Select Language
Español
English
×

Drug Formulary

Avoid High Medication Costs

Ask your doctor to choose a drug from this covered list.

Drug Formulary Alphabetical (pdf)
Special 90-Day Drug Formulary (pdf)

 

$5

 30-day supply of generic drugs

$12

 90-day supply of certain generic drugs*

$15

 30-day supply of brand-name drugs that are not available generically

*90-day formulations and dosages may vary and are at the discretion of the pharmacy.

Search the Formulary

Search Tips
Search on terms that appear in any column. Examples: “diabetes generic”, “cardio 90 day” or “cholestyramine”.
To sort by multiple columns, sort the first column then hold the shift key as you sort the second column.

Drug NameTrade NameBrand NameSupplyCategoryAgent ClassKeywords
30 days
30 days
abiraterone (tabs)ZYTIGAGeneric30 days
acarbosePRECOSEGeneric30 days or 90 daysEndocrine/DiabetesNon-Insulin Hypoglycemic Agents
acebutololSECTRALGeneric30 daysCardiovascular, Hypertension and LipidsBeta Blockersheart
acetaminophen/butalbital/caffeineGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychHeadache Therapy
acetaminophen/codeineTYLENOL #3, TYLENOL #4Generic30 daysAutonomic and CNS Drugs;Neurology and PsychCombination Narcotic;Analgesics
acetaminophen/hydrocodoneVICODIN, LORTAB, LORCET, LORTAB, NORCOGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychCombination Narcotic;Analgesics
acetaminophen/oxycodonePERCOCET, ENDOCETGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychCombination Narcotic;Analgesics
acetazolamideDIAMOXGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychAnticonvulsants;Oral Drugs for Glaucoma
acetic acid/HC oticACETASOL HCGeneric30 daysEar, Nose and Throat MedicationsMiscellaneous Otic Preparations
acyclovir 200mg caps, 400mgZOVIRAXGeneric30 days or 90 daysAnti-InfectivesMiscellaneous Antiviralsinfection; virus
acyclovir 800mgZOVIRAXGeneric30 daysAnti-InfectivesMiscellaneous Antiviralsinfection; virus
acyclovir (susp.)ZOVIRAXGeneric30 daysAnti-InfectivesMiscellaneous Antiviralsinfection; virus
acyclovir oint 5% (Limit: 15gm)ZOVIRAXGeneric30 days
adapalene w/benzoyl peroxide 0.1% or 0.3% w 2.5% (gel)EPIDUO AND EPIDUO FORTEGeneric30 days
adapelene gel 0.3%DIFFERINGeneric30 days
ADVAIR (Diskus, HFA) [Prior Authorization Required]ADVAIR DISKUS, ADVAIR HFABrand Name30 daysRespiratory, Allergy, Cough and ColdMiscellaneous Pulmonary Agents
AEROCHAMBER or equivalent (spacer)Brand Name30 daysRespiratory, Allergy, Cough and ColdMiscellaneous Agents
albendazole 200mg (tab) (Limit: 4 tabs)ALBENZAGeneric30 days
albuterol (inhaler, inhalation solution)PROVENTILGeneric30 daysRespiratory, Allergy, Cough and ColdInhaled Beta Agonists;Beta Agonists Oral
albuterol (nebul. Sol, syrup, tablet)PROVENTILGeneric30 daysRespiratory, Allergy, Cough and ColdInhaled Beta Agonists;Beta Agonists OralAsthma
alendronateFOSAMAXGeneric30 days or 90 daysMusculoskeletal and RheumatologyOsteoporosis Therapy;Miscellaneous Agents
alfuzosin (tabs)UROXATRALGeneric30 days or 90 days
allopurinol (tab)ZYLOPRIMGeneric30 days or 90 daysMusculoskeletal and RheumatologyGout Therapy
alogliptin various (tabs)NESINAGeneric30 days
alogliptin w/ pioglitazone (tabs)Generic30 days
alogliptin w/metformin (tabs)Generic30 days
ALPHAGAN 0.1% 0.15% (OPHTH SOLN) (Limit: Step Up from Generic)Brand Name30 days
ALPHAGAN-P [Prior Authorization Required]Brand Name30 daysOphthalmologyMiscellaneous Opthalmologics
alprazolamXANAX, NIRAVAM, XANAX, XANAX XRGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychAnxiolyticsAnxiety, Panic Disorders
Alprazoplam ER (tabs)XANAX XRGeneric30 days
ALREXBrand Name30 daysOphthalmologySteroids
amantadineSYMMETRELGeneric30 daysAnti-Infectives;Autonomic and CNS Drugs;Neurology and PsychMiscellaneous Antivirals/Antiparkinsonism Drugs
amilorideMIDAMORGeneric30 daysCardiovascular, Hypertension and LipidsThiazide and Related Diureticsheart
amiloride/hctzGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsThiazide and Related Diureticsheart
amiodarone 200mg (tabs) (Limit: 100mg 400mg limit 30 days)CORDARONE, PACERONEGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsAntiarrhythmic Agentsheart
amitriptylineELAVILGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychTricyclic Antidepressant Agents
amlodipineNORVASCGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsCalcium Channel Blockers (Dihydropyridines)
amlodipine w olmesartan various (tabs)AZORGeneric30 days or 90 days
amlodipine w/benazepril (cap)LOTRELGeneric30 days or 90 days
amoxicillin/clavunate (All dosage forms except XR)AUGMENTINGeneric30 daysAnti-InfectivesPenicillinsinfection
amphetamine saltsADDERALLGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychMiscellaneous Psychotherapeutic AgentsADHD
amphetamine salts combo-XR (cap)ADDERALL-XRGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychMiscellaneous Psychotherapeutic Agents
ampicillinPRINCIPENGeneric30 daysAnti-InfectivesPenicillinsinfection
anagrelide (caps)AGRYLINGeneric30 days or 90 days
anastrozoleARIMIDEXGeneric30 days or 90 daysAntineoplastic and Immunosuppressant DrugsAntiestrogens
ANORO (inhalation powder)ANORO ELLIPTABrand Name30 daysRespiratory, Allergy, Cough and ColdMiscellaneous Pulmonary AgentsCOPD
apraclonidine ophth.IOPIDINEGeneric30 daysOphthalmologySympathomimetics
Apri (tabs)Generic30 days or 90 days
ARANESP (Injectable)Brand Name30 days
aripiprazole (tab)ABILIFYGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychMiscellaneous Antipsychotics
ARNUITYARNUITYBrand Name30 days
Ascensia Contour Next EZBrand Name30 daysDiabetes Care Supplies
Ascensia Contour Next OneBrand Name30 daysDiabetes Care Supplies
ASMANEXBrand Name30 daysRespiratory, Allergy, Cough and ColdInhaled Corticosteroids
atenololTENORMINGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsBeta BlockersHeart, Angina, Hypertension
atenolol/chlorthalidoneTENORETICGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsBeta Blockers and Thiazide and Related Diureticsheart
atomoxetine (caps)STRATTERAGeneric30 days
atorvastatin (tab)LIPITORGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsLipid/Cholesterol Lowering Agentsheart, cholesterol
atovaquone 750mg/5ml (Suspension)MEPRONGeneric30 days
Atovaquone / proguanil 250mg/100mg (tabs)MALARONEGeneric30 days
atropine ophth.Generic30 daysOphthalmologyCycloplegic Mydriatics
ATROVENT HFABrand Name30 daysRespiratory, Allergy, Cough and ColdMiscellaneous Pulmonary Agents
azathioprine 100mgGeneric30 days
azathioprine 50mg (tab)AZASAN, IMURANGeneric30 days or 90 daysAntineoplastic and Immunosuppressant DrugsImmunosuppressant Drugs;Miscellaneous Rheumatological Agents
azelaic acid gel (gel (only))FINACEAGeneric30 days
azithromycin (powder, susp, tab)ZITHROMAX, ZPAKGeneric30 daysAnti-InfectivesMacrolidesinfection
bacitracin (ophth.)Generic30 daysOphthalmologyAntibiotics
bacitracin/neomycin /polymyxin/HC ophth.Generic30 daysOphthalmologySteroid-Antibiotic Combinations
baclofenLIORESAL, GABLOFENGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and RheumatologyMuscle Relaxants and Antispasmodic Agents
balsalazide disodiumGeneric30 daysGastroenterologyMiscellaneous Gastrointestinal Agents
balziva 0.04/0.035mgGeneric30 daysObstetrics and GynecologyOral Contraceptives and Related agents
BAQSIMI 3mg (Nasal Spray) (Limit: 2 units)Brand Name30 days
benazeprilLOTENSINGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsACE Inhibitorsheart
benzonatateTESSALONGeneric30 daysRespiratory, Allergy, Cough and ColdAntitussives
benzoyl peroxide (gel, liq)Generic30 daysDermatologicals/Topical TherapyTherapy for AcneSkin
benzoyl peroxide w/ erythromycin (gel)BENZAMYCIN, BENZAMYCIN PAKGeneric30 daysDermatologicals/Topical TherapyTherapy for AcneSkin
benztropineCOGENTINGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychAntiparkinsonism Drugs
betamethasone (augmented) (crm, oint)Generic30 daysDermatologicals/Topical TherapyTopical CorticosteroidsSkin
betamethasone (crm, oint)Generic30 daysDermatologicals/Topical TherapyTopical CorticosteroidsSkin
betamethasone (lotion)Generic30 days
betamethasone/clotrimazole (crm, oint)LOTRISONEGeneric30 daysDermatologicals/Topical TherapyTopical AntifungalsSkin
bethanecholURECHOLINEGeneric30 daysUrologicalsCholinergic Stimulants
BETIMOLBrand Name30 daysOphthalmologyBeta Blockers
bicalutamide (tabs)CASODEXGeneric30 days
bimatoprost Topical 0.03% (Solution)Generic30 days or 90 days
bisoprololZEBETAGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsBeta Blockersheart
bisoprolol/hctzZIACGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsOther Antihypertensive Combinationsheart
BLEPHAMIDEBrand Name30 daysOphthalmologySteroid-Sulfonamide Combinations
BREOBREOBrand Name30 days
BRILINTA (tab) [Prior Authorization Required]Brand Name30 days
brimonidine (Ophth Only)ALPHAGAN PGeneric30 days or 90 daysOphthalmologySympathomimetics
Brimonidine/Timolol Ophth Soln 0.2/0.5% (Drops)COMBIGANGeneric30 days or 90 days
brinzolamide ophth susp (drops)AZOPTGeneric30 days or 90 days
bromfed DM (liq)Generic30 days
bromocriptinePARLODELGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychAntiparkinsonism Drugs
budesonide (nebul sol)PULMICORT, RHINOCORT, ENTOCORT ECGeneric30 daysRespiratory, Allergy, Cough and ColdInhaled CorticosteroidsAllergies
budesonide (tabs or caps)ENTOCORT - UCERISGeneric30 days
budesonide/fumoterol inhaler (MDI)SYMBICORTGeneric30 days
bumetanideBUMEXGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsThiazide and Related Diureticsheart
buprenorphine w/naloxone (film)SUBOXONEGeneric30 days
bupropionWELLBUTRINGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychMiscellaneous Antidepressants
bupropion-SRWELLBUTRIN-SRGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and Psych;Diagnostics and Miscellaneous AgentsMiscellaneous Antidepressants
bupropion-XLWELLBUTRIN-XLGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychMiscellaneous Antidepressants
buspironeBUSPARGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychAnxiolytics
cabergolineDOSTINEXGeneric30 daysEndocrine/DiabetesMiscellaneous Agents
calcipotriene (crm, ointm, soln)CALCITRENE, DOVONEX, SORILUXGeneric30 daysDermatologicals/Topical TherapyAntipsoriatic;AntiseborrheicSkin
calcitonin sprayMIACALCIN, FORTICALGeneric30 daysEndocrine/DiabetesMiscellaneous Agents;Osteoporosis Therapy
calcitriol (caps)ROCALTROLGeneric30 days or 90 days
calcium acetatePHOSLO, ELIPHOS, PHOSLYRAGeneric30 daysVitamins, Hematinics and ElectrolytesOther Electrolytes
camila 0.35mgERRIN, JOLIVETTE, LYZA, NOR-QD, NORA-BE, ORTHO MICRONORGeneric30 days or 90 daysObstetrics and GynecologyOral Contraceptives and Related agentsnor-q-d, errin, jolivette, heather
capecitabine (tab)XELODAGeneric30 days
captoprilCAPOTENGeneric30 daysCardiovascular, Hypertension and LipidsACE Inhibitorsheart
captopril/hctzCAPOZIDEGeneric30 daysCardiovascular, Hypertension and LipidsOther Antihypertensive Combinationsheart
carbamazepineTEGRETOLGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychAnticonvulsants
carbamazepine-srTEGRETOL-XRGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychAnticonvulsants
carbidopa/levodopaSINEMET, PARCOPAGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychAntiparkinsonism Drugs
carbidopa/levodopa ODT (OD tabs)SINEMETGeneric30 days or 90 days
carbidopa/levodopa-srSINEMET-CRGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychAntiparkinsonism Drugs
carisoprodolSOMAGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychMuscle Relaxants and Antispasmodic AgentsMuscle Injuries
carisoprodol/aspirinSOMA COMPOUNDGeneric30 daysAutonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and RheumatologyMuscle Relaxants and Antispasmodic Agents
carteolol ophthalmicOCUPRESSGeneric30 daysOphthalmologyBeta Blockers
carvedilol (tablet)COREGGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsBeta BlockersHeart, Hypertension, Heart Failure
cefaclorCECLOR, RANICLORGeneric30 daysAnti-InfectivesCephalosporins, Second Generationinfection
cefadroxilDURICEFGeneric30 daysAnti-InfectivesCephalosporins, First Generationinfection
cefdinirOMNICEFGeneric30 daysAnti-InfectivesAntibioticsinfection,
cefpodoximeVANTINGeneric30 daysAnti-InfectivesCephalosporins, Third Generationinfection
cefuroximeCEFTIN, KEFUROX, ZINACEFGeneric30 daysAnti-InfectivesCephalosporins, Second Generationinfection
celecoxibCELEBREXGeneric30 daysAutonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and RheumatologyNSAIDS-specific COX II Inhibitors
cephalexinKEFLEXGeneric30 daysAnti-InfectivesCephalosporins, First Generationinfection
CEQUA 0.09% (OPHTH SOLN)Brand Name30 days
cevimeline (caps)EVOXACGeneric30 days
CHANTIXBrand Name30 daysDiagnostics and Miscellaneous AgentsSmoking Deterrents
chlorhexidine gluconatePERIDEXGeneric30 daysEar, Nose and Throat MedicationsMiscellaneous Agents
chloroquineARALEN PHOSPHATEGeneric30 daysAnti-InfectivesAntimalarialsinfection
chlorpromazineTHORAZINEGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychPhenothiazines
chlorthalidoneTHALITONE, HYGROTONGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsThiazide and Related Diureticsheart
cholestyramineQUESTRAN, PREVALITEGeneric30 daysCardiovascular, Hypertension and LipidsLipid/Cholesterol Lowering Agentsheart
cholestyramine liteQUESTRAN LIGHTGeneric30 daysCardiovascular, Hypertension and LipidsLipid/Cholesterol Lowering Agentsheart
ciclopirox (crm, gel, lotion, shampoo)PENLAC, LOPROXGeneric30 daysDermatologicals/Topical TherapyTopical AntifungalsSkin
cilostazol (tab)PLETALGeneric30 days or 90 days
cinacalcet (tabs)SENSIPARGeneric30 days or 90 days
Ciproflox/Dexameth Otic Susp. (Drops)CIPRODEXGeneric30 days
ciprofloxacinCIPRO, CIPRO XR, PROQUIN XR, CIPRO I.V., CIPRO CYSTITIS PACKGeneric30 daysAnti-InfectivesFluoroquinolones;Antibioticsinfection
citalopram 20, 40mgCELEXAGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychSelective Serotonin Reuptake Inhibitors (SSRIs)Depression
clarithromycin (susp, tab)BIAXINGeneric30 daysAnti-InfectivesMacrolidesinfection
CLEOCIN 100mg (vaginal suppos.)Brand Name30 daysObstetrics and GynecologyAntibiotics
clindamycin (cap, crm, gel, lotn, soln, pledgets)CLEOCINGeneric30 daysAnti-InfectivesMiscellaneous Anti-Infectives;Therapy for Acneinfection
clindamycin w/benzoyl peroxide gel 1-5%BENZACLINGeneric30 days
clobazam (tabs and liquid)ONFIGeneric30 days
clobetasol (crm, gel, oint, topical soln, E, foam, shampoo)CLOBEVATE, CLOBEX, CORMAX, EMBELINE, OLUX, TEMOVATEGeneric30 daysDermatologicals/Topical TherapyTopical CorticosteroidsSkin
clomipheneCLOMIDGeneric30 daysObstetrics and GynecologyOvulatory Stimulants;Drugs to Treat Infertility;IVF Agents
clomipramineANAFRANILGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychTricyclic Antidepressant Agents
clonazepam various (ODT tabs)Generic30 days
clonazepam various (tabs, ODT)KLONOPINGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychAnticonvulsantsSeizure, Panic Attack
clonidine (patch)CATAPRESGeneric30 daysCardiovascular, Hypertension and LipidsAdrenergic Antagonists and Related DrugsHeart, Hypertension
clonidine (tab)CATAPRESGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsAdrenergic Antagonists and Related DrugsHeart, Hypertension
clopidogrel 75mg (tab)PLAVIXGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsAntiplateletheart
clotrimazoleLOTRIMINE, DESENEXGeneric30 daysDermatologicals/Topical TherapyAntifungal AgentsSkin
colchicine 0.6mg (tab) (Limit: 1st fill - 30d ONLY)Generic30 days or 90 days
colestipolCOLESTIDGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsLipid/Cholesterol Lowering Agentsheart
