Connecticut Medicaid Alphabetized Preferred Drug (PDL ...

Connecticut Medicaid Preferred Drug List (PDL)

Preferred Drug

ABILIFY MAINTENA ER (INTRAMUSC.) ABIRATERONE TABLET (ORAL) ACARBOSE TABLET (ORAL) ACETIC ACID 2% SOLUTION (OTIC) ACITRETIN CAPSULE (ORAL) ACNE MEDICATION LOTION (BENZOYL PEROXIDE) (TOPICAL) ACYCLOVIR CAPSULE, TABLET (ORAL) ACYCLOVIR SUSPENSION (ORAL) ADAKVEO VIAL (INTRAVENOUS) ADASUVE (INHALATION) ADDERALL TABLET (ORAL) (DX CODE REQ.) ADDERALL XR CAPSULE (ORAL) (DX CODE REQ.) ADVAIR DISKUS (INHALATION) ADVAIR HFA (INHALATION) AFINITOR TABLET (ORAL) (not DISPERZ) AFTERA 1.5 MG TABLET (ORAL) AJOVY (SUBCUTANEOUS) ALBENDAZOLE TABLET (ORAL) ALBUTEROL / IPRATROPIUM NEB SOLUTION (INHALATION) ALBUTEROL NEB SOLN 0.63, 1.25, 2.5 MG/3 ML (INHALATION) ALBUTEROL NEB SOLN 100 MG/20 ML (INHALATION) ALBUTEROL NEB SOLN 2.5 MG/0.5 ML (INHALATION) ALBUTEROL SOLUTION, SYRUP (not TABLET) (ORAL) ALECENSA CAPSULE (ORAL) ALENDRONATE TABLET (ORAL) ALFUZOSIN ER TABLET (ORAL) ALKERAN TABLET (ORAL) ALLOPURINOL (ORAL) ALPHAGAN P 0.15% DROP (OPHTHALMIC) ALPHANATE (INTRAVEN.) ALPRAZOLAM IR TABLET (not ER or ODT) (ORAL) ALREX 0.2% (OPHTHALMIC) ALTAVERA-28 TABLET (ORAL) ALUNBRIG TABLET, TABLET PACK (ORAL) ALYACEN 1-35 28 TABLET (ORAL) AMANTADINE CAPSULE, SOLUTION, TABLET (ORAL) AMETHIA 0.15-0.03-0.01 MG TAB (ORAL) AMITIZA CAPSULE (ORAL) AMLODIPINE / BENAZEPRIL (ORAL) AMLODIPINE / OLMESARTAN (ORAL) AMLODIPINE / VALSARTAN (ORAL) AMLODIPINE TABLET (ORAL) AMMONIUM LACTATE 12% CREAM (TOPICAL) AMMONIUM LACTATE 12% LOTION (TOPICAL) AMOXICILLIN / CLAV SUSPENSION (ORAL) AMOXICILLIN / CLAV TABLET (not CHEW TAB or ER) (ORAL) AMPHETAMINE SALT COMBO TABLET (IR) (ORAL) (DX CODE REQ.) ANASTROZOLE TABLET (ORAL) ANDROGEL 1.62% GEL PUMP (TRANSDERMAL)* ANORO ELLIPTA (INHALATION) APAP / CODEINE #2, #3, #4 TABLET (ORAL) APAP / CODEINE 120-12 MG/5 ML SOLUTION (ORAL) APAP / CODEINE 300-30 MG/12.5 ML SOLUTION (ORAL) APREPITANT CAPSULE (not PACK) (ORAL) APRI 28 DAY TABLET (ORAL) APRISO ER CAPSULE (ORAL) ARANESP DISP SYRIN, VIAL (INJECTION) ARIPIPRAZOLE SOLUTION, TABLET (not ODT) (ORAL) ASMANEX TWISTHALER (not HFA) (INHALATION) ASPIRIN-DIPYRIDAM ER 25-200 MG (ORAL) (70436-0092-05)

Diagnosis Code Link

DIAGNOSIS CODE REQ DIAGNOSIS CODE REQ

DIAGNOSIS CODE REQ

Updated July 1, 2021

Brand Name

ZYTIGA PRECOSE VOSOL

ZOVIRAX

BRAND PREFERRED

BRAND PREFERRED

DUONEB

FOSAMAX UROXATRAL BRAND PREFERRED ZYLOPRIM BRAND PREFERRED XANAX

BRAND PREFERRED LOTREL AZOR EXFORGE NORVASC LAC-HYDRIN AUGMENTIN ADDERALL BRAND PREFERRED TYLENOL W/ CODEINE

BRAND PREFERRED ABILIFY AGGRENOX

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Preferred Drug

Diagnosis Code Link

ATENOLOL / CHLORTHALIDONE (ORAL)

