|
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 |
63 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 |
62 KB |
|
PDF File
|
ACCOLATE
|
zafirlukast (ACCOLATE) |
55 KB |
|
PDF File
|
ACTEMRA
|
tocilizumab (ACTEMRA) |
60 KB |
|
PDF File
|
ACTIQ
|
oral transmucosal fentanyl (ACTIQ) |
70 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) |
59 KB |
|
PDF File
|
ANTIEMETICS
|
AKYNZEO, ANZEMET, aprepitant (EMEND), GRANISETRON, SANCUSO |
25 KB |
|
PDF File
|
ANTIPSYCHOTICS
|
ABILIFY, ABILIFY MAINTENA, 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, RISPERIDONE, SAPHRIS, SEROQUEL, SEROQUEL XR, SYMBYAX, THIORIDAZINE, THIOTHIXENE, TRIFLUOPERAZINE, VERSACLOZ, VRAYLAR, ZIPRASIDONE, ZYPREXA, ZYPREXA RELPREVV, ZYPREXA ZYDIS |
27 KB |
|
PDF File
|
ANXIOLYTICS (alprazolam)
|
alprazolam (XANAX) |
62 KB |
|
PDF File
|
ANXIOLYTICS (chlordiaz., meprobamate, oxazepam)
|
chlordiazepoxide, meprobamate, oxazepam |
70 KB |
|
PDF File
|
ANXIOLYTICS (clonazepam, diazepam)
|
clonazepam (KLONOPIN), diazepam |
73 KB |
|
PDF File
|
ANXIOLYTICS (clorazepate)
|
clorazepate (TRANXENE) |
72 KB |
|
PDF File
|
ANXIOLYTICS (lorazepam)
|
lorazepam |
69 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 |
55 KB |
|
PDF File
|
ATTENTION DEFICIT MEDICATIONS (ER FORMULATIONS)
|
amphetamine/dextroamphetamine (MYDAYIS), amphetamine/dextroamphetamine salts (ADDERALL XR), amphetamine/dextroamphetamine salts (DYANAVEL XR), amphetamine/dextroamphetamine salts (ADZENYS ER), amphetamine/dextroamphetamine salts (ADZENYS XR-ODT), dexmethylphenidate (FOCALIN XR), dextroamphetamine (DEXEDRINE SPANSULE), lisdexamfetamine (VYVANSE) capsule, lisdexamfetamine (VYVANSE) chewable tablet, methylphenidate (APTENSIO XR), methylphenidate (METADATE CD), methylphenidate (RITALIN LA), methylphenidate (QUILLICHEW ER), methylphenidate (QUILLIVANT XR), methylphenidate (METADATE ER), methylphenidate (METHYLIN ER), methylphenidate (RITALIN SR), methylphenidate (CONCERTA), methylphenidate (COTEMPLA), methylphenidate (DAYTRANA TD) |
178 KB |
|
PDF File
|
ATTENTION DEFICIT MEDICATIONS (IR FORMULATIONS)
|
amphetamine/dextroamphetamine salts (ADDERALL), amphetamine sulfate tablet (EVEKEO), dexmethylphenidate (FOCALIN), dextroamphetamine (DEXEDRINE), dextroamphetamine solution (PROCENTRA), dextroamphetamine (ZENZEDI), methamphetamine (DESOXYN), methylphenidate (METHYLIN), methylphenidate (RITALIN) |
183 KB |
|
PDF File
|
ATTENTION DEFICIT MEDICATIONS (NON-STIMULANTS)
|
guanfacine SR (INTUNIV), atomoxetine (STRATTERA) |
56 KB |
|
PDF File
|
AUSTEDO & XENAZINE
|
deutetrabenazine (AUSTEDO), tetrabenazine (XENAZINE) |
62 KB |
|
PDF File
|
AVANDIA
|
rosiglitazone (AVANDIA) |
27 KB |
|
PDF File
|
Blood Glucose Monitors with Special Features
|
|
22 KB |
|
PDF File
|
BUNAVAIL / SUBOXONE / ZUBSOLV
|
buprenorphine/naloxone (BUNAVAIL, SUBOXONE, ZUBSOLV) |
58 KB |
|
PDF File
|
BUPRENORPHINE
|
buprenorphine |
54 KB |
|
PDF File
|
CARISOPRODOL-CONTAINING AGENTS
|
CARISOPRODOL, CARISOPRODOL COMPOUND TAB, CARISOPRODOL ASPIRIN AND CODEINE PHOSPHATE, CARISOPRODOL-ASPIRIN, SOMA |
64 KB |
|
PDF File
|
CGRP ANTAGONISTS
|
erenumab (AIMOVIG), fremanezumab (AJOVY), galcanezumab (EMGALITY) |
92 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) |
54 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, 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 |
108 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 |
120 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 |
