| ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS | nt_header_1 | nt_header_2 | nt_header_3 |
|---|---|---|---|
| Amphetamines | |||
| PREFERRED | |||
| amphetamine sulfate tab | |||
| amphetamine-dextroamphet er cap | |||
| amphetamine-dextroamphetamine tab | |||
| dextroamphetamine sulfate er cap | |||
| dextroamphetamine sulfate soln | |||
| dextroamphetamine sulfate tab | |||
| lisdexamfetamine dimesylate cap | |||
| lisdexamfetamine dimesylate tab | |||
| methamphetamine hcl tab | |||
| PROCENTRA | |||
| ZENZEDI 5 MG | 10 MG | ||
| NON PREFERRED | |||
| DESOXYN | |||
| EVEKEO ODT | |||
| ZENZEDI 2.5 MG | 15 MG | 20 MG | 30 MG |
| EXCLUDED | |||
| ADDERALL | |||
| ADDERALL XR | |||
| EVEKEO | |||
| VYVANSE | |||
| XELSTRYM | |||
| Anorexiants Non-Amphetamine | |||
| *not covered by some plans | |||
| PREFERRED | |||
| benzphetamine hcl tab [PA] | |||
| diethylpropion hcl er tab [PA] | |||
| diethylpropion hcl tab [PA] | |||
| phendimetrazine tartrate er cap [PA] | |||
| phendimetrazine tartrate tab [PA] | |||
| phentermine hcl cap [PA] | |||
| phentermine hcl tab [PA] | |||
| NON PREFERRED | |||
| ADIPEX-P [PA] | |||
| LOMAIRA [PA] | |||
| Anti-Obesity Agents | |||
| *not covered by some plans | |||
| PREFERRED | |||
| orlistat cap [PA] | |||
| SAXENDA [PA][INJ] | |||
| WEGOVY [PA][INJ] | |||
| NON PREFERRED | |||
| IMCIVREE [PA][INJ] | |||
| XENICAL [PA] | |||
| EXCLUDED | |||
| CONTRAVE | |||
| ZEPBOUND [INJ] | |||
| Attention-Deficit/Hyperactivity Disorder (ADHD) Agents | |||
| PREFERRED | |||
| atomoxetine hcl cap | |||
| clonidine hcl er tab | |||
| guanfacine hcl er tab | |||
| NON PREFERRED | |||
| KAPVAY | |||
| QELBREE [PA] | |||
| EXCLUDED | |||
| INTUNIV | |||
| STRATTERA | |||
| Histamine H3-Receptor Antagonist/Inverse Agonists | |||
| NON PREFERRED | |||
| WAKIX [PA] | |||
| Stimulants - Misc. | |||
| PREFERRED | |||
| armodafinil tab | |||
| dexmethylphenidate hcl er cap | |||
| dexmethylphenidate hcl tab | |||
| methylphenidate hcl er (cd) cap | |||
| methylphenidate hcl er (la) cap | |||
| methylphenidate hcl er (osm) tab | |||
| methylphenidate hcl er (xr) cap | |||
| methylphenidate hcl er tab | |||
| methylphenidate hcl soln | |||
| methylphenidate hcl tab | |||
| methylphenidate patch [PA] | |||
| modafinil tab | |||
| QUILLICHEW ER | |||
| QUILLIVANT XR | |||
| NON PREFERRED | |||
| APTENSIO XR | |||
| AZSTARYS [PA] | |||
| JORNAY PM | |||
| METHYLIN | |||
| EXCLUDED | |||
| CONCERTA | |||
| DAYTRANA | |||
| FOCALIN | |||
| FOCALIN XR | |||
| NUVIGIL | |||
| PROVIGIL | |||
| RITALIN | |||
| RITALIN LA | |||
| ALLERGENIC EXTRACTS/BIOLOGICALS MISC | |||
| Allergenic Extracts | |||
| *not covered by some plans | |||