ATENOLOL TABLET (ORAL)

ATOMOXETINE CAPSULE (ORAL)

ATORVASTATIN TABLET (ORAL)

ATROVENT HFA (INHALATION)

AUBRA (ORAL)

AUROVELA 1 MG-20 MCG TABLET (ORAL)

AUROVELA 21 1.5-30 TABLET (ORAL)

AUROVELA FE 1-20 MCG, FE 1.5-30 MCG (ORAL)

AUSTEDO TABLET (ORAL)

AVIANE-28 TABLET (ORAL)

AVONEX PEN, PREFILLED SYRINGE, VIAL (INTRAMUSC.)

AYVAKIT TABLET (ORAL)*

AZATHIOPRINE TABLET (ORAL)

AZELASTINE 0.1% SPRAY 137MCG (not 0.15%) (NASAL)

AZITHROMYCIN 1 GM POWDER PACKET (ORAL)

AZITHROMYCIN SUSPENSION, TABLET (ORAL)

BACITRACIN-POLYMYXIN B SULFATE OINTMENT (OPHTHALMIC)

BACLOFEN TABLET (ORAL)

BALVERSA TABLET (ORAL)

BAQSIMI (NASAL)

BENAZEPRIL TABLET (ORAL)*

BENEFIX KIT (INTRAVEN.)

BENZOYL PEROXIDE 5% and 10% GEL (OTC) (TOPICAL)

BENZOYL PEROXIDE 6% CLEANSER (OTC) (TOPICAL)

BENZOYL PEROXIDE CREAM, WASH (not FOAM) (TOPICAL)

BENZTROPINE (ORAL)

BETAMETHASONE DP AUG 0.05% CREAM (TOPICAL)

BETAMETHASONE VALERATE 0.1% CREAM (TOPICAL)

BETAMETHASONE VALERATE 0.1% LOTION (TOPICAL)

BETAMETHASONE VALERATE 0.1% OINTMENT (TOPICAL)

BETASERON KIT (not VIAL) (SUBCUTANEOUS)

BETHKIS AMPULE (INHALATION)

BETOPTIC S 0.25% (OPHTHALMIC)

BICALUTAMIDE TABLET (ORAL)

BILTRICIDE TABLET (ORAL)

BISOPROLOL (ORAL)

BLISOVI FE 1.5-30, BLISOVI FE 1-20 (ORAL)

BOSULIF TABLET (ORAL)

BRAFTOVI CAPSULE (ORAL)

BREO ELLIPTA (INHALATION)

BRILINTA TABLET (ORAL)

BRIMONIDINE 0.2% DROP (OPHTHALMIC)

BRUKINSA CAPSULE (ORAL)

BUDESONIDE EC (ORAL)

BUPRENORPHINE / NALOXONE TABLETS (not FILM) (SUBLINGUAL)*

BUPRENORPHINE SL TABLET (SUBLINGUAL)

BUPROPION HCL SR 150 MG TABLET (ORAL)

BUPROPION SR, BUPROPION XL (NOT 450MG) (ORAL)

BUPROPION TABLET (ORAL)

BUSPIRONE (ORAL)

BYDUREON PEN INJECT (not BCISE) (SUBCUTANEOUS)

BYETTA DOSE PEN (SUBCUTANEOUS)

CABOMETYX TABLET (ORAL)

CALCIPOTRIENE 0.005% OINTMENT, SOLUTION (TOPICAL)

CALCITONIN-SALMON 200 UNITS SPRAY (NASAL)

CALCIUM ACETATE CAPSULE, GELCAP, TABLET (ORAL)

CALQUENCE CAPSULE (ORAL)

CAMILA 0.35 MG TABLET (ORAL)

CANASA SUPPOSITORY (RECTAL)

