5-Tier Formulary wJan 2015 updates.xls

Transcription

1 Drug Name Preferred Generic Generic Preferred Non-preferred Specialty Suggested Alternative(s) 8-MOP PA 5 Specialty medication abacavir 2 abacavir / lamivudine / 2 zidovudine Abilify Maintena PA, QL (ST <23 years of age) 5 Specialty medication Abilify PA, QL (ST <23 years of 3 age) Abstral PA, QL 4 fentanyl citrate (PA) acamprosate 2 acarbose 2 acebutolol 2 acetaminophen / caffeine / 2 dihydrocodone QL acetaminophen / codeine QL 2 acetazolamide ER capsule 2 acetic acid 2 acetic acid / hydrocortisone 2 acitretin 5 Specialty medication Actemra PA, QL 5 Specialty medication Acthar gel PA, QL 5 Specialty medication Actimmune PA 5 Specialty medication Actonel QL 3 4 alendronate, ibandronate, risedronate Actonel Weekly QL 3 4 alendronate, ibandronate, risedronate Acuvail QL 4 ketorolac, diclofenac, bromfenac acyclovir 200mg capsule 1 acyclovir 400mg, 800mg tabs 2 acyclovir ointment 2 Aczone 4 tretinoin, benzoyl peroxide, clindamycin, adapalene (PA) Adagen PA 5 Specialty medication adapalene (PA >45 years of 2 age) Adcirca PA, QL 5 Specialty medication adefovir PA 5 Specialty medication Adempas PA, QL 5 Specialty medication Adrenaclick 4 5 EpiPen, Auvi-Q Advair 3 Advicor 4 atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, niacin ER Aerospan ST 4 Flovent HFA, QVAR, Asmanex Afinitor PA, QL 5 Specialty medication Aggrenox 4 clopidogrel, ticlopidine, dipyridamole, Effient alagesic 2 albuterol tabs 1 albuterol syrup 1 albuterol 0.85% neb 1

2 alclometasone dipropionate 2 Aldurazyme PA 5 Specialty medication alendronate 35mg, 70mg 1 alendronate 2 Alferon N PA 5 Specialty medication alfuzosin er 2 Alkeran 3 allopurinol 1 Alocril 4 azelastine, epinastine, Pataday, Patanol Alomide 4 azelastine, epinastine, Pataday, Patanol Alora QL 4 estradiol patch, Premarin Aloxi ST, QL 4 ondansetron Alphagan P 0.2% 4 betaxolol, brimonidine, carteolol, dorzolamide, latanoprost, levobunolol, timolol, Azopt, Betoptic S, Combigan alprazolam 2 alprazolam ODT ST 2 alprazolam Alrex 4 fluorometholone, prednisolone Altavera 2 Alvesco ST 4 Flovent HFA, QVAR, Asmanex amantadine 2 amcinonide 2 Amethia 2 Amethia Lo 2 Amethyst 2 Amevive PA, QL 5 Specialty medication amiodarone 2 Amitiza QL 3 amitriptyline 1 amlodipine / atorvastatin 2 amlodipine besylate 1 amlodipine besylate / 2 benazepril ammonium lactate 2 Amnesteem 2 amoxicillin 250mg capsule 1 amoxicillin susp 1 amoxicillin chew tabs 2 amoxicillin 500mg, 875mg 2 amoxicillin / clavulanate 2 amoxicillin / clavulanate ER 2 amphetamine / 2 dextroamphetamine ER QL (PA < 5 and >28 years of age) amphetamine salts QL (PA < 5 2 and >28 years of age) Ampyra PA, QL 5 Specialty medication Amturnide ST 3 Analpram HC cream 4 hydrocortisone/pramoxine Analpram HC lotion 4 hydrocortisone/pramoxine anastrozole 2 Androderm PA, ST 4 testosterone injection (PA), Androgel 2.63% (PA)

3 Androgel 2% PA, ST 3 Androgel 2.63% (PA) Androgel 2.63% PA 3 Android PA, ST 4 testosterone injection (PA), Androgel 2.63% (PA) androxy PA, ST 2 testosterone injection (PA), Androgel 2.63% (PA) Angeliq 4 Premarin, estradiol, estropipate Anoro Ellipta 3 Antipyrine-benzocaine ear drops 1 Anzemet ST, QL 4 ondansetron Apidra QL ST 4 Humalog, Novolog Apokyn PA, QL 5 Specialty medication apraclonidine 2 Apri 2 Apriso ER 3 Aptiom PA, QL 4 carbamazepine, oxcarbazepine, lamotrigine, valproic acid, levetiracetam, phenytoin, zonisamide Aptivus 3 Aquoral 4 Caphosol Aralast NP PA 5 Specialty medication Aranelle 2 Aranesp PA 5 Specialty medication arbinoxa 2 Arcalyst PA, QL 5 Specialty medication Arcapta ST 4 Serevent, Foradil Armour Thyroid 4 levothyroxine, liothyronine Asacol HD 3 Ascensia Blood Glucose Meters 3 Asmanex 3 Atelvia QL 3 4 alendronate, ibandronate, risedronate atenolol 1 atenolol / chlorthalidone 1 100/25 atenolol / chlorthalidone 50/25 2 atorvastatin 2 atovaquone suspension 2 Atripla 3 Atrovent HFA 3 Aubagio PA, QL 5 Specialty medication Aubra 2 aurodex 2 auroguard 2 Auvi-Q 3 Aveed PA, ST 4 testosterone injection (PA), Androgel 2.63% (PA) Aviane 2 Avodart 3 Avonex QL 5 Specialty medication Axert ST, QL 4 naratriptan, rizatriptan, sumatriptan, zolmitriptan Axiron PA, ST 4 testosterone injection (PA), Androgel 2.63% (PA) Azasite 4 erythromycin azathioprine 2