102 KB |
|
PDF File
|
COUGH & COLD
|
BENZONATATE |
102 KB |
|
PDF File
|
COX-2 INHIBITORS (CELEBREX)
|
celecoxib (CELEBREX) |
32 KB |
|
PDF File
|
COX-2 INHIBITORS (MOBIC)
|
meloxicam (MOBIC) |
64 KB |
|
PDF File
|
CYCLOBENZAPRINE
|
cyclobenzaprine (FLEXERIL / AMRIX) |
26 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
|
DICLOFENAC 1.5% & 2% SOLUTION
|
diclofenac 1.5% topical solution, diclofenac 2% topical solution (PENNSAID 2% PUMP) |
55 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 |
57 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 |
59 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) |
57 KB |
|
PDF File
|
DUPIXENT - INITIAL REQUESTS
|
dupilumab (DUPIXENT) |
62 KB |
|
PDF File
|
DUPIXENT - RENEWAL REQUESTS
|
dupilumab (DUPIXENT) |
21 KB |
|
PDF File
|
DURAGESIC
|
transdermal fentanyl (DURAGESIC) |
66 KB |
|
PDF File
|
ELIDEL & PROTOPIC 0.03%
|
pimecrolimus (ELIDEL), tacrolimus (PROTOPIC 0.03%) |
59 KB |
|
PDF File
|
EMFLAZA - INITIAL REQUESTS
|
deflazacort (EMFLAZA) |
75 KB |
|
PDF File
|
EMFLAZA - RENEWAL REQUESTS
|
deflazacort (EMFLAZA) |
24 KB |
|
PDF File
|
ENBREL
|
etanercept (ENBREL) |
55 KB |
|
PDF File
|
ENZYMES
|
ALDURAZYME, ADAGEN, CEPROTIN, ELAPRASE, FABRAZYME, LUMIZYME, NAGLAZYME, NITYR, ORFADIN, VIMIZIM |
61 KB |
|
PDF File
|
ENZYMES
|
ALDURAZYME, ADAGEN, CEPROTIN, ELAPRASE, FABRAZYME, LUMIZYME, NAGLAZYME, NITYR, ORFADIN, VIMIZIM |
61 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) |
67 KB |
|
PDF File
|
GABAPENTIN
|
gabapentin (NEURONTIN) |
60 KB |
|
PDF File
|
GLP-1 RECEPTOR AGONISTS
|
ADLYXIN, BYDUREON, BYDUREON BCISE, BYETTA, OZEMPIC, SOLIQUA, TANZEUM, TRULICITY, VICTOZA, XULTOPHY |
71 KB |
|
PDF File
|
GRALISE
|
gabapentin extended release (GRALISE) |
57 KB |
|
PDF File
|
GROWTH HORMONE - SEROSTIM
|
somatropin (SEROSTIM) |
52 KB |
|
PDF File
|
GROWTH HORMONE - ZORBTIVE
|
somatropin (ZORBITIVE) |
50 KB |
|
PDF File
|
GROWTH HORMONES - GENOTROPIN & NORDITROPIN
|
GENOTROPIN, NORDITROPIN |
109 KB |
|
PDF File
|
GROWTH HORMONES - GENOTROPIN & NORDITROPIN
|
GENOTROPIN, NORDITROPIN |
120 KB |
|
PDF File
|
GROWTH HORMONES - GENOTROPIN & NORDITROPIN
|
GENOTROPIN, NORDITROPIN |
109 KB |
|
PDF File
|
GROWTH HORMONES - OTHER PRODUCTS
|
HUMATROPE, NUTROPIN AQ, OMNITROPE, SAIZEN |
109 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) |
67 KB |
|
PDF File
|
ILUMYA
|
tildrakizumab (ILUMYA) |
50 KB |
|
PDF File
|
INCRELEX
|
mecasermin (INCRELEX) |
60 KB |
|
PDF File
|
INGREZZA
|
valbenazine (INGREZZA) |
58 KB |
|
PDF File
|
INHALED ANTIBIOTICS
|
BETHKIS, CAYSTON, KITABIS, tobramycin (TOBI, TOBI PODHALER) |
58 KB |
|
PDF File
|
KALYDECO
|
ivacaftor (KALYDECO) |
69 KB |
|
PDF File
|
KETOROLAC (INJECTION / NASAL)
|
ketorolac (TORADOL equiv) injection, ketorolac nasal spray |
73 KB |
|
PDF File
|
KETOROLAC (ORAL)
|
oral ketorolac (TORADOL equiv) |
73 KB |
|
PDF File
|
KEVEYIS
|
dichlorphenamide (KEVEYIS) |
50 KB |
|
PDF File
|
KEVZARA
|
sarilumab (KEVZARA) |
58 KB |
|
PDF File
|
KINERET
|
anakinra (KINERET) |
57 KB |
|
PDF File
|
LAZANDA & SUBSYS
|
fentanyl (LAZANDA / SUBSYS) |
61 KB |
|
PDF File
|
LIDODERM
|
lidocaine patch (LIDODERM) |
55 KB |
|
PDF File
|
LINZESS
|
linaclotide (LINZESS) |
86 KB |
|
PDF File
|
LOTRONEX
|
alosetron (LOTRONEX) |
52 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
|
hydroxyprogesterone caproate injection (MAKENA) |
44 KB |
|
PDF File
|
MAKENA
|
hydroxyprogesterone caproate injection (MAKENA) |