Brand Name

TENORETIC TENORMIN STRATTERA LIPITOR

ASTELIN ZITHROMAX ZITHROMAX LIORESAL

COGENTIN VALISONE

BRAND PREFERRED CASODEX BRAND PREFERRED

ALPHAGAN ENTOCORT EC SUBOXONE SL TABLETS WELLBUTRIN

DOVONOX FORTICAL PHOSLO, CALPHRON BRAND PREFERRED

Updated July 1, 2021

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Preferred Drug

CAPEX SHAMPOO (TOPICAL) CAPRELSA TABLET (ORAL) CAPSAICIN 0.025%, 0.075%, 0.1% CREAM (TOPICAL) CAPSAICIN 0.15% LIQUID (TOPICAL) CARBAMAZEPINE TAB CHEW, TABLET (ORAL) CARBATROL (ORAL) CARBIDOPA / LEVODOPA / ENTACAPONE TABLET (ORAL) CARBIDOPA / LEVODOPA ER TABLET (ORAL) CARBIDOPA / LEVODOPA TABLET (ORAL) CARTEOLOL 1% DROP (OPHTHALMIC) CARVEDILOL TABLET (not ER) (ORAL) CATAPRES-TTS PATCH (TRANSDERM) CEFACLOR CAPSULE (not SUSPENSION) (ORAL) CEFADROXIL CAPSULE, SUSPENSION (not TABLET) (ORAL) CEFDINIR CAPSULE, SUSPENSION (ORAL) CEFPROZIL SUSPENSION, TABLET (ORAL) CEFUROXIME TABLET (ORAL) CEPHALEXIN CAPSULE, SUSPENSION (not TABLET) (ORAL) CETIRIZINE SOFTGEL (not TABLETS) (OTC) (ORAL) CETIRIZINE SOLUTION, SYRUP (RX ONLY) (ORAL) CETIRIZINE-D TABLET (OTC) (ORAL) CHANTIX STARTING MONTH BOX, CONT MONTH BOX (ORAL) CHANTIX TABLET (ORAL) CHARLOTTE 24 FE CHEWABLE (ORAL)* CHATEAL-28 TABLET (ORAL) CHLORDIAZEPOXIDE (ORAL) CHLORPROMAZINE TABLET (ORAL) CHOLESTYRAMINE (with SUCROSE) (not LIGHT) (ORAL) CIMETIDINE OTC TABLET (not RX) (ORAL) CIPRO SUSPENSION (ORAL) CIPRODEX OTIC SUSPENSION (OTIC) CIPROFLOXACIN 0.3% SOLUTION (OPHTHALMIC) CIPROFLOXACIN TABLET (IR) (ORAL) CITALOPRAM TABLET, SOLUTION (ORAL) CITRANATAL B-CALM COMBO PACK (ORAL) CLARITHROMYCIN IR TABLET (not ER) (ORAL) CLEOCIN OVULES (VAGINAL) CLINDAMYCIN / BENZOYL PEROXIDE 1.2%-5% (DUAC) (TOPICAL) CLINDAMYCIN PH 1% PLEGET (TOPICAL) CLINDAMYCIN PH 1% SOLUTION (not GEL or LOTION) (TOPICAL) CLINDESSE 2% CREAM (VAGINAL) CLOBAZAM TABLET (ORAL) CLOBETASOL EMOLLIENT 0.05% CREAM (TOPICAL) CLOBETASOL PROPIONATE 0.05% CREAM (TOPICAL) CLOBETASOL PROPIONATE 0.05% GEL (TOPICAL) CLOBETASOL PROPIONATE 0.05% OINTMENT (TOPICAL) CLOBETASOL PROPIONATE 0.05% SOLUTION (TOPICAL) CLOBEX 0.05% SHAMPOO (TOPICAL) CLONAZEPAM IR TABLET (not ODT or ER) (ORAL) CLONIDINE ER (ORAL) CLONIDINE IR TABLET (ORAL) CLOPIDOGREL TABLET (ORAL) CLOTRIMAZOLE 1% CREAM (RX and OTC) (TOPICAL) CLOTRIMAZOLE 1% SOLUTION (RX ONLY) (TOPICAL) CLOTRIMAZOLE 10 MG TROCHE (MUCOUS MEM) CLOTRIMAZOLE-BETAMETHASONE CREAM (TOPICAL) CLOZAPINE TABLET (not ODT) (ORAL) COAGADEX (INTRAVEN) COLESTIPOL TABLET (not PACKET) (ORAL) COMBIGAN 0.2%-0.5% DROP (OPTHALMIC)

Diagnosis Code Link

Updated July 1, 2021

Brand Name

CHEWABLE OPTION BRAND PREFERRED STALEVO COREG BRAND PREFERRED

CHEWABLE OPTION BRAND PREFERRED BRAND PREFERRED

BRAND PREFERRED

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Preferred Drug

Diagnosis Code Link

COMBIVENT RESPIMAT (INHALATION)

COMETRIQ DAILY-DOSE PACK (ORAL)

COMPLETE NATAL DHA (ORAL)

COMPLETENATE CHEW TABLET (ORAL)

CONCERTA ER TABLET (ORAL) (DX CODE REQ.)