4 azelastine 2 Azelex ST 4 Generic topical acne agents Azilect 3 azithromycin QL 2 Azopt 3 baclofen 2 Bactroban nasal ointment 3 balsalazide disodium 2 Banzel PA 4 felbamate, lamotrigine, topiramate, valproate Baraclude PA 5 Specialty medication Bayer Blood Glucose Meters 3 Bayer Blood Glucose Test Strips 3 (QL > 28 years of age) Bayer Lancets (QL > 28 years of 3 age) Beconase AQ ST 4 fluticasone, flunisolide, Veramyst beflex 2 benazepril 1 benazepril / HCTZ 2 Benlysta PA 5 Specialty medication benprox 2 benzonatate 100mg 1 benzoyl peroxide 2 benztropine 1 Bepreve 4 azelastine, epinastine, Pataday, Patanol Berinert PA 5 Specialty medication Besivance 4 ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin, Zymar, Moxeza, Vigamox betamethasone 2 Betaseron ST, QL 5 Specialty medication betaxolol 2 Bethkis QL 5 Specialty medication Betimol 4 timolol, Betoptic S Betoptic S 3 Beyaz 3 Biafine 4 ammonium lactate, zenieva bicalutamide 2 bisoprolol 2 bisoprolol / HCTZ 1 Bivigam PA 5 Specialty medication Blephamide 3 Bosulif PA, QL 5 Specialty medication Botox PA, QL 5 Specialty medication bp 20-2 wash 2 BPO gel 2 Breeze Blood Glucose Meters 3 Breo Ellipta 3 Briellyn 2 Brilinta QL 4 clopidogrel, Effient brimonidine tartrate 2 Brintellix PA, QL 4 paroxetine, sertraline, citalopram, venlafaxine ER capsules, duloxetine (ST)

5 bromfenac ophthalmic solution Brovana 4 Serevent, Foradil budeprion XL 2 budesonide EC 2 budesonide nasal spray ST 2 budesonide respules 2 bumetanide 0.5mg, 1mg 1 Buphenyl tablet PA 5 Specialty medication buprenorphine PA, QL 2 buprenorphine/naloxone tablet PA, QL 2 4 Suboxone film (PA), Zubsolv (PA) bupropion 2 bupropion SA 2 buspirone 5mg, 10mg 1 butorphanol nasal spray QL 2 Bydureon QL 3 4 Byetta QL ST 3 4 Bydureon, Victoza Bystolic ST 4 atenolol, metoprolol, propranolol calcipotriene 2 calcitriol 2 calcium acetate 2 Camila 2 Camrese 2 Camrese Lo 2 Canasa 4 mesalamine, balsalazide disodium, sulfasalazine, sulfasalazine EC, Apriso, Asacol HD, Delzicol candesartan 2 candesartan / HCTZ 2 capecitabine PA 5 Specialty medication Caphosol 3 Caprelsa PA, QL 5 Specialty medication captopril 2 captopril / HCTZ 2 Carbaglu PA 5 Specialty medication carbamazepine 200mg 1 carbamazepine ER 2 carbidopa 2 carbidopa / levodopa 2 carbidopa / levodopa / 2 entacapone Cardene SR 4 diltiazem, cartia XT, nifedipine, nifedipine ER, taztia XT, verapamil, verapamil SR, Nifediac CC, amlodipine besylate Cardura XL ST, QL 4 doxazosin, tamsulosin, terazosin, prazosin, alfuzosin er Carimune NF PA 5 Specialty medication carisoprodol 2 carteolol 2 cartia XT 2 carvedilol 1 Cayston QL 5 Specialty medication Ceenu 3 cefaclor 2

6 cefadroxil 2 cefdinir 2 cefpodoxime 2 cefprozil 2 ceftazidime 2 ceftibuten 2 cefuroxime 2 Celebrex ST, QL 4 Generic NSAIDS (diclofenac, etodolac, ibuprofen, meloxicam, naproxen) Cenestin 4 Premarin, estradiol, estropipate cephalexin 250mg, 500mg 1 caps cephalexin 2 Cerezyme PA 5 Specialty medication cevimeline 2 Chantix ST, QL 3 Chateal 2 Chemet PA 4 chlordiazepoxide 2 chlorhexidine gluconate 1 mouthwash chlorpromazine (ST <23 years 2 of age) chlorpropamide 2 chlorthalidone 2 chlorzoxazone 2 cholestyramine 2 ciclopirox 2 cilostazol 2 Ciloxan 4 ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin, Zymar, Moxeza, Vigamox cimetidine 2 Cimzia PA, QL 5 Specialty medication Cinryze PA, QL 5 Specialty medication Cipro HC 3 Ciprodex 3 ciprofloxacin 250mg, 500mg 1 ciprofloxacin 2 ciprofloxacin 0.3% ear drops 2 ciprofloxacin ER QL 2 citalopram QL 1 Claravis 2 clarithromycin 2 clarithromycin ER 2 Climara-PRO QL 4 estradiol Clinac BPO 4 benzoyl peroxide clindamycin 2 clobetasol 2 clonazepam 2 clonazepam ODT ST 2 clonazepam clonidine tabs 1 clonidine 2

7 clonidine ER ST, QL 2 clopidogrel 2 clorazepate 2 clotrimazole 2 clozapine (ST <23 years of 2 age) clozapine ODT QL (ST <23 2 years of age) Coartem 3 codeine sulfate 2 Colcrys 3 Colestid granules 4 colestipol colestipol 2 Combigan 3 Combipatch QL 4 estradiol-norethindrone, Jinteli, Prempro, Premphase Combivent Respimat 3 Cometriq PA, QL 5 Specialty medication Complera 3 Contour Blood Glucose Meters 3 Copaxone QL 5 Specialty medication Copegus QL 5 Specialty medication Coreg CR 4 carvedilol cortamox 2 Cortef 4 hydrocortisone tablet Cortifoam 4 hydrocortisone suppositories, proctozone Cosopt PF 4 Azopt, betaxolol, Betoptic S, carteolol, dorzolamide, dorzolamide-timolol, timolol maleate Covera- HS 4 diltiazem, cartia XT, nifedipine, nifedipine ER, taztia XT, verapamil, verapamil SR, Nifediac CC, amlodipine besylate Creon 3 Crinone 5% gel 3 Crixivan 3 cromolyn 2 Cryselle 2 Cuprimine PA 3 Cuvposa (PA > 26 years of age) 4 glycopyrrolate tablet Cyclafem 2 cyclobenzaprine 1 cyclopentolate drops 2 Cycloset 4 bromocriptine cyclosporine 2 cyclosporine modified 2 Cystadane powder PA 5 Specialty medication Cystagon PA 3 Cystaran PA, QL 5 Specialty medication cytra-2 oral soln 1 Daliresp PA 4 Advair, Dulera, Foradil, Serevent, Spiriva, Symbicort, Tudorza danazol PA 2 dantrolene 2 Dapsone 3