44 KB |
|
PDF File
|
MOVANTIK / SYMPROIC
|
naloxegol (MOVANTIK), naldemedine (SYMPROIC) |
61 KB |
|
PDF File
|
NUPLAZID
|
pimavanserin (NUPLAZID) |
58 KB |
|
PDF File
|
NUVIGIL
|
armodafinil (NUVIGIL) |
59 KB |
|
PDF File
|
OLUMIANT
|
baricitinib (OLUMIANT) |
59 KB |
|
PDF File
|
OPIOID OVERUTILIZATION
|
ACETAMINOPHEN/CODEINE, AVINZA, BELBUCA, BELLA/OPIUM, BUPRENORPHINE, BUTORPHANOL, BUTRANS, CAPITAL/CODEINE, CODEINE SULFATE, DEMEROL, DILAUDID, DOLOPHINE, EMBEDA, ENDOCET, EXALGO, FIORICET, HYCET, HYDROCO/ACETAMINOPHEN, HYDROCOD/IBUPROFEN, HYDROMORPHONE, HYSINGLA ER, IBUDONE, KADIAN, LEVORPHANOL, LORCET, LORTAB, MEPERIDINE, METHADONE, MORPHABOND, MORPHINE SULFATE, MS CONTIN,
NALBUPHINE, NALOCET, NORCO, NUCYNTA (ER), OPANA (ER), OPIUM, XYCOD/ACETAMINOPHEN, OXYCOD/ASA, OXYCOD/IBUPROFEN, OXYCODONE, OXYMORPHONE, PENTAZ/NALOXONE, PERCOCET, REPREXAIN, ROXICET, ROXICODONE, TRAMADOL HCL, TYLENOL/CODEINE, ULTRACET, ULTRAM, VICODIN, VICOPROFEN, XARTEMIS XR, XODOL |
25 KB |
|
PDF File
|
ORALAIR
|
Grass Pollen Allergen Extract (ORALAIR) |
51 KB |
|
PDF File
|
ORENCIA
|
abatacept (ORENCIA) |
57 KB |
|
PDF File
|
ORILISSA
|
elagolix (ORILISSA) |
64 KB |
|
PDF File
|
ORKAMBI
|
lumacaftor / ivacaftor (ORKAMBI) |
52 KB |
|
PDF File
|
OTEZLA
|
apremilast (OTEZLA) |
60 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) |
149 KB |
|
PDF File
|
PHOSPHATE BINDERS
|
AURYXIA, calcium acetate (PHOSLYRA), lanthanum (FOSRENOL), VELPHORO |
52 KB |
|
PDF File
|
PROMETHAZINE & PROMETHAZINE CONTAINING PRODUCTS
|
PHENADOZ, PHENERGAN, PROMETHAZINE, PROMETHAZINE VC SYRUP, PROMETHAZINE VC-CODEINE SYRUP, PROMETHAZINE-CODEINE SYRUP, PROMETHAZINE-DM SYRUP, PROMETHEGAN |
54 KB |
|
PDF File
|
PROPYLTHIOURACIL
|
propylthiouracil |
18 KB |
|
PDF File
|
PROTOPIC 0.1%
|
tacrolimus (PROTOPIC) 0.1% |
55 KB |
|
PDF File
|
PROVIGIL
|
modafinil (PROVIGIL) |
59 KB |
|
PDF File
|
RANEXA
|
ranolazine (RANEXA) |
93 KB |
|
PDF File
|
RELISTOR
|
methylnaltrexone (RELISTOR) |
54 KB |
|
PDF File
|
REVATIO & ADCIRCA
|
sildenafil (REVATIO), tadalafil (ADCIRCA) |
53 KB |
|
PDF File
|
SAVELLA
|
milnacipran (SAVELLA) |
59 KB |
|
PDF File
|
SEDATIVES / HYPNOTICS - ADULTS
|
AMBIEN, AMBIEN CR, BELSOMRA, EDLUAR, ESTAZOLAM, ESZOPICLONE, INTERMEZZO, LUNESTA, RESTORIL, SONATA, TEMAZEPAM, TRIAZOLAM, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER |
64 KB |
|
PDF File
|
SEDATIVES / HYPNOTICS - BUTABARBITAL
|
butabarbital (BUTISOL) |
64 KB |
|
PDF File
|
SEDATIVES / HYPNOTICS - FLURAZEPAM
|
flurazepam |
63 KB |
|
PDF File
|
SEDATIVES / HYPNOTICS - ROZEREM
|
ramelteon (ROZEREM) |
63 KB |
|
PDF File
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SGLT2 INHIBITOR COMBINATION AGENTS
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INVOKAMET (XR), SEGLUROMET, SYNJARDY (XR), XIGDUO XR |
59 KB |
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SGLT2 INHIBITOR SINGLE AGENTS
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FARXIGA, INVOKANA, JARDIANCE, STEGLATRO |
59 KB |
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SILIQ
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brodalumab (SILIQ) |
56 KB |
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SIMPONI
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golimumab (SIMPONI) |
58 KB |
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STELARA
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ustekinumab (STELARA) |
60 KB |