DIAGNOSIS CODE REQ

COPAXONE 20 MG/ML SYRINGE (not 40 MG/ML) (SUBCUTANEOUS)

COPIKTRA CAPSULE (ORAL)

CORIFACT KIT (INTRAVEN)

COTELLIC TABLET (ORAL)

CREON CAPSULE (ORAL)

CROMOLYN SODIUM 4% (OPHTHALMIC)

CYCLAFEM 1-35-28, CYCLAFEM 7-7-7-28 (ORAL)

CYCLOBENZAPRINE TABLET (not ER) (ORAL)

CYCLOPHOSPHAMIDE CAPSULE, TABLET (ORAL)

CYCLOSPORINE MODIFIED CAPSULE, SOLUTION (ORAL)

DALIRESP TABLET (ORAL)

DASETTA 1-35-28 TABLET (ORAL)

DAURISMO TABLET (ORAL)

DEBLITANE 0.35 MG TABLET (ORAL)

DEPAKOTE SPRINKLE (ORAL)

DERMA-SMOOTHE-FS BODY OIL (TOPICAL)

DERMA-SMOOTHE-FS SCALP OIL (TOPICAL)

DESOGESTREL/ETHINYL ESTRADIOL (ORAL)

DESONIDE 0.05% OINTMENT (not LOTION) (TOPICAL)

DESVENLAFAXINE SUC ER (generic PRISTIQ) (ORAL)

DEXAMETHASONE TABLET (ORAL)

DEXMETHYLPHENIDATE IR (FOCALIN)(ORAL)(DX CODE REQ.)

DIAGNOSIS CODE REQ

DEXTROAMPHETAMINE / AMPHETAMINE TABLET (IR) (ORAL) (DX CODDIEAGRNEOQS.)IS CODE REQ

DEXTROAMPHETAMINE TABLET (IR) (not ER) (ORAL) (DX CODE REQ.D) IAGNOSIS CODE REQ

DIAZEPAM (RECTAL) (generic DIASTAT)

DIAZEPAM 5 MG/5 ML SOLUTION (not 5 MG/ML CONC) (ORAL)

DIAZEPAM DEVICE (RECTAL) (generic DIASTAT ACUDIAL)

DIAZEPAM TABLET (ORAL)

DICLEGIS (ORAL)

DICLOFENAC 0.1% DROP (OPHTHALMIC)

DICLOFENAC 1% GEL (TOPICAL)

DICLOFENAC SODIUM DR & EC TABLET (not ER 100 MG) (ORAL)

DIFFERIN 0.1% CREAM (TOPICAL) (not OTC GEL) (DX CODE REQ.) DIAGNOSIS CODE REQ

DIFFERIN 0.1% LOTION (TOPICAL) (DX CODE REQ.)

DIAGNOSIS CODE REQ

DIFFERIN 0.3% GEL PUMP (TOPICAL) (DX CODE REQ.)

DIAGNOSIS CODE REQ

DILTAIZEM 24HR ER CAPSULE (not TABLET) (ORAL)

DILTIAZEM 12HR ER CAPSULE (ORAL)

DILTIAZEM TABLET (ORAL)

DIOVAN TABLET (ORAL)

DIPYRIDAMOLE TABLET (ORAL)

DIVALPROEX ER (ORAL)

DIVALPROEX SOD DR TABLET (ORAL)

DONEPEZIL 5MG & 10MG TABLET (not 23MG) (ORAL)

DONEPEZIL ODT (ORAL)

DORZOLAMIDE / TIMOLOL DROP (OPHTHALMIC)

DORZOLAMIDE 2% DROP (OPHTHALMIC)

DOVONEX 0.005% CREAM (TOPICAL)

DOXAZOSIN MESYLATE TABLET (ORAL)

DOXYCYCLINE HYCLATE CAPSULE (not DR) (ORAL)

DOXYCYCLINE HYCLATE TABLET (not DR) (ORAL)

DOXYCYCLINE MONOHYDRATE 50 MG, 100 MG CAPSULE (ORAL)

DOXYCYCLINE MONOHYDRATE TABLET (ORAL)

DRONABINOL CAPSULE (ORAL)