COMBIPATCH 0.05, 0.14Brand Name30 daysObstetrics and GynecologyEstrogen Combinations
COMBIVENTCOMBIVENT, DUONEBBrand Name30 daysRespiratory, Allergy, Cough and ColdMiscellaneous Pulmonary Agents
CREONBrand Name30 daysGastroenterologyDigestive Enzymes
CRINONE (gel)CRINONE, PROMETRIUM, ENDOMETRINBrand Name30 daysObstetrics and GynecologyProgestins
cromolyn (nebul soln)INTALGeneric30 daysRespiratory, Allergy, Cough and ColdMiscellaneous Pulmonary Agents
cromolyn 4% (Opth drops)Generic30 days
cyclobenzaprineFLEXERILGeneric30 days or 90 daysMusculoskeletal and RheumatologyMuscle Relaxants and Antispasmodic AgentsMuscle Pain, Spasms
cyclopentolate ophth.AK-PENTOLATE, CYCLOGYL, CYLATE, OCU-PENTOLATE, PENTOLAIRGeneric30 daysOphthalmologyCycloplegic Mydriatics
cyclosporine (cap)NEORAL, GENGRAF, SANDIMMUNEGeneric30 daysAntineoplastic and Immunosuppressant DrugsImmunosuppressant Drugs
cyclosporine ophth emulsion 0.05% (drops) (Limit: restricted to ophthamology/Optometry)RESTASISGeneric30 days
cyproheptadinePERIACTINGeneric30 daysRespiratory, Allergy, Cough and ColdAntihistamines
danazolDANOCRINEGeneric30 daysEndocrine/DiabetesAndrogens
dapsone gel (Limit: failed erythro & clinda)Generic30 days
Daysee (tabs)SEASONIQUEGeneric30 days or 90 days
dermotic ear (drops)Generic30 days
desipramineNORPRAMINGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychTricyclic Antidepressant Agents
desmopressinDDAVPGeneric30 daysEndocrine/DiabetesMiscellaneous Agents
desonideDESONATEGeneric30 daysDermatologicals/Topical TherapyTopical CorticosteroidsSkin
desoximetasoneTOPICORTGeneric30 daysDermatologicals/Topical TherapyTopical CorticosteroidsSkin
desvenlafaxine (tab)PRISTIQGeneric30 days or 90 days
dexamethasoneDECADRONGeneric30 daysEndocrine/DiabetesCorticosteroids;Adrenal Hormones
Dexcom G6 CGMBrand Name30 days
Dexcom G7 CGMBrand Name30 days
dexmethylphenidate various (tabs, caps)FOCALIN, FOCALIN-XRGeneric30 days
diazepam (tab, gel)VALIUMGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychAnticonvulsants/Muscle Relaxants and Antispasmodic Agents;Anxiolytics
diclofenac (tab)VOLTAREN, ZORVOLEXGeneric30 daysAutonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and RheumatologyNSAIDS
diclofenac gel 3%Generic30 days
dicloxacillinGeneric30 daysAnti-InfectivesPenicillinsinfection
dicyclomine 10, 20mgBENTYLGeneric30 days or 90 daysGastroenterology;UrologicalsAntispasmodics;Anticholinergics
diflorasoneAPEXICON, MAXIFLOR, PSORCONGeneric30 daysDermatologicals/Topical TherapyTopical CorticosteroidsSkin
diflunisalDOLOBIDGeneric30 daysAutonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and RheumatologyNSAIDS
difluprednate 0.05% (Ophth Emulsion)DUREZOLGeneric30 days
digoxin (tab)LANOXINGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsCardiac Glycosidesheart
diltiazem 30, 60, 90, 120mg (tab)CARDIZEMGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsCalcium Channel Blockers (Non-Dihydropyridines)
diltiazem-CDCARDIZEM-CDGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsCalcium Channel Blockers (Non-Dihydropyridines)heart
dimethyl fumarate 240mg (caps)TECFIDERAGeneric30 days or 90 days
dipyridamolePERSANTINEGeneric30 daysCardiovascular, Hypertension and LipidsAntiplatelet Drugsheart
disopyramideNORPACEGeneric30 daysCardiovascular, Hypertension and LipidsAntiarrhythmic Agentsheart
divalproex sodiumDEPAKOTEGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychAnticonvulsants
divalproex-ERDEPAKOTE-ERGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychAnticonvulsants
Dofetilide (cap)TYKOSINGeneric30 days
donepezil (tab)ARICEPTGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychMiscellaneous Neurological Therapy
dorzolamideTRUSOPTGeneric30 days or 90 daysOphthalmologyOther Glaucoma Drugs
dorzolamide/timololCOSOPTGeneric30 days or 90 daysOphthalmologyOther Glaucoma Drugs
doxazosinCARDURAGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsAdrenergic Antagonists and Related Drugs;Benign Prostatic Hyperplasia Therapyheart
doxepin (caps & liquid)SINEQUANGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychTricyclic Antidepressant Agents
doxycycline hyclate & monohydr 50mg + 100mg (tab and cap)DORYX, MONODOX, ORACEAGeneric30 daysAnti-InfectivesTetracyclinesinfection
doxylamine w/ pyridoxine 10mg/10mg (tab)DICLEGISGeneric30 days
dronabinol (caps) (Limit: require diag code)MARINOLGeneric30 days
DULERABrand Name30 daysRespiratory, Allergy, Cough and ColdMiscellaneous Pulmonary Agents
duloxetine 20-30-60mgCYMBALTAGeneric30 days or 90 days
dutasteride 0.5mg (caps)AVODARTGeneric30 days or 90 days
econazole 1% (cream)Generic30 days
eletriptan 20mg and 40mg (pk of 6) (tabs)REPLAXGeneric30 days
Eligard (injectable)Brand Name30 days
ELIQUIS (tab)Brand Name30 days
ELLA 30mg (tab) (Limit: 1 tablet)Brand Name30 days
EMGALITY (injectable)Brand Name30 days
emtricitabine w/tenofovir dp fum various (tab) (Limit: must confirm labs every 90 days)TRUVADAGeneric30 days
enalaprilVASOTECGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsACE Inhibitorsheart
enalapril/hctzVASERETICGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsOther Antihypertensive Combinationsheart
ENBREL PFS/MINI/SURECLICK (injectable)Brand Name30 days
enoxaparin (injectable) (Limit: up to 30 days w/o PA)LOVENOXGeneric30 days
enpresse-28TRIPHASIL-28, TRI-LEVLEN-28Generic30 days or 90 daysObstetrics and GynecologyOral Contraceptives and Related agentstriphasic,trivora-28
Entacapone (tab)COMTANGeneric30 days or 90 days
entecavir (tabs)BARACLUDEGeneric30 days or 90 days
ENTRESTO (tab)Brand Name30 days
epinephrine auto-injectorEPIPENGeneric30 daysRespiratory, Allergy, Cough and ColdAdrenergics
epinephrine auto-injector jr.EPIPEN-JRGeneric30 daysRespiratory, Allergy, Cough and ColdAdrenergics
eplerenone (tabs)INSPRAGeneric30 days or 90 days
erythromycin (topical gel, ophth oint, oral susp) (Limit: no tabs/caps)Generic30 daysAnti-Infectives;Dermatologicals/Topical TherapyMacrolides;Therapy for Acne;AntibioticsSkin
escitalopram (tab)LEXAPROGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychSelective Serotonin Reuptake Inhibitors (SSRIs)
estradiol (crm, patch)CLIMARA, VIVELLE, ESTRACE, ESTRADERM, FEMTRACE, GYNODIOLGeneric30 daysObstetrics and GynecologyOsteoporosis Therapy;Estrogens
estradiol (tab)ESTRACEGeneric30 days or 90 daysObstetrics and GynecologyOsteoporosis Therapy;Estrogens
estradiol 0.1% gel packetsDIVIGELGeneric30 days
estrogen/methyltestosteroneGeneric30 daysObstetrics and GynecologyAndrogens
estropipate 0.75, 1.5mg (tab)OGEN 0.625, OGEN 1.25, OGEN 2.5, ORTHO-ESTGeneric30 daysMusculoskeletal and Rheumatology;Obstetrics and GynecologyOsteoporosis Therapy
ethambutolMYAMBUTOLGeneric30 daysAnti-InfectivesAntimycobacterialsinfection
ethosuximideZARONTINGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychAnticonvulsants
etodolacLODINEGeneric30 daysAutonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and RheumatologyNSAIDS
Etonogestrel/ethinyl estradiolNUVARINGGeneric30 days or 90 days
everolimus (tab)AFINITORGeneric30 days
exemestane 25mg (tabs)AROMASINGeneric30 days
ezetimibeZETIAGeneric30 days or 90 days
famciclovirFAMVIRGeneric30 daysAnti-InfectivesMiscellaneous Antiviralsinfection; virus
famotidine 40mgPEPCIDGeneric30 days or 90 daysGastroenterologyH2 Antagonists
FARXIGA (tabs)Brand Name30 days
febuxostat (tabs)ULORICGeneric30 days or 90 days
fenofibrate (tab)TRICOR, LIPOFEN, FENOGLIDEGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsLipid/Cholesterol Lowering AgentsHeart, Cholesterol
fentanylDURAGESIC, FENTORA, ONSOLISGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychNarcotic Analgesics
finasteride 5mg only (tab)PROSCARGeneric30 days or 90 daysUrologicalsBenign Prostatic Hyperplasia TherapyBenign Prostatic Hyperplasia (BPH)