| PREFERRED | |||
| GRASTEK [PA] | |||
| ODACTRA | |||
| PALFORZIA [PA] | |||
| RAGWITEK [PA] | |||
| ANALGESICS - ANTI-INFLAMMATORY | |||
| Antirheumatic - Enzyme Inhibitors | |||
| PREFERRED | |||
| RINVOQ [PA] | |||
| XELJANZ [PA] | |||
| XELJANZ XR [PA] | |||
| NON PREFERRED | |||
| OLUMIANT [PA] | |||
| Anti-TNF-alpha - Monoclonal Antibodies | |||
| PREFERRED | |||
| adalimumab-adaz auto-inj [PA][INJ] | |||
| adalimumab-adaz prefill syr [PA][INJ] | |||
| AMJEVITA [PA][INJ] | |||
| CYLTEZO [PA][INJ] | |||
| HUMIRA [PA][INJ] | |||
| HUMIRA PEN [PA][INJ] | |||
| HYRIMOZ [PA][INJ] | |||
| SIMPONI [PA][INJ] | |||
| NON PREFERRED | |||
| SIMPONI ARIA [PA][INJ] | |||
| EXCLUDED | |||
| ABRILADA [INJ] | |||
| adalimumab-aacf [INJ] | |||
| adalimumab-adbm [INJ] | |||
| adalimumab-adbm prefill syr [INJ] | |||
| adalimumab-fkjp [INJ] | |||
| adalimumab-fkjp prefill syr [INJ] | |||
| HADLIMA [INJ] | |||
| HADLIMA PUSHTOUCH [INJ] | |||
| HULIO [INJ] | |||
| IDACIO [INJ] | |||
| YUFLYMA [INJ] | |||
| YUFLYMA PEN [INJ] | |||
| YUSIMRY [INJ] | |||
| Gold Compounds | |||
| PREFERRED | |||
| RIDAURA | |||
| Interleukin-1 Blockers | |||
| NON PREFERRED | |||
| ARCALYST [PA][INJ] | |||
| Interleukin-1 Receptor Antagonist (IL-1Ra) | |||
| EXCLUDED | |||
| KINERET [INJ] | |||
| Interleukin-1beta Blockers | |||
| PREFERRED | |||
| ILARIS [PA][INJ] | |||
| Interleukin-6 Receptor Inhibitors | |||
| NON PREFERRED | |||
| ACTEMRA [PA][INJ] | |||
| ACTEMRA ACTPEN [PA][INJ] | |||
| EXCLUDED | |||
| KEVZARA [INJ] | |||
| Nonsteroidal Anti-inflammatory Agents (NSAIDs) | |||
| PREFERRED | |||
| celecoxib cap | |||
| diclofenac potassium 50 mg tab | |||
| diclofenac sodium er tab | |||
| diclofenac sodium tab | |||
| diclofenac-misoprostol tab | |||
| etodolac cap | |||
| etodolac er tab | |||
| etodolac tab | |||
| fenoprofen calcium tab | |||
| flurbiprofen tab | |||
| IBU | |||
| ibuprofen susp | |||
| ibuprofen tab | |||
| indomethacin cap | |||
| indomethacin er cap | |||
| ketorolac tromethamine tab | |||
| meclofenamate sodium cap | |||
| meloxicam tab | |||
| nabumetone tab | |||
| naproxen sodium tab | |||
| naproxen susp | |||
| naproxen tab | |||
| oxaprozin tab | |||
| piroxicam cap | |||
| sulindac tab | |||
| NON PREFERRED | |||
| ANAPROX DS | |||
| ARTHROTEC | |||
| DAYPRO | |||
| EC-NAPROSYN | |||
| FELDENE | |||
| indomethacin supp [PA] | |||
| LODINE | |||
| NAPROSYN | |||
| EXCLUDED | |||
| CELEBREX | |||
| INDOCIN | |||
| meloxicam susp | |||
| NALFON | |||
| Phosphodiesterase 4 (PDE4) Inhibitors | |||
| PREFERRED | |||
| OTEZLA [PA] | |||
| Pyrimidine Synthesis Inhibitors | |||
| PREFERRED | |||
| leflunomide tab | |||
| NON PREFERRED | |||
| ARAVA | |||
