ritonavir and dasabuvir (VIEKIRA XR), sofosbuvir/velpatasvir/voxilaprevir (VOSEVI), elbasvir/grazoprevir (ZEPATIER) |
77 KB |
|
PDF File
|
HEREDITARY ANGIOEDEMA (HAE) AGENTS
|
BERINERT, CINRYZE, FIRAZYR, HAEGARDA, KALBITOR, RUCONEST, TAKHZYRO |
64 KB |
|
PDF File
|
HORIZANT
|
gabapentin enacarbil (HORIZANT) |
60 KB |
|
PDF File
|
HP ACTHAR
|
corticotropin (HP ACTHAR) |
36 KB |
|
PDF File
|
HUMIRA
|
adalimumab (HUMIRA) |
79 KB |
|
PDF File
|
ILARIS
|
canakinumab (ILARIS) |
70 KB |
|
PDF File
|
ILUMYA
|
tildrakizumab (ILUMYA) |
55 KB |
|
PDF File
|
INCRELEX
|
mecasermin (INCRELEX) |
60 KB |
|
PDF File
|
INGREZZA
|
valbenazine (INGREZZA) |
65 KB |
|
PDF File
|
INHALED ANTIBIOTICS
|
BETHKIS, CAYSTON, KITABIS, tobramycin (TOBI, TOBI PODHALER) |
59 KB |
|
PDF File
|
KALYDECO
|
ivacaftor (KALYDECO) |
70 KB |
|
PDF File
|
KETOROLAC (INJECTION / NASAL)
|
ketorolac (TORADOL equiv) injection, ketorolac nasal spray |
73 KB |
|
PDF File
|
KETOROLAC (ORAL)
|
oral ketorolac (TORADOL equiv) |
74 KB |
|
PDF File
|
KEVEYIS
|
dichlorphenamide (KEVEYIS) |
50 KB |
|
PDF File
|
KEVZARA
|
sarilumab (KEVZARA) |
58 KB |
|
PDF File
|
KINERET
|
anakinra (KINERET) |
59 KB |
|
PDF File
|
LIDODERM
|
lidocaine (LIDODERM) 5% patch, ZTLIDO 1.8% |
56 KB |
|
PDF File
|
LINZESS
|
linaclotide (LINZESS) |
86 KB |
|
PDF File
|
LOTRONEX
|
alosetron (LOTRONEX) |
59 KB |
|
PDF File
|
LOVAZA & VASCEPA
|
omega-3-acid ethyl esters (LOVAZA), icosapent ethyl (VASCEPA) |
57 KB |
|
PDF File
|
MAKENA
|
hydroxyprogesterone caproate injection (MAKENA) |
44 KB |
|
PDF File
|
MAKENA - CHC / COOK / FIRSTCARE / TCHP
|
hydroxyprogesterone caproate injection (MAKENA) |
44 KB |
|
PDF File
|
MAKENA - PARKLAND
|
hydroxyprogesterone caproate injection (MAKENA) |
44 KB |
|
PDF File
|
MOTEGRITY
|
prucalopride (MOTEGRITY) |
57 KB |
|
PDF File
|
MOVANTIK
|
naloxegol (MOVANTIK) |
56 KB |
|
PDF File
|
NPD & NAP DRUGS - 1 YEAR LOOKBACK
|
ACIPHEX, DEXILANT, ESOMEPRAZOLE MAGNESIUM, LANSOPRAZOLE, NEXIUM, OMEPRAZOLE, OMEPRAZOLE/SODIUM BICARBONATE, PREVACID, PROTONIX, RABEPRAZOLE, ZEGERID |
33 KB |
|
PDF File
|
NPD & NAP DRUGS - 6 MONTH LOOKBACK
|
|
30 KB |
|
PDF File
|
NPD & NAP DRUGS - LIFETIME LOOKBACK
|
|
30 KB |
|
PDF File
|
NUPLAZID
|
pimavanserin (NUPLAZID) |
58 KB |
|
PDF File
|
NUVIGIL
|
armodafinil (NUVIGIL) |
61 KB |
|
PDF File
|
OLUMIANT
|
baricitinib (OLUMIANT) |
64 KB |
|
PDF File
|
OPIOID OVERUTILIZATION
|
ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE, ACETAMINOPHEN/CODEINE, ASCOMP WITH CODEINE, BELBUCA, BELLADONNA/OPIUM, BENZHYDROCODONE/ACETAMINOPHEN, BUPRENORPHINE PATCH, BUTALBITAL/CAFFEINE/ACETAMINOPHEN/CODEINE, BUTALBITAL/CAFFEINE/ASPIRIN/CODEINE, BUTORPHANOL, BUTRANS, CODEINE SULFATE, DEMEROL, DILAUDID, DOLOPHINE, DVORAH, EMBEDA, ENDOCET, HYDROCODONE/ACETAMINOPHEN, HYDROCODONE/IBUPROFEN, HYDROMORPHONE, HYSINGLA ER, IBUDONE, KADIAN, LEVORPHANOL, LORCET, MEPERIDINE, METHADONE, METHADOSE, MORPHABOND, MORPHINE SULFATE, MS CONTIN, NALBUPHINE, NALOCET, NORCO, NUCYNTA (ER), OPANA, OPIUM TINCTURE, OXYCODONE, OXYCODONE/ACETAMINOPHEN, OXYCODONE/ASPIRIN, OXYCODONE/IBUPROFEN, OXYMORPHONE, PENTAZOCINE/NALOXONE, PERCOCET, ROXICODONE, TRAMADOL/ACETAMINOPHEN, TRAMADOL HYDROCHLORIDE, TYLENOL/CODEINE, ULTRACET, ULTRAM, VICODIN |
28 KB |
|
PDF File
|
ORALAIR
|
Grass Pollen Allergen Extract (ORALAIR) |
57 KB |
|
PDF File
|
ORENCIA
|
abatacept (ORENCIA) |
58 KB |
|
PDF File
|
ORILISSA
|
elagolix (ORILISSA) |
64 KB |
|
PDF File
|
ORKAMBI
|
lumacaftor / ivacaftor (ORKAMBI) |
59 KB |
|
PDF File
|
OTEZLA
|
apremilast (OTEZLA) |
57 KB |
|
PDF File
|
OXBRYTA
|
voxeletor (OXBRYTA) |
59 KB |
|
PDF File
|
OXYCONTIN ER - HIGH DOSE
|
oxycodone (OXYCONTIN) 60mg & 80mg |
60 KB |
|
PDF File
|
OXYCONTIN ER - LOW DOSE
|
oxycodone (OXYCONTIN) 10mg, 15mg, 20mg, 30mg, 40mg, XTAMPZA |
56 KB |
|
PDF File
|
PCSK9 INHIBITORS
|
alirocumab (PRALUENT), evolocumab (REPATHA) |
274 KB |
|
PDF File
|
PDE5-INHIBITORS
|
sildenafil (REVATIO), tadalafil (ADCIRCA) |
74 KB |
|
PDF File
|
PHOSPHATE BINDERS
|
AURYXIA, calcium acetate (PHOSLYRA), lanthanum (FOSRENOL), VELPHORO |
54 KB |
|
PDF File
|
PROMETHAZINE & PROMETHAZINE CONTAINING PRODUCTS
|
PHENADOZ, PHENERGAN, PROMETHAZINE, PROMETHAZINE VC SYRUP, PROMETHAZINE VC-CODEINE SYRUP, PROMETHAZINE-CODEINE SYRUP, PROMETHAZINE-DM SYRUP, PROMETHEGAN |
55 KB |
|
PDF File
|
PROPYLTHIOURACIL
|
propylthiouracil |
18 KB |
|
PDF File
|
PROTOPIC 0.1%
|
tacrolimus (PROTOPIC) 0.1% |
62 KB |
|
PDF File
|
PROVIGIL
|
modafinil (PROVIGIL) |
60 KB |
|
PDF File
|
RANEXA
|
ranolazine (RANEXA) |
93 KB |
|
PDF File
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RELISTOR
|
methylnaltrexone (RELISTOR) |
56 KB |
|
PDF File
|
RINVOQ
|
upadacitinib (RINVOQ) |
74 KB |
|
PDF File
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SAVELLA
|
milnacipran (SAVELLA) |
59 KB |
|
PDF File
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SEDATIVES / HYPNOTICS - ADULTS
|
AMBIEN, AMBIEN CR, BELSOMRA, EDLUAR, ESTAZOLAM, ESZOPICLONE, INTERMEZZO, LUNESTA, RESTORIL, SONATA, TEMAZEPAM, TRIAZOLAM, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER |
64 KB |
|
PDF File