flecainideTAMBOCORGeneric30 daysCardiovascular, Hypertension and LipidsAntiarrhythmic Agentsheart
FLOVENT (Diskus, HFA)Brand Name30 daysRespiratory, Allergy, Cough and ColdInhaled Corticosteroids
fluconazole (oral suspension, tab)DIFLUCANGeneric30 daysAnti-InfectivesAntifungal Agents;Vaginal Antifungalsinfection
fludrocortisoneFLORINEF ACETATEGeneric30 daysEndocrine/DiabetesAdrenal Hormones
fluocinolone Otic 0.01% (drops)DERMOTICGeneric30 days
fluocinonide 0.05%LIDEXGeneric30 days
fluoride oral supplementsGeneric30 daysVitamins, Hematinics and ElectrolytesVitamins and Hematinics
fluoride oral supplements MVI (chewables, drops)Generic30 days or 90 daysVitamins, Hematinics and ElectrolytesVitamins and Hematinics
fluorometholone (ophth. ointm & susp.)FMLGeneric30 daysOphthalmologySteroids
fluorouracil (crm, top. soln)Generic30 daysDermatologicals/Topical TherapyMiscellaneous DermatologicalsSkin
fluoxetine (caps, oral susp)PROZACGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychSelective Serotonin Reuptake Inhibitors (SSRIs)Depression
fluphenazineGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychPhenothiazines
flurbiprofenANSAIDGeneric30 daysMusculoskeletal and RheumatologyNSAIDS
fluticasone (inhaler, cream, ointment) FLOVENT, CUTIVATEGeneric30 daysDermatologicals/Topical Therapy;Ear, Nose and Throat Medications;Respiratory, Allergy, Cough and ColdIntranasal SteroidsRhinitis, Skin
fluticasone w-salmeterol various (Diskus & HFA)ADVAIRGeneric30 days
fluvoxamineLUVOXGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychSelective Serotonin Reuptake Inhibitors (SSRIs)
folic acid 1mgFA-8, FOLACIN-800Generic30 days or 90 daysVitamins, Hematinics and ElectrolytesVitamins and Hematinics
Fosfomycin 3gm (packet) (Limit: 1 packet)MONUROLGeneric30 days
Freestyle Libre 2Brand Name30 days
Freestyle Libre 3Brand Name30 days
furosemideLASIX, LASIX, DIAQUA-2, LO-AQUAGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsThiazide and Related DiureticsHeart, Hypertension
gabapentinNEURONTINGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychAnticonvulsantsSeizures
ganciclovirGeneric30 daysAnti-InfectivesMiscellaneous Antiviralsinfection; virus
gemfibrozilLOPIDGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsLipid/Cholesterol Lowering Agentsheart, cholesterol
Gemtesa 75mg (tabs)Brand Name30 days
gentamicin (crm, ophth, oint, soln)GENTAK, GARAMYCINGeneric30 daysAnti-Infectives;Dermatologicals/Topical Therapy;OphthalmologyAntibioticsEyes, Skin
glimepirideAMARYLGeneric30 days or 90 daysEndocrine/DiabetesNon-Insulin Hypoglycemic Agents
glipizideGLIPIZIDEGeneric30 days or 90 daysEndocrine/DiabetesNon-Insulin Hypoglycemic Agents
glipizide-XLGLUCOTROL-XLGeneric30 days or 90 daysEndocrine/DiabetesNon-Insulin Hypoglycemic Agents
GLUCAGON KITGeneric30 daysEndocrine/DiabetesGlucose Elevating Agents
glyburideGeneric30 days or 90 daysEndocrine/DiabetesNon-Insulin Hypoglycemic Agents
glyburide micronizedGeneric30 days or 90 daysEndocrine/DiabetesNon-Insulin Hypoglycemic Agents
glycopyrrolate (tab)ROBINUL, ROBINUL HPGeneric30 days
GOLYTELY (powder)Brand Name30 days
griseofulvin v (susp, tab)GRIFULVINGeneric30 daysAnti-InfectivesAntifungal Agentsinfection
guaifenesin/codeineGeneric30 daysRespiratory, Allergy, Cough and ColdAntitussive Combinations
guanfacine (tab)TENEXGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and Psych;Cardiovascular, Hypertension and LipidsMiscellaneous Psychotherapeutic Agents;Adrenergic Antagonists and Related Drugsblood pressure; ADHD; hypertension
Guanfacine ER (tabs)INTUNIV ERGeneric30 days
H.Pylori 14-day Triple Therapy Amox/Clarithomycin/LansoprazoleGeneric30 daysGastroenterologyOther Ulcer Therapy
HADLIMA various (injectable)Brand Name30 days
haloperidol (tab)HALDOLGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychPhenothiazines
heparinGeneric30 daysVitamins, Hematinics and ElectrolytesAnticoagulants - Heparin
homatropineGeneric30 daysOphthalmologyCycloplegic Mydriatics
homatropine/hydrocodone (syr)TUSSIGONGeneric30 daysRespiratory, Allergy, Cough and ColdAntitussive Combinations
hydralazineAPRESOLINEGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsVasodilatorsheart
hydrochlorothiazideHYDRODIURILGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsThiazide and Related DiureticsHeart, Hypertension
hydrocortisone 2.5% (lotion)Generic30 days
hydrocortisone (tab, suppository)Generic30 daysDermatologicals/Topical Therapy;Respiratory, Allergy, Cough and ColdTopical Corticosteroids;Antipsoriatic;Antiseborrheic;Miscellaneous Gastrointestinal AgentsSkin
hydrocortisone/iodoquinol 1%-1% (cream)DERMAZENEGeneric30 daysDermatologicals/Topical TherapyMiscellaneous DermatologicalsSkin
hydrocortisone/pramoxineANALPRAM, HC PRAMOXINE, NOVACORT, PRAMOSONE, PROCTOFOAM HC, RECTOCORT HC, PRAMCORTGeneric30 daysDermatologicals/Topical TherapyMiscellaneous Gastrointestinal AgentsSkin
hydromorphoneDILAUDIDGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychNarcotics
hydroquinone (crm)Generic30 daysDermatologicals/Topical TherapyMiscellaneous DermatologicalsSkin
hydroxychloroquinePLAQUENILGeneric30 days or 90 daysAnti-InfectivesAntimalarials;Miscellaneous Rheumatological Agentsinfection
hydroxyurea (cap)DROXIAGeneric30 days
hydroxyzineATARAX, VISTARIL, HYZINEGeneric30 daysRespiratory, Allergy, Cough and ColdAntihistamines
hyoscyamine (tabs and sl tabs)Generic30 daysGastroenterologyAnticholinergics and Antispasmodics
hyoscyamine-erGeneric30 daysGastroenterologyAnticholinergics and Antispasmodics
ibandronate 150mg (tabs)BONIVAGeneric30 days or 90 days
ibuprofen 400mg, 600mg, 800mg (tab)MOTRINGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychNSAIDSInflammation
icosapent ethyl 1 gram (caps)VASCEPAGeneric30 days or 90 days
imatinib (tabs) (Limit: 30 only on first fill)GLEEVACGeneric30 days or 90 days
imipramineTOFRANILGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychTricyclic Antidepressant Agents
imiquimod (Limit: 12 packets/30 days)ALDARA, ZYCLARAGeneric30 daysDermatologicals/Topical TherapyMiscellaneous DermatologicalsSkin Growths
INCRUSE Ellipta (inhalation powder)INCRUSEBrand Name30 daysRespiratory, Allergy, Cough and ColdMiscellaneous Pulmonary AgentsCOPD
indapamideLOZOLGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsThiazide and Related Diureticsheart
indomethacin, indomethacin-er 25mg, 50mg, 75mgINDOCINGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychNSAIDS
insulin degludec (Flextouch pen)TRESIBAGeneric30 days
Insulin lispro (injectable)HUMALOGGeneric30 days
ipratropium (neb. sol)ATROVENTGeneric30 daysRespiratory, Allergy, Cough and ColdMiscellaneous Pulmonary Agents
ipratropium w/ albuterol (nebulizer solution)DUONEBGeneric30 days
irbesartan (tabs)AVAPROGeneric30 days or 90 days
irbesartan w/hctz (tabs)AVALIDEGeneric30 days or 90 days
isoniazidNYDRAZIDGeneric30 daysAnti-InfectivesAntimycobacterialsinfection
isosorbide dinitrateDILATRATE-SRGeneric30 daysCardiovascular, Hypertension and LipidsLong Acting Nitratesheart
isosorbide mononitrate 30mg, 60mg, 120mgIMDURGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsLong Acting Nitratesheart
isotretinoin (caps) (Limit: Dermatologist only)Generic30 days
itraconazole 100mg (caps)SPORANOXGeneric30 days
ivermectin 1% (Cream)SOOLANTRAGeneric30 days
Jaimiess (tabs)SEASONIQUEGeneric30 days or 90 days
JANUMETBrand Name30 daysEndocrine/DiabetesNon-Insulin Hypoglycemic Agents
JANUMET-XRBrand Name30 daysEndocrine/DiabetesNon-Insulin Hypoglycemic Agents
JANUVIABrand Name30 daysEndocrine/DiabetesNon-Insulin Hypoglycemic Agents
JARDIANCE (tabs)Brand Name30 days
jinteli 1/0.005mgGeneric30 daysObstetrics and GynecologyOral Contraceptives and Related agents
jolivette 0.35mgORTHO-MICRONOR,