8 Dasetta 2 Daysee 2 Delatestryl PA, ST 4 testosterone injection (PA), Androgel 2.63% (PA) Delyla 2 Delzicol 3 Demser PA 5 Specialty medication Denavir 4 For cold sore treatment use over-the-counter agents Depen PA 3 5 Specialty medication Depo-Testosterone PA, ST 4 testosterone injection (PA), Androgel 2.63% (PA) Dermatop 4 Generic topical steroids desogestrel / ethinyl estradiol 2 desonide 2 desoximetasone 2 Desvenlafaxine ER ST, QL 4 citalopram, fluoxetine, paroxetine, sertraline, venlafaxine, venlafaxine ER capsules, duloxetine (ST) dexamethasone 0.5mg, 0.75mg 1 dexamethasone 2 dexmethylphenidate ER QL 2 (PA < 5 and 28 years of age) dexmethylphenidate QL (PA < 2 5 and 28 years of age) dextroamphetamine QL (PA < 5 2 and 28 years of age) Diastat 3 Diastat Acudial 4 diazepam diazepam 2 Dibenzyline PA 5 Specialty medication diclofenac 2 diclofenac ophthalmic solution 1 diclofenac-misoprostol 2 dicyclomine 10mg, 20mg 1 dicloxacillin 2 didanosine 2 Dificid ST, QL 5 Specialty medication diflorasone 2 digoxin 2 dihydroergotamine 2 diltiazem 2 diltiazem ER 2 Dipentum ST 4 balsalazide disodium, Apriso, Asacol HD, Delzicol dipyridamole 2 disulfuram 2 divalproex sodium 2 divalproex sodium ER 2 Divigel 4 estradiol donepezil PA 2 dorzolamide 2 dorzolamide / timolol 2

9 doxazosin 2 doxercalciferol 2 doxycycline 2 drithocreme 2 Dritho-Scalp 3 dronabinol 2 Duavee 4 estradiol-norethindrone, Jinteli, Prempro, Premphase Dulera 3 duloxetine ST, QL 2 Durasal 4 salicyclic acid Durezol 4 fluorometholone, prednisolone Dymista ST 4 fluticasone, flunisolide, Veramyst Dynacirc CR 4 diltiazem, cartia XT, nifedipine, nifedipine ER, taztia XT, verapamil, verapamil SR, Nifediac CC, amlodipine besylate dyphylline gg 2 Dyrenium 4 triamterene-hctz Dysport PA, QL 5 Specialty medication Edarbi ST 4 losartan, eprosartan, irbesartan, candesartan, telmisartan, valsartan Edarbyclor ST 4 candesartan-hctz, irbesartan-hctz, losartan-hctz, telmisartan-hctz, valsartan-hctz Edurant 3 Effient QL 3 Elaprase PA 5 Specialty medication Elelyso PA 5 Specialty medication Elidel PA 4 Generic topical steroids Eligard PA, QL 5 Specialty medication Elinest 2 eliphos 2 Eliquis QL 3 Ella 4 levonorgestrel, Next Choice Elmiron 3 Emadine 4 azelastine, epinastine, Pataday, Patanol Emcyt PA 5 Specialty medication Emend capsule QL 3 Emend vial QL 4 Emoquette 2 Emtriva 3 enalapril 1 enalapril-hctz 1 Enbrel PA, QL 5 Specialty medication Endocet QL 2 Enjuvia 4 estradiol, estropipate, Premarin enoxaparin QL 2 Enpresse 2 Enskyce 2 entacapone 2 Entyvio PA, QL 5 Specialty medication epinastine ophthalmic solution 2 epinephrine 2 EpiPen 3

10 eplerenone 2 Epogen PA 5 Specialty medication epoprostenol PA 5 Specialty medication eprosartan 2 Epzicom 3 ergotamine / caffeine 2 Erivedge PA, QL 5 Specialty medication Errin 2 EryPed 4 erythromycin Ery-tab EC 2 Ery-tab EC 500mg 3 erythromycin 5mg/gm oint 1 erythromycin 2 erythromycin / benzoyl 2 peroxide gel escitalopram ST, QL 2 Estarylla 2 Estrace cream 4 estradiol, estropipate, Premarin Estraderm QL 4 estradiol estradiol 1 estradiol / norethindrone 2 estradiol patch QL 2 Estring 4 estradiol, estropipate, Premarin Estrogel 4 Premarin estropipate 2 eszopiclone ST, QL 2 etidronate 2 etodolac 2 etoposide PA 5 Specialty medication Euflexxa PA, QL 5 Specialty medication Evamist 4 estradiol Evzio PA, QL 5 Specialty medication Exelon patch PA 4 rivastigmine tartrate capsules (PA), donepezil (PA), Namenda (PA) exemestane 2 Exjade PA 5 Specialty medication Eylea PA 5 Specialty medication Fabior (PA >45 years of age) 4 Generic topical acne agents Fabrazyme PA 5 Specialty medication Factive QL 4 ciprofloxacin, levofloxacin Falmina 2 famciclovir QL 2 famotidine 1 Fanapt PA, QL (ST <23 years of age) 4 risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) Fareston PA 5 Specialty medication felbamate 2 felodipine 2 FemHRT 4 estradiol-norethindrone, Jinteli, Prempro, Premphase Femring 4 estradiol, estropipate, Premarin Femtrace 4 estradiol, estropipate, Premarin fenofibrate 2

11 fenofibric acid ST 2 fenoprofen 2 fentanyl citrate PA, QL 2 fentanyl transdermal QL 2 Fentora PA, ST, QL 4 fentanyl citrate (PA), Abstral (PA) Ferriprox PA 5 Specialty medication Fetzima PA, QL 4 venlafaxine ER, duloxetine (ST) Finacea 4 Generic topical acne agents finasteride 2 Firazyr PA, QL 5 Specialty medication Firmagon PA, QL 5 Specialty medication First Testosterone 3% cream PA, 4 testosterone injection (PA), Androgel 2.63% (PA) ST First Testosterone 3% ointment 4 testosterone injection (PA), Androgel 2.63% (PA) PA, ST First-BXN Mouthwash 4 diphenhydramine, lidocaine, nystatin Flarex 4 fluorometholone, prednisolone Flebogamma PA 5 Specialty medication flecainide 2 Flovent HFA 3 fluconazole 150mg QL 1 fluconazole QL 2 flunisolide 2 fluocinolone 2 fluocinonide 2 Fluor-A-Day chew 2 Fluor-A-Day drops 3 fluorometholone 2 fluoxetine 1 fluoxetine DR QL 2 fluphenazine (ST <23 years of 2 age) flurbiprofen 2 fluticasone 2 fluvastatin 2 fluvoxamine 2 FML Forte 4 fluorometholone, prednisolone FML S.O.P. 3 folic acid 1mg 1 fondaparinux QL 2 Foradil 3 Forteo ST, QL 5 Specialty medication Fortesta PA, ST 4 testosterone injection (PA), Androgel 2.63% (PA) fosinopril 2 fosinopril / HCTZ 2 Fosrenol 4 calcium acetate, sevelamer carbonate, Renvela powder packet Fragmin QL 5 Specialty medication Frova ST, QL 4 naratriptan, rizatriptan, sumatriptan, zolmitriptan Fulyzaq PA, QL 5 Specialty medication furosemide 1 Fuzeon 5 Specialty medication