| Selective Costimulation Modulators | |||
| NON PREFERRED | |||
| ORENCIA [PA][INJ] | |||
| ORENCIA CLICKJECT [PA][INJ] | |||
| Soluble Tumor Necrosis Factor Receptor Agents | |||
| PREFERRED | |||
| ENBREL [PA][INJ] | |||
| ENBREL MINI [PA][INJ] | |||
| ENBREL SURECLICK [PA][INJ] | |||
| ANALGESICS - NonNarcotic | |||
| Analgesic Combinations | |||
| PREFERRED | |||
| BAC | |||
| butalbital-apap-caffeine tab | |||
| TENCON | |||
| NON PREFERRED | |||
| ALLZITAL | |||
| ESGIC | |||
| FIORICET | |||
| Analgesics Other | |||
| NON PREFERRED | |||
| LOTREXONE | |||
| NALTREX | |||
| ANALGESICS - OPIOID | |||
| Opioid Agonists | |||
| PREFERRED | |||
| codeine sulfate tab | |||
| fentanyl citrate loz [PA] | |||
| fentanyl patch [PA] | |||
| hydromorphone hcl er tab | |||
| hydromorphone hcl liquid | |||
| hydromorphone hcl supp | |||
| hydromorphone hcl tab | |||
| methadone hcl conc [PA] | |||
| METHADONE HCL INTENSOL [PA] | |||
| methadone hcl soln [PA] | |||
| methadone hcl tab [PA] | |||
| METHADOSE [PA] | |||
| METHADOSE SUGAR-FREE [PA] | |||
| morphine sulfate (concentrate) soln | |||
| morphine sulfate er beads cap | |||
| morphine sulfate er cap | |||
| morphine sulfate er tab | |||
| morphine sulfate soln | |||
| morphine sulfate supp | |||
| morphine sulfate tab | |||
| oxycodone hcl cap | |||
| oxycodone hcl conc | |||
| oxycodone hcl soln | |||
| oxycodone hcl tab | |||
| OXYCONTIN | |||
| oxymorphone hcl er tab | |||
| oxymorphone hcl tab | |||
| tramadol hcl 50 mg tab | |||
| NON PREFERRED | |||
| DILAUDID | |||
| meperidine hcl soln | |||
| meperidine hcl tab | |||
| MS CONTIN | |||
| ROXICODONE | |||
| EXCLUDED | |||
| fentanyl citrate tab | |||
| FENTORA | |||
| NUCYNTA | |||
| oxycodone hcl er tab | |||
| QDOLO | |||
| tramadol hcl 100 mg tab | |||
| tramadol hcl 5mg/ml soln | |||
| Opioid Combinations | |||
| PREFERRED | |||
| acetaminophen-codeine soln | |||
| acetaminophen-codeine tab | |||
| apap-caff-dihydrocodeine cap | |||
| ASCOMP-CODEINE | |||
| butalbital-apap-caff-cod cap | |||
| butalbital-asa-caff-codeine cap | |||
| ENDOCET | |||
| hydrocodone-acetaminophen soln | |||
| hydrocodone-acetaminophen tab | |||
| hydrocodone-ibuprofen tab | |||
| oxycodone-acetaminophen soln | |||
| oxycodone-acetaminophen tab | |||
| tramadol-acetaminophen tab | |||
| NON PREFERRED | |||
| TREZIX | |||
| EXCLUDED | |||
| APADAZ | |||
| benzhydrocodone-acetaminophen tab | |||
| PERCOCET | |||
| Opioid Partial Agonists | |||
| PREFERRED | |||
| BELBUCA [PA] | |||
| buprenorphine hcl soln [INJ] | |||
| buprenorphine hcl tab | |||
| buprenorphine hcl-naloxone hcl film | |||
| buprenorphine hcl-naloxone hcl tab | |||
| buprenorphine patch [PA] | |||