AYGESTIN, CAMILA, ERRI, NOR-QD, NORA-BE, ORTHO MICRONOR		Generic30 days or 90 daysObstetrics and GynecologyOral Contraceptives and Related agentsortho-micronor, nor-q-d, errin, camila, heather
junel 1/0.02mg or 1.5/.03mgLOESTRINGeneric30 days or 90 daysObstetrics and GynecologyOral Contraceptives and Related agents
junel-fe 1/0.02mg or 1.5/0.03mgLOESTRIN-FEGeneric30 days or 90 daysObstetrics and GynecologyOral Contraceptives and Related agents
Junel-FE 24 (tabs)Generic30 days or 90 days
karivaMIRCETTE, APRI, AZURETTE, CAZIANT, CESIA, CYCLESSA, DESOGEN, EMOQUETTE, KARIVA, MIRCETTE, ORTHO-CEPT, RECLIPSEN, SOLIA, VELIVET, VIORELEGeneric30 days or 90 daysObstetrics and GynecologyOral Contraceptives and Related agents
kelnor 1/0.035mgDEMULEN 1/35-28, KELNOR, ZOVIA 1/35, ZOVIA 1/50Generic30 days or 90 daysObstetrics and GynecologyOral Contraceptives and Related agentszovia 1/35
Keralyt 6% (gel, shampoo, kit)Brand Name30 days
ketoconazole 2% (cream)Generic30 days
ketoconazole (shampoo)NIZORALGeneric30 daysAnti-Infectives;Dermatologicals/Topical TherapyAntifungal Agents;Topical AntifungalsSkin
ketoprofenACTRON, ORUDISGeneric30 daysAutonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and RheumatologyNSAIDS
ketorolacTORADOLGeneric30 daysAutonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and Rheumatology;OphthalmologyNSAIDSEyes
labetololGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsBeta Blockersheart
lacosamide various (tabs, liquid)VIMPATGeneric30 days
lactulose (syrup)Generic30 days or 90 daysGastroenterologyMiscellaneous Gastrointestinal Agents
LAGEVRIO (caps)Brand Name30 days
lamotrigine (ER tabs) (Limit: Not ODT)LAMICTALGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychAnticonvulsantsSeizures
lamotrigine (IR tabs) (Limit: Not ODT)LAMICTALGeneric30 days or 90 days
Lansoprazole (cap) (Limit: 6 months/rx)PREVACIDGeneric30 days or 90 days
LANTUS Insulin 100u/ml MDV Only (injectable)Brand Name30 daysEndocrine/DiabetesInsulin Therapy
latanoprost ophth.XALATANGeneric30 days or 90 daysOphthalmologyOther Glaucoma Drugsglaucoma
leenaTRI-NORINYLGeneric30 daysObstetrics and GynecologyOral Contraceptives and Related agentstriphasic
leflunomide (tab)Generic30 days
Lenalidomide various (caps)REVLIMIDGeneric30 days
letrozoleFEMARAGeneric30 days or 90 daysAntineoplastic and Immunosuppressant DrugsAntiestrogens
leucovorin ca (tabs)Generic30 days
leuprolide injectionGeneric30 daysAntineoplastic and Immunosuppressant Drugs;Obstetrics and GynecologyDrugs to Treat Infertility;IVF Agents
levalbuterol HFA & solution (inhalation)XOPENEXGeneric30 days
levetiracetam (tabs, ER tabs, Liq)KEPPRAGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychAnticonvulsantsSeizures
levobunolol ophth.BETAGANGeneric30 daysOphthalmologyBeta Blockers
levofloxacinLEVAQUINGeneric30 daysAnti-InfectivesFluoroquinolones;Antibioticsinfection
levothyroxine (tablet)Generic30 days or 90 days
levoxylSYNTHROIDBrand Name30 daysEndocrine/DiabetesAntithyroid Agents
lidocaine (crm, gel, ointm, viscous liq)Generic30 daysDermatologicals/Topical TherapyTopical Anesthetics;Miscellaneous AgentsSkin
lidocaine 5% patch (patch)LIDODERM 5% PATCHGeneric30 days
lidocaine/prilocaine (top.)EMLAGeneric30 daysDermatologicals/Topical TherapyTopical AnestheticsSkin
lindaneGeneric30 daysDermatologicals/Topical TherapyTopical Scabicides;PediculicidesSkin
linezolid (tabs)ZYVOXGeneric30 days
liothyronineCYTOMEL, TRIOSTATGeneric30 daysEndocrine/DiabetesThyroid Hormones
lisinoprilPRINIVIL, ZESTRILGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsACE Inhibitors
lisinopril/hctzPRINZIDE, ZESTORETICGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsOther Antihypertensive Combinationsheart
lithium carbonateLITHOBIDGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychMiscellaneous Psychotherapeutic Agentspsychiatry
LOKELMA (pckt)Brand Name30 days
Lo-Loestrin FE (tabs)Brand Name30 days
lorazepamATIVANGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychAnxiolyticsAnxiety
Loryna (tabs)YAZGeneric30 days or 90 days
losartanCOZAARGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsAngiotensin II Receptor Blockers and Renin Inhibitors
losartan/hctzHYZAARGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsAngiotensin II Receptor Blockers and Renin Inhibitorsheart
LOTEMAXBrand Name30 daysOphthalmologySteroids
lovastatinMEVACOR, ALTOCORGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsLipid/Cholesterol Lowering AgentsHeart, High Cholesterol
low-ogestrel 0.3/0.03mgLO/OVRAL-21, CRYSELLE 28, LO/OVRAL-28, LOW-OGESTREL, OGESTREL-28Generic30 days or 90 daysObstetrics and GynecologyOral Contraceptives and Related agentscryselle-28
loxapineLOXITANE, LOXITANE, LOXITANE C, LOXITANE IMGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychMiscellaneous Psychotherapeutic Agentspsychiatry
lubiprostone (gelcap)AMITIZAGeneric30 days
LUMIGAN 0.01% (OPHTH SOLN)Brand Name30 days
lurasidone (tab) (Limit: Psychiatric Providers)LATUDAGeneric30 days or 90 days
medroxyprogesterone (injectable (90-d), tab(30-d))DEPO-PROVERA, PROVERAGeneric30 days or 90 daysObstetrics and GynecologyProgestins
mefloquineLARIAMGeneric30 daysAnti-InfectivesAntimalarialsinfection
megestrol (tab)MEGACEGeneric30 days or 90 daysObstetrics and GynecologyHormones
meloxicamMOBICGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and RheumatologyNSAIDSArthritis
memantine (tab)NAMENDAGeneric30 days or 90 days
mercaptopurine 50mg (tab)Generic30 days
mesalamine (cap)PENTASAGeneric30 days or 90 daysGastroenterologyMiscellaneous Gastrointestinal Agents
mesalamine (supp, rectal suspension)Generic30 days
metformin various (tabs, ER tabs)FORTAMET, GLUCOPHAGE, GLUCOPHAGE XR, GLUMETZA, RIOMETGeneric30 days or 90 daysEndocrine/DiabetesNon-Insulin Hypoglycemic AgentsDiabetes
methazolamideGLAUCTABS, MZM, NEPTAZANEGeneric30 daysOphthalmologyOral Drugs for Glaucoma
Methenemine Hippurate 1 GM (Tabs)HIPREXGeneric30 days
methergine 0.2mg (tabs) (Limit: 12 tabs)Generic30 days
methimazoleNORTHYX, TAPAZOLEGeneric30 days or 90 daysEndocrine/DiabetesAntithyroid Agents
methocarbamolROBAXIN, ROBAXIN-750, CARBACOT, SKELEXGeneric30 daysMusculoskeletal and RheumatologyMuscle Relaxants and Antispasmodic Agents
methotrexate 2.5mg (tab)Generic30 days or 90 daysAntineoplastic and Immunosuppressant Drugs;Musculoskeletal and RheumatologyAntimetabolites;Miscellaneous Rheumatological Agents
methoxsalen 10mg (cap)OXSORALEN ULTRAGeneric30 days
methylphenidate (IR tabs only)RITALIN, METADATE, METHYLINGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychMiscellaneous Psychotherapeutic AgentsADHD
methylphenidate ERCONCERTA, RITALIN LAGeneric30 days
methylprednisoloneMEDROLGeneric30 daysEndocrine/DiabetesAdrenal Hormones
metoclopramide (syr, tab)METOZOLV ODT, REGLANGeneric30 days or 90 daysGastroenterologyMiscellaneous Gastrointestinal Agents
metolazoneZAROXOLYN, MYKROXGeneric30 daysCardiovascular, Hypertension and LipidsThiazide and Related Diureticsheart
metoprololLOPRESSORGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsBeta Blockers
metoprolol/hctzLOPRESSOR HCTGeneric30 daysCardiovascular, Hypertension and LipidsOther Antihypertensive Combinationsheart
metoprolol-xlTOPROL-XLGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsBeta Blockersheart
Metronidazole 1% (Gel)Generic30 days
metronidazole 250mg, 500mg 0.75% (tabs , vag gel, topical)FLAGYL, METROGELGeneric30 daysAnti-Infectives;Dermatologicals/Topical Therapy;Obstetrics and GynecologyAntiparasitics;Therapy for AcneSkin
metronidazole oral susp 500mg/5mlGeneric30 days
mexiletineMEXITILGeneric30 daysOphthalmologyAntiarrhythmic Agents
MicrochamberMICROCHAMBER30 days
microgestin 1/0.02mg or 1.5/0.03mgLOESTRINGeneric30 days or 90 daysObstetrics and GynecologyOral Contraceptives and Related agents