12 Fycompa PA, QL 4 felbamate, lamotrigine, topiramate, valproate gabapentin 100mg 2 gabapentin 2 Gablofen 4 galantamine ER PA 2 galantamine PA 2 Galzin PA 3 Gammagard PA 5 Specialty medication Gammaked PA 5 Specialty medication Gammaplex PA 5 Specialty medication Gamunex PA 5 Specialty medication Gamunex-C PA 5 Specialty medication ganciclovir 2 gatifloxacin 2 Gattex PA, QL 5 Specialty medication gavilyte-g 2 gemfibrozil 2 Gentak eye drops 1 gentamicin eye drops 0.3% 1 gentamicin 0.1% oint, cream 1 Generess FE 4 Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Gianvi 2 Gildagia 2 Gildess 2 Gilenya PA, ST, QL 5 Specialty medication Gilotrif PA, QL 5 Specialty medication Glassia PA 5 Specialty medication Gleevec PA, QL 5 Specialty medication glimepiride 1 glipizide 1 glipizide / metformin 2 glipizide ER 2 Glucagon 3 glyburide micronized 1 glyburide 2 glyburide / metformin 2 Glyset 4 acarbose Gralise PA, QL 4 gabapentin granisetron ST, QL 2 ondansetron granisol ST, QL 2 ondansetron Granix PA 5 Specialty medication griseofulvin 2 guanfacine 1 Halflytely 4 peg-4450, Suprep, Moviprep halobetasol 2 Halog 4 Generic topical steroids haloperidol (ST <23 years of 1 age) HCTZ 1 Heather 2 Helidac 4 bismuth subsalicylate (OTC), metronidazole, tetracycline

13 Hetlioz PA, QL 5 Specialty medication Hexalen 5 Specialty medication Hizentra PA 5 Specialty medication Horizant PA, QL 4 gabapentin, pramipexole, ropinirole Humalog 50/50 QL 3 Humalog 75/35 QL 3 Humalog QL 3 Humira PA, QL 5 Specialty medication Humulin 50/50 QL 3 Humulin 70/40 QL 3 Humulin N QL 3 Humulin R QL 3 Hycamtin PA 5 Specialty medication hydralazine 1 hydrocodone / ibuprofen 2 hydrocodone/ acetaminophen 2 QL hydrocort / pramoxine cream 2 hydrocortisone 1%, 2.5% 1 cream hydrocortisone 2 hydromorphone 2 hydroxychloroquine 2 hydroxyurea 2 hydroxyzine 2 hyoscyamine 2 ibandronate IV ST, QL 4 alendronate, ibandronate, risedronate ibandronate tablet QL 2 ibuprofen 400mg, 600mg, 1 800mg tablets ibuprofen susp 1 Iclusig PA, QL 5 Specialty medication Ilaris PA, QL 5 Specialty medication Ilevro 4 ketorolac, diclofenac, bromfenac indapamide 1.25mg, 2.5mg 1 Imbruvica PA, QL 5 Specialty medication imiquimod 2 Increlex PA 5 Specialty medication Incruse Ellipta 4 Spiriva, Tudorza indomethacin 25mg 1 indomethacin 2 Infergen PA, QL 5 Specialty medication Inlyta PA, QL 5 Specialty medication Innopran XL ST 4 atenolol, metoprolol, propranolol Intelence PA 3 Intron A PA 5 Specialty medication Introvale 2 Intuniv ST, QL 4 guanfacine Invega PA, QL (ST <23 years of age) 4 risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST)

14 Invega Sustenna PA, QL (ST <23 years of age) 5 Specialty medication Invirase 3 Invokana QL 4 metformin, glyburide, glipizide, Januvia, Tradjenta ipratropium bromide neb 1 ipratropium 2 ipratropium / albuterol solution 2 irbesartan 2 irbesartan / HCTZ 2 Iressa PA, QL 5 Specialty medication Isentress 3 Isoniazid 300mg 1 Isopto Carbachol 4 betaxolol, brimonidine, carteolol, dorzolamide, latanoprost, levobunolol, timolol, Combigan, Azopt, Betoptic S Isopto Homatropine 4 homatropine, atropine, cyclopentolate, mydral, tropicamide isosorbide 2 isradipine 2 Istalol 4 timolol itraconazole capsule PA, QL 2 Jakafi PA, QL 5 Specialty medication Jalyn 3 Janumet 3 Janumet XR 3 Januvia 3 Jencycla 2 Jentadueto 3 Jetrea PA, QL 5 Specialty medication Jinteli 2 Jolessa 2 Jolivette 2 Junel 2 Junel FE 2 Juxtapid PA, QL 5 Specialty medication Kalbitor PA 5 Specialty medication Kaletra 3 Kalydeco PA, QL 5 Specialty medication Kariva 2 Kazano ST 4 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Ketek QL 4 azithromycin, clarithromycin ER, erythromycin ketoconazole 2 ketoprofen 2 ketorolac ophthalmic solution 2 ketorolac QL 2 Khedezla ER ST, QL 4 citalopram, fluoxetine, paroxetine, sertraline, venlafaxine, venlafaxine ER capsules, duloxetine (ST) Kineret PA, QL 5 Specialty medication Kombiglyze XR ST 4 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Korlym PA, QL 5 Specialty medication Krystexxa PA, QL 5 Specialty medication