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SEDATIVES / HYPNOTICS - FLURAZEPAM
|
flurazepam |
63 KB |
|
PDF File
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SEDATIVES / HYPNOTICS - ROZEREM & HETLIOZ
|
ramelteon (ROZEREM), tasimelteon (HETLIOZ) |
62 KB |
|
PDF File
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SGLT2 INHIBITOR COMBINATION AGENTS
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INVOKAMET (XR), SEGLUROMET, SYNJARDY (XR), XIGDUO XR |
60 KB |
|
PDF File
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SGLT2 INHIBITOR SINGLE AGENTS
|
FARXIGA, INVOKANA, JARDIANCE, STEGLATRO |
59 KB |
|
PDF File
|
SILIQ
|
brodalumab (SILIQ) |
58 KB |
|
PDF File
|
SIMPONI
|
golimumab (SIMPONI) |
60 KB |
|
PDF File
|
SKYRIZI
|
risankizumab (SKYRIZI) |
66 KB |
|
PDF File
|
STELARA
|
ustekinumab (STELARA) |
60 KB |
|
PDF File
|
SUNOSI
|
solriamfetol (SUNOSI) |
61 KB |
|
PDF File
|
SYMDEKO
|
tezacaftor/ivacaftor and ivacaftor (SYMDEKO) |
77 KB |
|
PDF File
|
SYMLIN
|
pramlintide (SYMLIN) |
95 KB |
|
PDF File
|
SYMPROIC
|
naldemedine (SYMPROIC) |
60 KB |
|
PDF File
|
TALTZ
|
ixekizumab (TALTZ) |
58 KB |
|
PDF File
|
TEXAS STANDARD PRIOR AUTHORIZATION REQUEST FORM
|
PRESCRIPTION DRUG BENEFITS |
233 KB |
|
PDF File
|
TOPICAL ACNE AGENTS
|
BENZACLIN GEL, BENZACLIN PUMP GEL, ERYTHROMYCIN-BENZOYL GEL, CLINDAMYCIN-BENZOYL PEROXIDE GEL 1.2-5%, CLINDAMYCIN-BENZOYL PEROXIDE GEL, DUAC 1.2-5% GEL |
25 KB |
|
PDF File
|
TOPICAL RETINOIDS
|
ADAPALENE, ADAPALENE-BENZYL PEROXIDE, ALTRENO, ATRALIN, AVITA, CLINDAMYCIN-TRETINOIN, DIFFERIN, EPIDUO, EPIDUO FORTE, FABIOR, TAZAROTENE, TAZORAC, TRETINOIN, ZIANA |
24 KB |
|
PDF File
|
TREMFYA
|
guselkumab (TREMFYA) |
62 KB |
|
PDF File
|
TRIKAFTA
|
elexcaftor/tezacaftor/ivacaftor (TRIKAFTA) |
70 KB |
|
PDF File
|
TRULANCE
|
plecanatide (TRULANCE) |
58 KB |
|
PDF File
|
TYVASO STARTER KIT - CHIP PLANS ONLY
|
treprostinil (TYVASO STARTER KIT) |
16 KB |
|
PDF File
|
UREA CYCLE DISORDER AGENTS
|
CARBAGLU, RAVICTI, sodium phenylbutyrate (BUPHENYL) |
24 KB |
|
PDF File
|
VIBERZI
|
eluxadoline (VIBERZI) |
60 KB |
|
PDF File
|
XELJANZ / XELJANZ XR
|
tofacitinib citrate (XELJANZ / XELJANZ XR) |
63 KB |
|
PDF File
|
XENICAL
|
orlistat (XENICAL) |
44 KB |
|
PDF File
|
XIFAXAN 200 MG
|
rifaximin 200mg (XIFAXAN 200mg) |
58 KB |
|
PDF File
|
XIFAXAN 550 MG
|
rifaximin 550mg (XIFAXAN 550mg) |
60 KB |
|
PDF File
|
XYREM
|
sodium oxybate (XYREM) |
54 KB |
|
PDF File
|
ZELBORAF
|
vemurafenib (ZELBORAF) |
22 KB |
|
PDF File
|
ZYCLARA
|
imiquimod 3.75 % cream (ZYCLARA) |
45 KB |
|
PDF File
|
ZYFLO
|
zileuton (ZYFLO) |
56 KB |