microgestin-fe 1/0.02mg or 1.5/0.03mgLOESTRIN-FEGeneric30 days or 90 daysObstetrics and GynecologyOral Contraceptives and Related agents
midodrine (tabs)PROAMATINEGeneric30 days or 90 days
minocyclineDYNACIN, MINOCIN, MINOCIN PAC, MYRAC, SOLODYN, VECTRINGeneric30 daysAnti-InfectivesTetracyclinesinfection
minoxidilLONITENGeneric30 daysCardiovascular, Hypertension and LipidsVasodilatorsheart
mirabegron (tabs)MYRBETRIQGeneric30 days or 90 days
mirtazapine (tab)REMERONGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychMiscellaneous Antidepressants
misoprostolCYTOTECGeneric30 daysGastroenterology;Obstetrics and GynecologyProstaglandins
modafinil (tabs)PROVIGILGeneric30 days
mometasone (crm, lotion, ointment)ELOCONGeneric30 daysDermatologicals/Topical TherapyTopical CorticosteroidsSkin
montelukast (chew, tab)SINGULAIRGeneric30 days or 90 daysRespiratory, Allergy, Cough and ColdMiscellaneous Pulmonary Agents
morphine (IR or ER Tabs only)MS CONTINGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychNarcotics
MOUNJARO (Diag: T2D Only)Brand Name30 days
Moxifloxacin Opht Drops 0.5% (drops)VIGAMOXGeneric30 days
MULTAQ (TAB) (Limit: Cardiologist Only)Brand Name30 days
mupirocin (ointment only)BACTROBANGeneric30 daysDermatologicals/Topical TherapyTopical AntibacterialsSkin
MYCOBUTINBrand Name30 daysAnti-InfectivesAntimycobacterialsinfection
mycophenolate DR various (Tabs)MYFORTICGeneric30 days
mycophenolate mofetilCELLCEPTGeneric30 daysAntineoplastic and Immunosuppressant DrugsImmunosuppressant Drugs
nabumetoneRELAFENGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychNSAIDS
nadololCORGARDGeneric30 daysCardiovascular, Hypertension and LipidsBeta Blockersheart
naltrexoneREVIAGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychNarcotic Antagonists/Opioid Dependence
naproxenNAPROSYN, ALEVEGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychNSAIDSInflammation
naproxen-ec [Prior Authorization Required]EC-NAPROSYNGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychNSAIDS
naratriptan 9 tabs per 30 daysAMERGEGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychHeadache Therapy
NAYZILAM (NS)Brand Name30 days
nebivolol (tabs)BYSTOLICGeneric30 days or 90 days
neomycinGeneric30 daysAnti-InfectivesMiscellaneous Anti-Infectivesinfection
Neomycin/Polymixin/Dexameth 0.1% (Ophth drops)MAXITROLGeneric30 days
Neomycin/Polymixin/Dexameth 0.1% (Ophth Oint)MAXITROLGeneric30 days
neomycin/polymyxin/ HC. (crm, ointm, ophth and otic)Generic30 daysOphthalmologyAntibiotics
neomycin/polymyxin/gramicidin ophth or oticGeneric30 daysOphthalmologyAntibiotics
NEXLETOL (tab)Brand Name30 days
NEXLIZET (tabs)Brand Name30 days
nicotine (gum, lozenges, patches)NICODERM, NICORETTE, NICOTROLGeneric30 daysDiagnostics and Miscellaneous AgentsSmoking Deterrents
nifedipinePROCARDIA, NIFEDICALGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsCalcium Channel Blockers (Dihydropyridines)
Nikki (tabs)YAZGeneric30 days or 90 days
nitrofurantoinMACROBID, MACRODANTINGeneric30 daysAnti-InfectivesUrinary Tract Agentsinfection
nitroglycerin (ointm, patch, SL, spray)Generic30 daysCardiovascular, Hypertension and LipidsRapid/Long Acting Nitratesheart
nivestym (PFS)NEUPOGENGeneric30 days
norethindrone 0.35mg (tabs) CAMILA, ERRIN, JOLIVETTE, NOR-QD, NORA-BE, ORTHO MICRONOR, HEATHERGeneric30 days or 90 daysObstetrics and GynecologyProgestins
norethindrone 5mg (tabs)AYGESTINGeneric30 days
nortriptylinePAMELOR, AVENTYL HCLGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychTricyclic Antidepressant Agents
NOVOLIN 70/30Brand Name30 daysEndocrine/DiabetesInsulin Therapy
NOVOLIN NBrand Name30 daysEndocrine/DiabetesInsulin Therapy
NOVOLIN RBrand Name30 daysEndocrine/DiabetesInsulin Therapy
NOVOLOGBrand Name30 daysEndocrine/DiabetesInsulin Therapy
NULYTELY (powder)Brand Name30 days
NURTEC ODT 75mg (tab)Brand Name30 days
nystatin (crm, ointm, powd, susp)MYCOSTATIN TOPICAL, NYSTOPGeneric30 daysAnti-Infectives;Dermatologicals/Topical TherapyAntifungal Agents;Topical AntifungalsSkin
nystatin/triamcinoloneMYCOLOGGeneric30 days
ocella 3-0.03mgYASMIN, GIANVI, LORYNA, OCELLA, SYEDA, VESTURA, YASMIN, YAZ, ZARAHGeneric30 days or 90 daysObstetrics and GynecologyOral Contraceptives and Related agentssyeda, zarah
ofloxacin (ophth, otic)FLOXIN, OCUFLOXGeneric30 daysEar, Nose and Throat Medications;OphthalmologyFluoroquinolones;Miscellaneous Otic Preparations
olanzapine (tabs)ZYPREXAGeneric30 days
olmesartan (tabs)BENICARGeneric30 days or 90 days
olmesartan w/htcz (tab)BENICAR HCTGeneric30 days or 90 days
omega-3 fatty acids (cap)LOVAZAGeneric30 days or 90 days
Omeprazole (cap) (Limit: 6 months/rx)PRILOSECGeneric30 days or 90 days
omeprazole 2mg/ml (susp)Generic30 days
ondansetron various (tabs, liq)ZOFRANGeneric30 days
OPZELURA 1.5% (CREAM) (Limit: max refills - 2)Brand Name30 days
orphenadrineNORFLEX, ORPHENATEGeneric30 daysAutonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and RheumatologyMuscle Relaxants and Antispasmodic Agents
orphenadrine compoundGeneric30 daysAutonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and RheumatologyMuscle Relaxants and Antispasmodic Agents
oxcarbazepine (tab)Generic30 days
oxcarbazepine oral susp 300mg/5ml (liq)TRILEPTALGeneric30 days
oxybutyninDITROPANGeneric30 days or 90 daysUrologicalsAnticholinergics and Antispasmodics
oxybutynin-XLDITROPAN-XLGeneric30 days or 90 daysUrologicalsAnticholinergics and Antispasmodics
oxycodoneOXYCONTINGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychNarcotics
oxycodone/acetaminophenENDOCET, PERCOCETGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychCombination Narcotic;Analgesics
oxycodone-ERGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychNarcotics
OZEMPIC (Diag: T2D Only)Brand Name30 days
paliperidone various (ER tabs)INVEGAGeneric30 days
PANCREAZEBrand Name30 daysGastroenterologyDigestive Enzymes
pantoprazolePROTONIXGeneric30 days or 90 daysGastroenterologyProton Pump InhibitorsGERD
paroxetinePAXILGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychSelective Serotonin Reuptake Inhibitors (SSRIs)Depression
PAXLOVID (tabs)Brand Name30 days
peg 3350/electrolytesGeneric30 daysGastroenterologyBowel Evacuants
penicilln vkGeneric30 daysAnti-InfectivesPenicillinsinfection
pentoxifylline-erGeneric30 days or 90 daysCardiovascular, Hypertension and Lipids;Vitamins, Hematinics and ElectrolytesMiscellaneous Coagulation Agentsheart
permethrinGeneric30 daysDermatologicals/Topical TherapyTopical Scabicides;PediculicidesSkin
perphenazineTRILAFONGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychPhenothiazines
perphenazine/amitriptylineETRAFON, TRIAVILGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychMiscellaneous Antidepressants
phenazopyridineGeneric30 daysUrologicalsUrinary Anesthetics
phenobarbitalGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychAnticonvulsants
phenytoinDILANTINGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychAnticonvulsants
phytonadione 5mg (tabs) (Limit: 30 tabs)MEPHYTONGeneric30 days
pilocarpine (ophth.)ISOPTO CARPINE, PILOPINE HSGeneric30 daysOphthalmologyDirect Acting Miotics
pimecrolimus 1% (Cream) (Limit: Restricted to Derms)Generic30 days
pioglitazone (tab)ACTOSGeneric30 days or 90 days
pirfenidone various (caps, tabs)ESBRIETGeneric30 days
piroxicamFELDENEGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychNSAIDS
podofiloxCONDYLOXGeneric30 daysDermatologicals/Topical Therapy;Diagnostics and Miscellaneous AgentsMiscellaneous DermatologicalsSkin
polymyxin-b & trimethoprimGeneric30 daysOphthalmologyAntibiotics
portia-28 0.15/0.03mgNORDETTE-28Generic30 days or 90 daysObstetrics and GynecologyOral Contraceptives and Related agentsaltavera, levora-28
posaconazole (tabs only) (Limit: PA required for 90 days)NOXAFILGeneric30 days