15 Kurvelo 2 Kuvan PA 5 Specialty medication Kynamro PA, QL 5 Specialty medication labetalol 2 lactulose 2 lamivudine 2 lamivudine / zidovudine 2 lamivudine HBV PA 2 lamotrigine 2 lansoprazole / amoxicillin / 2 clarithromycin pack lansoprazole QL 2 Lantus QL 3 Larin 2 Larin Fe 2 Lastacaft 4 azelastine, epinastine, Pataday, Patanol latanoprost 2 Latuda ST, QL (ST <23 years of age) 4 risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) Lazanda PA, ST, QL 4 fentanyl citrate (PA), Abstral (PA) Leena 2 leflunomide 2 Lessina 2 Letairis PA, QL 5 Specialty medication letrozole 2 Leukeran 3 Leukine PA 5 Specialty medication leuprolide PA 5 Specialty medication levalbuterol ST 2 Levatol ST 4 atenolol, metoprolol, propranolol Levemir QL 3 levetiracetam 2 levetiracetam ER QL 2 levobunolol 2 levocetirizine 2 levofloxacin 2 levofloxacin ophthalmic 2 Levonest 2 levonorgestrel 2 Levora 2 levothyroxine 1 Lexiva 3 Lialda ST 4 balsalazide disodium, Apriso, Asacol HD, Delzicol lidocaine patch ST, QL 2 lidocaine-hc gel 2 lidocaine viscous 2% soln 1 LidoVir ointment compounding kit 4 For cold sore treatment use over-the-counter agents Lifescan Blood Glucose Meters 3 Lifescan Blood Glucose Test 3 Strips (QL > 28 years of age)

16 Lifescan Lancets (QL > 28 years 3 of age) Linzess QL 4 Amitiza liothyronine 2 Lipofen 4 fenofibrate Liptruzet ST 4 atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, Zetia lisinopril 1 lisinopril / HCTZ 1 lithium carbonate 300mg 1 Lo Loestrin FE 4 Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Loestrin 35 FE 4 Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Lomedia 35 FE 4 Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Lo Minastrin FE 4 Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Lomustine 3 loratadine 1 lorazepam 2 Lorcet HD QL 2 Lorcet plus QL 2 Lortab QL 2 Loryna 2 losartan 2 losartan / HCTZ 2 Lotemax 4 fluorometholone, prednisolone Lotronex PA 5 Specialty medication lovastatin 1 Low-ogestrel 2 loxapine (ST <23 years of age) 2 Lucentis PA 5 Specialty medication Lumigan 3 Lumizyme PA 5 Specialty medication Lupaneta PA, QL 5 Specialty medication Lupron PA, QL 5 Specialty medication Lyrica PA, QL 4 gabapentin, Savella (PA) Lysodren PA 5 Specialty medication Lyza 2 Makena PA 5 Specialty medication malathion 2 Matulane 5 Specialty medication matzim LA 2 Maxair ST, QL 4 Ventolin HFA Maxaquin 4 ciprofloxacin, levofloxacin Maxidex 4 fluorometholone, prednisolone meclizine 2 medroxyprogesterone tabs 1 medroxyprogesterone acetate 2 injection QL

17 mefenamic acid 2 Mekinist PA, QL 5 Specialty medication meloxicam 1 Menest 4 Premarin, estradiol, estropipate Menostar QL 4 estradiol meperidine tablet 2 mercaptopurine 2 mesalamine 2 metaxalone 2 metformin 1 metformin ER 1 Methadose 2 methamphetamine QL (PA < 5 2 and 28 years of age) methazolamide 2 Methitest PA 4 testosterone injection (PA), Androgel 2.63% (PA) methocarbamol 2 methotrexate 2 methoxsalen PA 2 5 Specialty Medication methyldopa 250mg 1 methylin ER QL (PA < 5 and 2 28 years of age) methylin QL (PA < 5 and 28 2 years of age) methylphenidate ER QL (PA < 2 5 and 28 years of age) methylphenidate QL (PA < 5 2 and 28 years of age) methylprednisolone 2 metipranolol 2 metoclopramide 1 metoprolol tartrate 1 metoprolol succinate 2 metoprolol / HCTZ 2 metoprolol ER 2 metronidazole 2 Miacalcin 4 alendronate, ibandronate, risedronate Microgestin 2 Microgestin FE 2 midazolam syrup 2 Migergot 2 migragesic IDA 2 Mimvey 2 Mimvey Lo 2 Minastrin 35 Fe 4 Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Minivelle QL 4 estradiol patch, Premarin minocycline 2 Mirapex ER ST 4 pramipexole, ropinirole mirtazapine 2 Mirvaso PA 4 metronidazole, sodium sulfacetamide/sulfur, tretinoin, adapalene

18 modafinil PA, QL 2 Moderiba QL 5 Specialty medication moexipril 2 moexipril / HCTZ 2 mometasone 2 Mono-linyah 2 MonoNessa 2 montelukast QL 2 Monurol 3 morphine sulfate ER tablet QL 2 morphine sulfate IR 2 Moviprep 3 Moxeza 3 moxifloxacin 2 Mozobil PA, QL 5 Specialty medication Multaq 3 mupirocin 2 Myalept PA, QL 5 Specialty medication mycophenolate mofetil 2 mycophenolate sodium 2 Myobloc PA, QL 5 Specialty medication Myorisan 2 Myozyme PA 5 Specialty medication Myrbetriq ER QL 4 oxybutynin, oxybutynin ER, trospium, trospium ER, tolterodine, tolterodine ER, Toviaz, Vesicare Myzilra 2 nabumetone 2 nadolol 2 nadolol / bendroflumethiazide 2 Naglazyme PA 5 Specialty medication Namenda PA 3 Namenda XR PA 3 naproxen 375mg, 500mg 1 naproxen 125mg/5ml 1 naproxen sodium 2 naratriptan QL 2 Nasonex ST 4 flunisolide, fluticasone, Veramyst Natazia 3 nateglinide 2 Nebupent 3 Necon 2 Nesina ST 4 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Neulasta PA 5 Specialty medication Neumega 5 Specialty medication Neupogen PA 5 Specialty medication Neupro 4 pramipexole, ropinirole Nevanac 4 ketorolac, diclofenac, bromfenac nevirapine 2 nevirapine ER 2 Nexavar PA, QL 5 Specialty medication