| butorphanol tartrate soln [INJ] | |||
| nalbuphine hcl soln [INJ] | |||
| SUBLOCADE [PA][INJ] | |||
| NON PREFERRED | |||
| BRIXADI [PA][INJ] | |||
| pentazocine-naloxone hcl tab | |||
| EXCLUDED | |||
| BUTRANS | |||
| SUBOXONE | |||
| ANDROGENS-ANABOLIC | |||
| Androgens | |||
| *not covered by some plans | |||
| PREFERRED | |||
| ANDRODERM [PA] | |||
| danazol cap [PA] | |||
| methyltestosterone cap [PA] | |||
| testosterone cypionate soln [PA][INJ] | |||
| testosterone enanthate soln [PA][INJ] | |||
| NON PREFERRED | |||
| DEPO-TESTOSTERONE [PA][INJ] | |||
| KYZATREX [PA] | |||
| TESTONE CIK [PA][INJ] | |||
| ANORECTAL AND RELATED PRODUCTS | |||
| Intrarectal Steroids | |||
| PREFERRED | |||
| budesonide foam | |||
| hydrocortisone enema | |||
| UCERIS [PA] | |||
| NON PREFERRED | |||
| CORTENEMA | |||
| Rectal Combinations | |||
| PREFERRED | |||
| ANALPRAM-HC LOT | |||
| hydrocortisone ace-pramoxine cream | |||
| hydrocort-pramoxine (perianal) cream | |||
| lidocaine-hydrocort (perianal) cream | |||
| lidocaine-hydrocortisone ace gel | |||
| lidocaine-hydrocortisone ace kit | |||
| LIDOCORT | |||
| PROCTOFOAM HC | |||
| NON PREFERRED | |||
| ANALPRAM HC | |||
| ANALPRAM HC SINGLES | |||
| PROCORT | |||
| Rectal Products - Misc. | |||
| NON PREFERRED | |||
| BARRIGEL | |||
| Rectal Steroids | |||
| PREFERRED | |||
| HEMMOREX-HC | |||
| hydrocortisone (perianal) cream | |||
| hydrocortisone acetate supp | |||
| PROCTO-MED HC | |||
| PROCTOSOL HC | |||
| PROCTOZONE-HC | |||
| NON PREFERRED | |||
| PROCTOCORT | |||
| EXCLUDED | |||
| ANUSOL-HC | |||
| Vasodilating Agents | |||
| PREFERRED | |||
| RECTIV | |||
| ANTIANGINAL AGENTS | |||
| Antianginals-Other | |||
| PREFERRED | |||
| ranolazine er tab | |||
| Nitrates | |||
| PREFERRED | |||
| isosorbide mononitrate er tab | |||
| isosorbide mononitrate tab | |||
| NITRO-BID | |||
| nitroglycerin patch | |||
| nitroglycerin tab | |||
| NITRO-TIME | |||
| NON PREFERRED | |||
| NITRO-DUR | |||
| NITROSTAT | |||
| ANTIANXIETY AGENTS | |||
| Antianxiety Agents - Misc. | |||
| PREFERRED | |||
| buspirone hcl tab | |||
| hydroxyzine hcl syr | |||
| hydroxyzine hcl tab | |||
| hydroxyzine pamoate cap | |||
| NON PREFERRED | |||
| meprobamate tab | |||
| VISTARIL | |||
| Benzodiazepines | |||
| PREFERRED | |||
| alprazolam er tab | |||
| ALPRAZOLAM INTENSOL | |||
| alprazolam tab | |||
| chlordiazepoxide hcl cap | |||
| clorazepate dipotassium tab | |||
| diazepam conc | |||
| DIAZEPAM INTENSOL | |||
| diazepam soln | |||
| diazepam tab | |||
| lorazepam conc | |||
| LORAZEPAM INTENSOL | |||
| lorazepam tab | |||
| NON PREFERRED | |||
| oxazepam cap | |||
| EXCLUDED | |||
| VALIUM | |||
| XANAX | |||
| XANAX XR |