potassium chlorideKLOR-CON, K-DURGeneric30 days or 90 daysVitamins, Hematinics and ElectrolytesMiscellaneous Urologicals;Electrolytes
potassium chloride-erGeneric30 days or 90 daysVitamins, Hematinics and ElectrolytesMiscellaneous Urologicals;Electrolytes
potassium citrate (tabs)UROCIT-KGeneric30 days or 90 days
pramipexole tabs (Limit: Not ER)MIRAPEXGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychAntiparkinsonism Drugs
pravastatinPREVACHOL, PRAVACHOLGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsLipid/Cholesterol Lowering AgentsHeart, High Cholesterol
prazosinMINIPRESSGeneric30 daysCardiovascular, Hypertension and LipidsAdrenergic Antagonists and Related Drugsheart
prednicarbateDERMATOPGeneric30 daysDermatologicals/Topical TherapyTopical CorticosteroidsSkin
prednisolone (oral liquid, ophth. Drop)ORAPRED, PEDIAPRED, PRELONE, PRED FORTEGeneric30 daysEndocrine/Diabetes, OphthalmologySteroids
prednisone (tab)DELTASONEGeneric30 days or 90 daysEndocrine/DiabetesSteroidsSwelling, Allergic Reactions
Pregabalin (caps)LYRICAGeneric30 days
PREMARIN (tab, vag crm)Brand Name30 daysObstetrics and GynecologyOsteoporosis Therapy;Estrogens
PREMPHASEBrand Name30 daysObstetrics and GynecologyEstrogen Combinations
PREMPROBrand Name30 daysObstetrics and GynecologyEstrogen Combinations
prenatal plus vitaminsGeneric30 days or 90 daysVitamins, Hematinics and ElectrolytesVitamins and Hematinics
PreNatal Vits w DHA (tab)Generic30 days or 90 days
primidoneMYSOLINEGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychAnticonvulsants
probenecidBENEMIDGeneric30 daysMusculoskeletal and RheumatologyGout Therapy
procainamideGeneric30 daysCardiovascular, Hypertension and LipidsAntiarrhythmic Agentsheart
prochlorperazineCOMPAZINEGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and Psych;GastroenterologyAntivertigo and Antiemetic Drugs
PROCTOZONE-HC 2.5% (crm)Brand Name30 days
progesterone 100mg or 200mg (caps)PROMETRIUMGeneric30 days
progesterone 50mg/ml (injection)PROMETRIUMGeneric30 daysObstetrics and GynecologyProgestins
PROLIA 60mg/ml (syringe)Brand Name30 days
promethazine (syr, tab)PHENERGANGeneric30 daysGastroenterology;Respiratory, Allergy, Cough and ColdAntivertigo and Antiemetic Drugs;Antihistamines
promethazine/codeinePHENERGAN W/ CODEINEGeneric30 daysRespiratory, Allergy, Cough and ColdAntitussive Combinations
promethazine-dmGeneric30 daysRespiratory, Allergy, Cough and ColdAntitussive Combinations
propranololINDERALGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsBeta Blockersheart
propranolol-ERGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsBeta Blockersheart
propranolol-LAGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsBeta Blockersheart
propylthiouracilGeneric30 daysEndocrine/DiabetesAntithyroid Agents
PROVENTIL HFABrand Name30 daysRespiratory, Allergy, Cough and ColdInhaled Beta Agonists
PULMICORT FLEXHALERBrand Name30 daysRespiratory, Allergy, Cough and ColdInhaled Corticosteroids
PULMOZYMEBrand Name30 daysRespiratory, Allergy, Cough and ColdMiscellaneous Pulmonary Agents
PYLERA (caps)Brand Name30 days
pyrazinamideGeneric30 daysAnti-InfectivesAntimycobacterialsinfection
pyridostigmineGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychMuscle Relaxants and Antispasmodic Agents
Quetiapine Fum ER (tabs) (Limit: restricted to psychiatrist)SEROQUEL XRGeneric30 days
quetiapine fumarateSEROQUELGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychMiscellaneous Antipsychoticspsychiatry
quinidine sulfateGeneric30 daysCardiovascular, Hypertension and LipidsAntiarrhythmic Agentsheart
quinidine sulfate-erGeneric30 daysCardiovascular, Hypertension and LipidsAntiarrhythmic Agentsheart
QULIPTA (tabs)Brand Name30 days
QVARBrand Name30 daysRespiratory, Allergy, Cough and ColdInhaled Corticosteroids
raloxifene 60mg (tabs)EVISTAGeneric30 days or 90 days
ramiprilALTACEGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsACE Inhibitorsblood pressure
ranolazine (tab)RANEXAGeneric30 days or 90 days
REGRANEXBrand Name30 daysDermatologicals/Topical TherapyMiscellaneous DermatologicalsSkin
RENAGELBrand Name30 daysDiagnostics and Miscellaneous AgentsMiscellaneous Agents
repaglinide (tab)Generic30 days or 90 days
Repatha Sureclick auto-injector 140mg/ml (inj)Brand Name30 days
RETACRIT (injectable)Brand Name30 days
REXULTI various (tabs)Brand Name30 days
Rezvoglar KwikPen 100u/ml (pen injectable)LANTUS SOLOSTARGeneric30 days
RHOPRESSA 0.02% (OPHTH SOLN)Brand Name30 days
ribavirin (caps, tabs)COPEGUS, REBETOL, RIBAPAK, RIBASPHERE, RIBATAB, VIRAZOLEGeneric30 daysAnti-InfectivesMiscellaneous Antiviralsinfection; virus
rifabutin 150mg (caps)MYCOBUTINGeneric30 days
rifampinRIFADIN, RIMACTANEGeneric30 daysAnti-InfectivesAntimycobacterialsinfection
riluzole (tab)RULETIKGeneric30 days or 90 days
ripseridone consta (Injectable) (Limit: filled by specialty pharmacy)RISPERDALE CONSTAGeneric30 days
risedronate 35mg (tab)ACTONELGeneric30 days or 90 days
risedronate 150mg (tabs)ACTONELGeneric30 days or 90 days
risperidone (tab)RISPERDALGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychMiscellaneous Antipsychotics
risperidone oral soln 1mg/1ml (Soln)Generic30 days
rivastigmine various (patch)EXELONGeneric30 days
rizatriptan 9 tabs per 30 daysMAXALTGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychHeadach Therapymigraine; headache
ROCKLATAN OPHTH DROPS (Limit: restricted to Ophthamology and optometry)Brand Name30 days
ropiniroleREQUIPGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychAntiparkinsonism Drugs
rosuvastatinCRESTORGeneric30 days or 90 days
RYBELSUS (Tabs)Brand Name30 days
SANTYLBrand Name30 daysDermatologicals/Topical TherapyTopical EnzymesSkin
Selarsdi (injectable)Brand Name30 days
selegilineELDEPRYL, ZELAPARGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychAntiparkinsonism Drugs
selenium sulfide (lotion)Generic30 daysDermatologicals/Topical TherapyAntipsoriatic;AntiseborrheicSkin
sertralineZOLOFTGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychSelective Serotonin Reuptake Inhibitors (SSRIs)
sevelamer carbonate 800mg tabs 800mg (tab)RENVELAGeneric30 days or 90 days
silodosin (cap)RAPAFLOGeneric30 days or 90 days
silver sulfadiazineSILVADENEGeneric30 daysDermatologicals/Topical TherapyBurn TherapySkin
simvastatinZOCORGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsLipid/Cholesterol Lowering AgentsHeart, High Cholesterol
sirolimus various (tabs)RAPAMUNEGeneric30 days
sitagliptin (tabs)Generic30 days or 90 days
Sod Chloride f/Inhalation various (soln)Generic30 days
Sodium Chloride for Irrigation 0.9% (liq)Generic30 days
sodium citrate/citric acid (liq)BICITRA, CYTRA-2, LIQUI-DUAL CITRA, ORACITGeneric30 days or 90 daysUrologicalsMiscellaneous Urologicals
sodium polystyrene sulfonateKAYEXALATEGeneric30 days
solifenacin (tab)VESICAREGeneric30 days or 90 days
SOLU-CORTEFBrand Name30 daysEndocrine/DiabetesCorticosteroids
sotalol 80mgBETAPACE, SORINEGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsAntiarrhythmic Agentsheart
spironolactone 25mg. 50mg, 100mg (tab)ALDACTONEGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsThiazide and Related DiureticsHeart, Hypertension
spironolactone/hctzALDACTAZIDEGeneric30 daysCardiovascular, Hypertension and LipidsThiazide and Related Diureticsheart
sprintec 0.25/0.035mgMONONESSA, ORTHO TRI-CYCLEN, ORTHO TRI-CYCLEN LO, ORTHO-CYCLEN, PREVIFEM, SPRINTEC, TRI-LO-SPRINTEC, TRI-PREVIFEM, TRI-SPRINTEC, TRINESSAGeneric30 days or 90 daysObstetrics and GynecologyOral Contraceptives and Related Agents
sucralfateCARAFATEGeneric30 daysGastroenterologyOther Ulcer Therapy
sulfacetamide sodium 10% ophth.Generic30 daysOphthalmologyAntibiotics
sulfacetamide/prednisoloneGeneric30 daysOphthalmologyAntibiotics
sulfacetamide/sulfur 10%/5% (topical cleanser)Generic30 days