19 Nexium ST, QL 4 omeprazole, lansoprazole, pantoprazole Next Choice 2 Next Choice One Dose 2 niacin ER 2 nicotine gum QL 2 nicotine lozenges QL 2 nicotine patches QL 2 Nicotrol Inhaler ST, QL 3 4 Nicotrol Nasal Spray ST, QL 3 4 nifediac CC 2 nifedipine 2 nifedipine ER 2 Nikki 2 Nilandron PA 5 Specialty medication nimodipine 2 nisoldipine 2 nisoldipine ER 2 nitrofurantoin 2 nitroglycerin 2 Nitrostat 4 nitroglycerin nizatidine 2 nodolor 2 Nora-BE 2 Norditropin PA 5 Specialty medication Norlyroc 2 Noroxin 4 ciprofloxacin, levofloxacin Nortrel 2 nortriptyline 1 Norvir 3 Novolin 70/40 QL 3 Novolin N QL 3 Novolin QL 3 Novolin R QL 3 Novolog Mix 70/40 QL 3 Novolog QL 3 Noxafil PA 5 Specialty medication Nplate PA 5 Specialty medication Nuedexta PA, QL 5 Specialty medication Nulojix PA 5 Specialty medication Numoisyn 4 Caphosol Nuvaring QL 3 Nuvigil PA, QL 4 amphetamine salts, amphetamine/dextroamphetamine ER, dexmethylphenidate, dexmethylphenidate ER, methylphenidate, methylphenidate ER, modafinil (PA) NuZon 4 hydrocortisone nystatin 100,000u/gm cream 1 Ocella 2 octreotide 5 Specialty medication ofloxacin 2 Oforta PA 5 Specialty medication Ogestrel 2

20 olanzapine / fluoxetine PA, QL 2 (ST <23 years of age) olanzapine QL (ST <23 years of 2 age) olanzapine vial 2 Olysio PA, QL 5 Specialty medication Omeclamox-Pak 4 omeprazole, clarithromycin, amoxicillin omega-4 acid ethyl esters 2 omeprazole QL 2 Omnaris ST 4 fluticasone, flunisolide, Veramyst Omontys PA 5 Specialty medication ondansetron QL 2 One Touch Blood Glucose 3 Meters One Touch Blood Glucose Test 3 Strips (QL > 28 years of age) Onfi PA, QL 4 felbamate, lamotrigine, topiramate, valproate Onglyza ST 4 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Onmel PA, QL 4 itraconazole (PA) Onsolis PA, ST, QL 4 fentanyl citrate (PA), Abstral (PA) Opana ER QL 3 Opsumit PA, QL 5 Specialty medication OramagicRx 4 lidocaine, First-Mouthwash Orap (ST <23 years of age) 3 Orencia PA, QL 5 Specialty medication Orenitram PA 5 Specialty medication Orfadin PA 5 Specialty medication Orsythia 2 Ortho Tri-Cyclen LO 3 Oseni 4 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Osmoprep 4 peg-4450, Suprep, Moviprep Otezla PA, QL 5 Specialty medication Otosporin ear drops 4 Acetic acid/hydrocortisone Otrexup PA, QL 5 Specialty medication oxaprozin 2 oxazepam 2 oxcarbazepine 2 Oxsoralen PA 5 Specialty medication oxybutynin 2 oxybutynin ER 2 oxycodone / acetaminophen 2 QL oxycodone / aspirin QL 2 oxycodone / ibuprofen QL 2 oxycodone IR 2 Oxycontin PA, QL 4 morphine sulfate ER, fentanyl patches, oxymorphone ER oxymorphone 2 oxymorphone ER QL 2 Pancreaze ST 4 Creon Pancrelipase ST 4 Creon Pandel 4 Generic topical steroids Panretin PA 5 Specialty medication

21 pantoprazole QL 2 paricalcitol 2 paroxetine 10mg, 20mg 1 paroxetine 30mg, 40mg 2 paroxetine CR QL 2 Pataday 3 Patanase 4 azelastine Patanol 3 peg Peganone PA 4 carbamazepine, lamotrigine, oxcarbazepine, phenytoin, topiramate, valproic acid Pegasys PA, QL 5 Specialty medication Peg-Intron PA, QL 5 Specialty medication pemoline 2 penicillin 250mg 1 penicillin 125mg/5ml, 1 250mg/5ml soln penicillin 500mg 2 Pentasa 4 balsalazide disodium, sulfasalazine, sulfasalazine EC, Apriso, Asacol HD, Delzicol pentazocine / acetaminophen 2 QL pentazocine/ naloxone 2 Perforomist 4 Serevent, Foradil perindopril 2 permethrin cream 2 perphenazine (ST <23 years of 2 age) Pertzye ST 4 Creon phenelzine 2 phenobarbital 2 phenazopyridine 1 phenytoin 2 Philith 2 Phospholine Iodide 4 pilocarpine Picato PA 4 5-fluorouracil, imiquimod pilocarpine 2 Pilopine HS 4 pilocarpine Pimtrea 2 pindolol 2 pioglitazone 2 pioglitazone / glimepiride 2 pioglitazone / metformin 2 Pirmella 2 piroxicam 2 podofilox 2 Pomalyst PA, QL 5 Specialty medication Portia 2 potassium chloride 2 Potiga PA, QL 4 carbamazepine, phenytoin, oxcarbazepine, valproic acid, levetiracetam, topiramate, tiagabine, zonisamide Pradaxa QL 3

22 pramipexole 2 Pramosone 4 hydrocortisone/pramoxine Prandimet 4 metformin, repaglinide pravastatin 2 prazosin 2 Pred Mild 4 fluorometholone, prednisolone prednicarbate 2 prednisolone 2 prednisone 2.5mg, 5mg, 10mg, 1 20mg tabs prednisone 2 Prefest 4 estradiol-norethindrone, Jinteli, Prempro, Premphase Premarin 3 Premarin Vaginal Cream 3 Premphase 3 Prempro 3 Prenate 4 generic prenatal vitamins Prepopik 4 peg-4450, Suprep, Moviprep Prevident 4 sodium fluoride gel Prezista 3 primidone 2 Pristiq ST, QL 4 citalopram, fluoxetine, paroxetine, sertraline, venlafaxine, venlafaxine ER capsules, duloxetine (ST) Privigen PA 5 Specialty medication ProAir HFA ST, QL 4 Ventolin HFA prochlorperazine 5mg, 10mg 1 Procrit PA 5 Specialty medication Proctofoam-HC 3 Procysbi PA, QL 5 Specialty medication progesterone capsule 2 Prolastin PA 5 Specialty medication Prolastin-C PA 5 Specialty medication Prolensa 4 ketorolac, diclofenac, bromfenac Proleukin 5 Specialty medication Prolia PA, QL 5 Specialty medication Promacta PA, QL 5 Specialty medication promethazine syrup 1 promethazine 25mg 1 promethazine-dm syrup 1 propafenone ER 2 propranolol 1 propranolol / HCTZ 2 propranolol SA 2 Protopic PA 4 Generic topical steroids protriptyline 2 Proventil HFA ST, QL 4 Ventolin HFA pruvate Pulmicort Flexhaler ST 4 QVAR, Flovent HFA, Asmanex Pulmozyme PA, QL 5 Specialty medication QNASL ST 4 flunisolide, fluticasone, Veramyst Quartette 4 Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral