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STEP THERAPY Non-Preferred Drug (NPD or NAP)
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23 KB |
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SYMDEKO
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tezacaftor/ivacaftor and ivacaftor (SYMDEKO) |
68 KB |
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SYMLIN
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pramlintide (SYMLIN) |
95 KB |
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TALTZ
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ixekizumab (TALTZ) |
56 KB |
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TEXAS STANDARD PRIOR AUTHORIZATION REQUEST FORM
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PRESCRIPTION DRUG BENEFITS |
233 KB |
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TOPICAL ACNE AGENTS
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BENZACLIN GEL, BENZACLIN PUMP GEL, ERYTHROMYCIN-BENZOYL GEL, CLINDAMYCIN-BENZOYL PEROXIDE GEL 1.2-5%, CLINDAMYCIN-BENZOYL PEROXIDE GEL, DUAC 1.2-5% GEL |
24 KB |
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TOPICAL RETINOIDS
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ADAPALENE, ADAPALENE-BENZYL PEROXIDE, ATRALIN, AVITA, CLINDAMYCIN-TRETINOIN, DIFFERIN, EPIDUO, EPIDUO FORTE, FABIOR, RETIN-A MICRO GEL, TAZAROTENE, TAZORAC, TRETINOIN, TRETINOIN GEL MICRO, ZIANA |
24 KB |
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TREMFYA
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guselkumab (TREMFYA) |
53 KB |
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TRULANCE
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plecanatide (TRULANCE) |
56 KB |
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TYVASO STARTER KIT - CHIP PLANS ONLY
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treprostinil (TYVASO STARTER KIT) |
16 KB |
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UREA CYCLE DISORDER AGENTS
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CARBAGLU, RAVICTI, sodium phenylbutyrate (BUPHENYL) |
24 KB |
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VIBERZI
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eluxadoline (VIBERZI) |
54 KB |
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XELJANZ / XELJANZ XR
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tofacitinib citrate (XELJANZ / XELJANZ XR) |
61 KB |
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XENICAL
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orlistat (XENICAL) |
44 KB |
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XIFAXAN 200 MG
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rifaximin 200mg (XIFAXAN 200mg) |
57 KB |
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XIFAXAN 550 MG
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rifaximin 550mg (XIFAXAN 550mg) |
60 KB |
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XYREM
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sodium oxybate (XYREM) |
54 KB |
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ZELBORAF
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vemurafenib (ZELBORAF) |
22 KB |
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ZYCLARA
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imiquimod 3.75 % cream (ZYCLARA) |
45 KB |
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ZYFLO
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zileuton (ZYFLO) |
55 KB |