sulfamethoxazole-trimethoprimGeneric30 daysAnti-InfectivesSulfas and Related Agentsinfection
sulfasalazineAZULFIDINE, SULFAZINEGeneric30 days or 90 daysGastroenterologyMiscellaneous Gastrointestinal Agents;Miscellaneous Rheumatological Agents
sulfasalazine-ecGeneric30 days or 90 daysGastroenterologyMiscellaneous Gastrointestinal Agents;Miscellaneous Rheumatological Agents
sulindacCLINORILGeneric30 daysAutonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and RheumatologyNSAIDS
sumatriptan 9 tabs per 30 days (tabs)IMITREXGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychHeadache TherapyMigraines
sumatriptan succ 6mg/0.5ml (injectable) (Limit: 2 syr per month)IMITREXGeneric30 days
SUPREP (liq)Brand Name30 days
SUTAB (tabs)Brand Name30 days
SYMBICORT 80 or 160 (inh)Brand Name30 days
SynjardyBrand Name30 days
Synjardy XR (tab)Brand Name30 days
SYNTHROIDBrand Name30 daysEndocrine/DiabetesAntithyroid Agents
tacrolimus (cap & ointment)PROTOPIC, PROGRAFGeneric30 daysAntineoplastic and Immunosuppressant DrugsImmunosuppressant DrugsTransplant Organ Rejection
TAMIFLUBrand Name30 daysAnti-InfectivesMiscellaneous Antiviralsinfection; virus
tamoxifenSOLTAMOXGeneric30 days or 90 daysAntineoplastic and Immunosuppressant DrugsAntiestrogens
tamsulosinFLOMAXGeneric30 days or 90 daysUrologicalsBenign Prostatic Hyperplasia Therapy
tavaborole 5% (soln)KERYDINGeneric30 days
tazarotene (Gel or Cream only) (Limit: limit up to 60gm)TORAZACGeneric30 days
telmisartan various (tabs)MICARDISGeneric30 days or 90 days
telmisartan w/hctz various (tabs)MICARDIS-HCTGeneric30 days or 90 days
temazepamRESTORILGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychHypnotic AgentsInsomnia
temozolomide (caps)Generic30 days
tenofovir 300mg (tab)VIREADGeneric30 days or 90 days
teraconazole vaginalGeneric30 daysObstetrics and GynecologyVaginal Antifungals
terazosinHYTRINGeneric30 days or 90 daysCardiovascular, Hypertension and Lipids;UrologicalsAdrenergic Antagonists and Related Drugs;Benign Prostatic Hyperplasia Therapyheart
terbinafine (tab)LAMISILGeneric30 days or 90 daysAnti-InfectivesAntifungal Agentsinfection
teriflunomide 7mg & 14mg (tabs)AUBAGIOGeneric30 days or 90 days
testosterone depotDEPO-TESTOSTERONEGeneric30 daysEndocrine/DiabetesAndrogens
testosterone gel packets 1% (gel packets)ANDROGEL PACKETSGeneric30 days
testsoterone gel pump 1.62% (gel pump)ANDROGEL PUMPGeneric30 days
tetracyclineALA-TET, PANMYCIN, SUMYCINGeneric30 daysAnti-InfectivesTetracyclinesinfection
theophyllineGeneric30 daysRespiratory, Allergy, Cough and ColdXanthines
ticagrelor 60mg & 90mg (tabs)BRILINTAGeneric30 days or 90 days
timolol (sol)BLOCADRENGeneric30 days or 90 daysOphthalmologyBeta Blockers
timolol-xe (ophth.)Generic30 daysOphthalmologyBeta Blockers
tinidazole 250mg or 500mg (tabs) (Limit: 20 tabs)Generic30 days
tobramycin ophth.Generic30 daysOphthalmologyAntibiotics
tobramycin/dexamethasone ophth. 0.3-0.1%TOBRADEXGeneric30 daysOphthalmologySteroid-Antibiotic Combinations
TOBREX (ophth. ointment)Brand Name30 daysOphthalmologyAntibiotics
tolterodineDETROLGeneric30 days or 90 daysUrologicalsAnticholinergics and Antispasmodicsbladder, urinary incontinence
topiramateTOPAMAXGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychAnticonvulsantsSeizures
topiramate ER 25mg, 50mg 100mg (caps) (Limit: restricted to neurologists)TOPAMAXGeneric30 days
torsemideDEMADEXGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsThiazide and Related Diureticsheart
tramadolULTRAMGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychMiscellaneous AnalgesicsModerate Pain
Tranexamic Acid (tabs) (Limit: 30 tabs)LYSTEDAGeneric30 days
TRANSDERM-SCOPBrand Name30 daysAutonomic and CNS Drugs;Neurology and PsychAntivertigo and Antiemetic Drugs
travoprost Ophth Soln 0.04% (drops)TRAVATAN ZGeneric30 days or 90 days
trazodoneDESYRELGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychMiscellaneous Antidepressants
TRELEGY Ellipta (Inhaler)TRELEGYBrand Name30 days
tretinoin 0.1%, 0.05%, 0.01% & 0.025% (cream or gel) (Limit: acne vulgaris)RETIN AGeneric30 days
triamcinolone (crm)KENALOGGeneric30 daysDermatologicals/Topical TherapyTopical CorticosteroidsSkin
triamcinolone (ointm)ARISTOCORTGeneric30 daysDermatologicals/Topical TherapyTopical CorticosteroidsSkin
triamcinolone/orabaseGeneric30 daysEar, Nose and Throat MedicationsMiscellaneous Agents
triamterene/hctzDYAZIDE, MAXZIDEGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsThiazide and Related Diureticsheart
trifluoperazineSTELAZINEGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychPhenothiazines
trifluridine ophth.TRIFLURIDINE, VIROPTICGeneric30 daysOphthalmologyAntivirals
trihexyphenidylARTANE, TRIHEXANEGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychAntiparkinsonism Drugs
tri-lo-sprintecORTHO TRICYCLEN-LOGeneric30 days or 90 days
trimethobenzamideTIGAN, TICON, BENZACOTGeneric30 daysAutonomic and CNS Drugs;Neurology and Psych;GastroenterologyAntivertigo and Antiemetic Drugs
trimethoprim/polymyxinGeneric30 daysOphthalmologyAntibiotics
tri-sprintecMONONESSA, ORTHO TRI-CYCLEN, ORTHO TRI-CYCLEN LO, ORTHO-CYCLEN, PREVIFEM, SPRINTEC, TRI-LO-SPRINTEC, TRI-PREVIFEM, TRI-SPRINTEC, TRINESSAGeneric30 days or 90 daysObstetrics and GynecologyOral Contraceptives and Related Agents
trospium (tabs or ER caps)Generic30 days
TRULICITY (inj)Brand Name30 days
UBRELVY 50mg & 100mg (tab)Brand Name30 days
urea 40% (crm, gel)URAMAXIN GTGeneric30 daysDermatologicals/Topical TherapyMiscellaneous DermatologicalsSkin
ursodiolACTIGALL, URSOGeneric30 days or 90 daysGastroenterologyBile Acids
valacyclovirVALTREXGeneric30 daysAnti-InfectivesMiscellaneous Antiviralsinfection; virus
valganciclovir (tab)VALCYTEGeneric30 days
valproic acidDEPAKENE, STAVZOR, DEPACONGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychAnticonvulsants
valsartanDIOVANGeneric30 days or 90 days
Valsartan/hctz (tab)DIOVAN/HCTZGeneric30 days or 90 days
vancomycin 125mg or 250mg (caps) (Limit: 50 caps)Generic30 days
VANOXIDE-HCBrand Name30 daysDermatologicals/Topical TherapyMiscellaneous DermatologicalsSkin
VELTASSA (pckt)Brand Name30 days
venlafaxine (cap)EFFEXORGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychMiscellaneous Antidepressants
venlafaxine-ER (cap)EFFEXOR-XRGeneric30 days or 90 daysAutonomic and CNS Drugs;Neurology and PsychMiscellaneous Antidepressants
VENTOLIN HFAVENTOLIN HFABrand Name30 days
verapamilCALAN, VERELANGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsCalcium Channel Blockers (Non-Dihydropyridines)
verapamil-erCALAN-SRGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsCalcium Channel Blockers (Non-Dihydropyridines)heart
voriconazole (Limit: Transplant - up to 90 days)Generic30 days or 90 days
Vtama 1% (Cream)Brand Name30 days
VYVANSEBrand Name30 days
VYZULTA 0.024% (OPHTH SOLN)Brand Name30 days
warfarinCOUMADINGeneric30 days or 90 daysCardiovascular, Hypertension and LipidsAnticoagulantsHeart, Thrombosis
XARELTO (tabs)Brand Name30 days
XIFAXAN various (tabs)Brand Name30 days
XIIDRA 5% (OPHTH SOLN)Brand Name30 days
XOLAIR various (inj) (Limit: Restricted to Allergist)Brand Name30 days
Xulane (patch)ORTHO-EVRAGeneric30 days
Yesintek (injectable)Brand Name30 days
YUSIMRY various (injectable)Brand Name30 days
zafirlukastACCOLATEGeneric30 daysRespiratory, Allergy, Cough and ColdMiscellaneous Pulmonary Agents
ZENPEPBrand Name30 daysGastroenterologyDigestive Enzymes
Ziprasidone (caps)GEODONGeneric30 days
zolpidemAMBIENGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychHypnotic Agentssleep, insomnia
zonisamideZONEGRANGeneric30 daysAutonomic and CNS Drugs;Neurology and PsychAnticonvulsants
ZORYVE various (Cream, foam)Brand Name30 days

Scroll to Top
x Powerful Protection for WordPress, from Shield Security
This Site Is Protected By
ShieldPRO →