23 Quasense 2 quetiapine PA, QL (ST <23 2 years of age) quinapril 2 quinapril / HCTZ 2 Qutenza PA, QL 5 Specialty medication QVAR 3 raloxifene 2 ramipril 2 Ranexa 3 ranitidine 1 Rapaflo ST 4 doxazosin, tamsulosin, terazosin, prazosin, alfuzosin er Ravicti PA, QL 5 Specialty medication Rebif ST, QL 5 Specialty medication Rectiv PA 4 topical diltiazem compound, topical nifedipine compound Regranex QL 5 Specialty medication Relenza QL 4 amantadine Relistor PA 5 Specialty medication Relpax ST, QL 4 naratriptan, rizatriptan, sumatriptan, zolmitriptan Remicade PA 5 Specialty medication Remodulin PA 5 Specialty medication renalpren 2 Renvela powder packet 3 repaglinide 2 reprexain 2 Rescriptor 3 Rescula ST 4 latanoprost, Lumigan Restasis QL 3 Revlimid PA, QL 5 Specialty medication Reyataz 3 Ribasphere QL 5 Specialty medication Ribatab QL 5 Specialty medication ribavirin QL 5 Specialty medication rifabutin 2 rifampin 2 riluzole PA, QL 5 Specialty medication Riomet 4 metformin risedronate QL 2 Risperdal Consta PA, QL (ST <23 years of age) 5 Specialty medication risperidone ODT QL (ST <23 2 years of age) risperidone QL (ST <23 years 2 of age) Rituxan PA, QL 5 Specialty medication rivastigmine tartrate capsules 2 PA rizatriptan QL 2 ropinirole 2 ropinirole ER 2 Roxicet solution 3 Sabril PA, QL 5 Specialty medication

24 Safyral 3 salicylic acid 2 Samsca PA, QL 5 Specialty medication Sancuso ST, QL 4 ondansetron Sandostatin LAR PA, QL 5 Specialty medication Santyl 3 Saphris ST, QL (ST <23 years of age) Savella PA, QL 3 selegiline 2 selenium sulfide shampoo 2 Selzentry PA 3 Sensipar 3 Serevent 3 Seroquel XR PA, ST, QL (ST <23 years of age) Serostim PA 5 Specialty medication sertraline 1 \ sevelamer carbonate 2 Signifor PA, QL 5 Specialty medication sildenafil 30mg PA, QL 5 Specialty medication 4 risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) 4 risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) silver sulfadiazine topical 1 cream Simbrinza 4 brimonidine, dorzolamide, Azopt, Combigan Simcor ST 3 4 simvastatin, niacin ER Simponi Aria PA, QL 5 Specialty medication Simponi PA, QL 5 Specialty medication simvastatin 1 sirolimus PA 2 Sirturo PA 4 Sivextro QL 5 Specialty medication sodium fluoride gel 2 sodium phenylbutyrate powder PA 5 Specialty medication sodium sulfacetamide / sulfur / 2 urea Soliris PA 5 Specialty medication Somatuline PA, QL 5 Specialty medication Somavert PA, QL 5 Specialty medication sotalol 80mg 1 sotalol 2 Sovaldi PA, QL 5 Specialty medication Spectracef 4 cefpodoxime, cefdinir Spiriva 3 spironolactone 25mg 1 spironolactone 2 spironolactone / HCTZ 2 Sporanox solution PA 4 itraconazole capsule (PA) Sprintec 2 Sprycel PA, QL 5 Specialty medication stavudine 2 Stelara PA, QL 5 Specialty medication

25 Stivarga PA, QL 5 Specialty medication Strattera QL 3 Striant PA, ST 4 testosterone injection (PA), Androgel 2.63% (PA) Stribild 3 Suboxone film PA, QL 3 Subsys PA, ST, QL 4 fentanyl citrate (PA), Abstral (PA) Suclear 4 peg-4450, Suprep, Moviprep Sucraid PA 5 Specialty medication sulfacetamide sodium 2 sulfamethoxazole / 1 trimethoprim tabs sulfasalazine 2 sulfasalazine EC 2 sulfisoxazole 2 sulindac 2 sumatriptan QL 2 Sumavel DosePro QL 4 naratriptan, rizatriptan, sumatriptan, zolmitriptan Supprelin LA PA, QL 5 Specialty medication Suprax 4 cefpodoxime, cefdinir Suprep 3 Sustiva 3 Sutent PA, QL 5 Specialty medication Syeda 2 Sylatron PA 5 Specialty medication Sylvant PA 5 Specialty medication Symbicort 3 Symlin ST, QL 3 Synagis PA, QL 5 Specialty medication Synarel PA, QL 5 Specialty medication Synvisc One PA, QL 5 Specialty medication Synvisc PA, QL 5 Specialty medication Syprine PA 3 5 Specialty medication Tabloid PA 3 tacrolimus 2 Tafinlar PA, QL 5 Specialty medication Tamiflu QL 4 amantadine tamoxifen 2 tamsulosin 2 Tanzeum QL ST 4 Bydureon, Victoza Tarceva PA, QL 5 Specialty medication Targretin PA 5 Specialty medication Tasigna PA, QL 5 Specialty medication Tasmar 4 entacapone Tazorac (PA >45 years of age) 4 Generic topical acne agents taztia XT 2 Tecfidera PA, QL 5 Specialty medication Tekamlo ST 3 Tekturna HCT ST 3 Tekturna ST 3 telmisartan 2 telmisartan / amlodipine 2 telmisartan / HCTZ 2

26 temazepam 2 temozolomide PA 5 Specialty medication Tencon 2 terazosin 1 terbinafine tabs QL 1 Testim PA, ST 4 testosterone injection (PA), Androgel 2.63% (PA) Testopel PA 4 testosterone injection (PA), Androgel 2.63% (PA) Testosterone gel PA, ST 4 testosterone injection (PA), Androgel 2.63% (PA) testosterone injection PA 2 Testred PA, ST 4 testosterone injection (PA), Androgel 2.63% (PA) tetracaine ophthalmic 2 tetracycline 2 Thalomid PA, QL 5 Specialty medication Theo-35 ER 3 4 theophylline ER theophylline ER 2 thioridazine (ST <23 years of 2 age) thiothixene (ST <23 years of 2 age) Thyrogen 5 Specialty medication tiagabine 2 ticlopidine 2 Tikosyn 3 Tilia FE 2 timolol 2 tinidazole 2 Tirosint 4 levothyroxine Tivicay 3 tizanidine tablet 2 TOBI Podhaler QL 5 Specialty medication Tobradex ST 4 tobramycin/dexamethasone tobramycin 0.3% ophth 2 tobramycin 2 tobramycin / dexamethasone 2 tobramycin solution for nebulization QL 5 Specialty medication Tobrex 4 ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin, Zymar, Moxeza, Vigamox tolazamide 2 tolbutamide 2 tolmetin 2 tolterodine 2 tolterodine ER 2 topiragen QL 2 topiramate 2 topiramate sprinkle QL 2 Toviaz 3 Tracleer PA, ST, QL 5 Specialty medication Tradjenta 3 tramadol / acetaminophen QL 2

27 tramadol ER tablet QL 2 tramadol QL 2 trandolapril 2 trandolapril / verapamil 2 tranexamic acid PA, QL 2 Transderm-Scop 4 meclizine tranylcypromine 2 Travatan Z ST 4 latanoprost, Lumigan, travoprost (ST) travoprost ST 2 trazodone 1 Trelstar PA, QL 5 Specialty medication tretinoin oral 5 Specialty medication tretinoin topical 2 Trezix 2 triamcinolone 0.025%, 0.1%, 1 0.5% cream triamcinolone 0.1% oint 1 triamcinolone 2 triamterene / HCTZ 1 Tri-estarylla 2 trifluoperazine (ST <23 years 2 of age) trihexyphenidyl 2mg 1 Tri-legest FE 2 Tri-linyah 2 Trilyte 2 Trinessa 2 Tri-previfem 2 Tri-sprintec 2 Trivora 2 trospium 2 trospium ER 2 Truvada 3 Tudorza Pressair 3 Tykerb PA, QL 5 Specialty medication Tysabri PA, ST, QL 5 Specialty medication Tyvaso PA 5 Specialty medication Tyzeka PA 5 Specialty medication Uceris PA 4 budesonide Ulesfia 3 4 Uloric ST, QL 3 allopurinol Ultresa ST 4 Creon unithroid 2 urea 2 Urocit-K 4 potassium citrate ursodiol 2 Vagifem 4 Premarin, estradiol, estropipate valacyclovir QL 2 Valchlor PA 5 Specialty medication Valcyte 4 ganciclovir valproate 2 valsartan 2

28 valsartan / HCTZ 2 vancomycin capsules 2 Vanoxide-HC 4 benzoyl peroxide Vantas PA, QL 5 Specialty medication Vascepa 4 fenofibrate, atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin Vasolex 4 Santyl Vectical QL 4 calcipotriene Veletri PA 5 Specialty medication Velivet 2 Velphoro 4 calcium acetate, sevelamer carbonate venlafaxine 2 venlafaxine ER capsule QL 2 Ventavis PA 5 Specialty medication Ventolin HFA QL 3 Veramyst 3 verapamil 80mg, 120mg 1 verapamil 2 verapamil ER PM 2 verapamil extended release 2 verapamil SR 2 Veregen 4 podofilox, imiquimod Vesicare 3 Vestura 2 Vexol 4 fluorometholone, prednisolone Victoza ST 3 Videx solution 3 Vigamox 3 Viibryd PA, QL 4 paroxetine, sertraline, citalopram, venlafaxine ER capsules, duloxetine (ST) Vimizim PA 5 Specialty medication Vimpat PA 4 carbamazepine, lamotrigine, oxcarbazepine, phenytoin, zonisamide Viokace ST 4 Creon Viracept 3 Viread 3 visqid a/a 2 vistra 2 vitamins (generic pediatric) 2 vitamins (generic prenatal) 2 Vivelle-DOT QL 4 estradiol patch, Premarin Vivitrol PA 5 Specialty medication Vogelxo PA, ST 4 testosterone injection (PA), Androgel 2.63% (PA) Voltaren Gel QL 4 diclofenac, ibuprofen, naproxen voriconazole QL 2 Votrient PA, QL 5 Specialty medication VPRIV PA 5 Specialty medication Vyfemla 2 Vytorin ST 4 atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, Zetia

29 Vyvanse QL (PA < 5 and >28 years of age) 4 amphetamine salts, dexmethylphenidate, methylphenidate, amphetamine-dextroamphetamine ER, methylin, methylin ER, methylphenidate ER, Strattera warfarin 1 Welchol 3 Wera 2 WP Thyroid 4 levothyroxine Wymzya Fe 2 Xalkori PA, QL 5 Specialty medication Xarelto QL 3 Xeljanz PA, QL 5 Specialty medication Xenazine PA, QL 5 Specialty medication Xeomin PA, QL 5 Specialty medication Xerac AC 3 Xgeva PA, QL 5 Specialty medication Xifaxan 300mg QL 4 ciprofloxacin, loperamide Xifaxan 550mg PA, QL 4 lactulose Xolair PA, QL 5 Specialty medication Xopenex HFA ST, QL 4 Ventolin HFA Xtandi PA, ST, QL 5 Specialty medication xulane QL 2 Xyrem PA, QL 5 Specialty medication zafirlukast 2 zaleplon 2 Zarah 2 Zavesca PA 5 Specialty medication Zelapar 4 carbidopa/levodopa, entacapone, ropinirole, pramipexole, carbidopa/levodopa/entacapone, Azilect Zelboraf PA, QL 5 Specialty medication Zemaira PA 5 Specialty medication Zenatane 2 Zenchent Fe 2 zenieva 2 Zenpep ST 3 4 Creon Zeosa 2 Zetia 3 Zetonna ST 4 fluticasone, flunisolide, Veramyst Zinotic ES 4 acetic acid/hydrocortisone, Ciprodex Zioptan ST 4 latanoprost, Lumigan ziprasidone QL (ST <23 years 2 of age) Zirgan gel 3 Zithranol-RR cream 4 Drithocreme Zmax QL 4 azithromycin, clarithromycin, erythromycin Zoladex PA, QL 5 Specialty medication zoledronic acid 5mg 5 Specialty medication zoledronic acid 5mg ST, QL 2 Zolinza PA, QL 5 Specialty medication zolmitriptan QL 2 zolpidem tartrate 2 Zomig nasal spray QL 4 naratriptan, rizatriptan, sumatriptan, zolmitriptan zonisamide 2

30 Zontivity PA, QL 4 clopidogrel, Effient Zorbtive PA 5 Specialty medication Zortress PA 3