DROSPIRENONE-EE 3-0.02 MG TAB (ORAL)

DROSPIRENONE-EE 3-0.03 MG TAB (ORAL)

Updated July 1, 2021

Brand Name

CHEWABLE OPTION BRAND PREFERRED BRAND PREFERRED

BRAND PREFFERED BRAND PREFFERED BRAND PREFFERED

BRAND PREFERRED BRAND PREFERRED BRAND PREFERRED BRAND PREFERRED

BRAND PREFERRED

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Preferred Drug

DROXIA CAPSULE (ORAL) DULERA (INHALATION) DULOXETINE 20MG, 30MG, 60MG CAPSULES (not 40MG) (ORAL) DUTASTERIDE CAPSULE (ORAL) DYSPORT VIAL (INTRAMUSC) E.E.S 200 SUSPENSION (GRANULES) (ORAL) ELETRIPTAN TABLET (ORAL) ELIDEL 1% CREAM (TOPICAL) ELIGARD SYRINGE (SUBCUTANEOUS) ELINEST-28 TABLET (ORAL) ELIQUIS STARTER PACK (ORAL) ELIQUIS TABLET (ORAL) ELLA 30 MG TABLET (ORAL) EMCYT CAPSULE (ORAL) EMEND 80 MG CAPSULE (not TRIPACK) (ORAL)* EMGALITY 120 MG/ML PEN (SUBCUTANEOUS) EMGALITY 120MG SYRINGE (not 100 MG) (SUBCUTANEOUS) EMOQUETTE 28 DAY TABLET (ORAL) ENALAPRIL, ENALAPRIL / HCTZ (ORAL) ENBREL DISP SYRINGE, KIT, PEN (INJECTION) ENBREL VIAL (SUBCUTANEOUS) ENDARI POWDER PACKET(ORAL) ENOXAPARIN SYRINGE (SUBCUTANEOUS) ENOXAPARIN VIAL (SUBCUTANEOUS) ENSKYCE (ORAL) ENTRESTO TABLET (ORAL) EPIDIOLEX (ORAL) EPIDUO FORTE 0.3-2.5% GEL PUMP (TOPICAL) (DX CODE REQ.)* EPINEPHRINE 0.15 MG (49502-0101-02) (INJECTION) EPINEPHRINE 0.3 MG (49502-0102-02) (INJECTION) ERIVEDGE CAPSULE (ORAL) ERLEADA TABLET (ORAL) ERRIN (ORAL) ERY-TAB DR TABLET (ORAL) ERYTHROCIN 250 MG FILMTAB (ORAL) ERYTHROMYCIN 0.5% OINTMENT (OPHTHALMIC) ERYTHROMYCIN 2% SOLUTION (not GEL) (TOPICAL) ERYTHROMYCIN DR 250 MG CAPSULE (not FILMTAB) (ORAL) ERYTHROMYCIN DR TABLET (not ES 400MG) (ORAL) ESCITALOPRAM SOLUTION, TABLET (ORAL) ESOMEPRAZOLE 20MG CAPSULE (not PACKET) (ORAL) ESOMEPRAZOLE 40MG CAPSULE (ORAL) ESTARYLLA 0.25-0.035 MG (ORAL) ESZOPICLONE TABLET (ORAL) ETHOSUXIMIDE CAPSULE, SOLUTION (ORAL) ETHYNODIOL/ETHINYL ESTRADIOL 1MG-50MCG (ORAL) EUCRISA 2% OINTMENT (TOPICAL) EVEROLIMUS TABLET (ORAL)* EXELON PATCH (TRANSDERMAL) EXEMESTANE TABLET (ORAL) EZETIMIBE TABLET (ORAL) FALMINA-28 (ORAL) FAMCICLOVIR TABLET (ORAL) FAMOTIDINE SUSPENSION (ORAL) FAMOTIDINE TABLET (Rx and OTC) (ORAL) FARXIGA TABLET (ORAL) FARYDAK CAPSULE (ORAL) FASENRA PEN, SYRINGE (SUBCUTANEOUS) FAZACLO ODT (ORAL) FEIBA NF (INTRAVEN)

Diagnosis Code Link

DIAGNOSIS CODE REQ

Updated July 1, 2021

Brand Name

BRAND PREFERRED RELPAX BRAND PREFERRED

ZORTRESS BRAND PREFFERED BRAND PREFFERED

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Preferred Drug

Diagnosis Code Link

FELODIPINE ER (ORAL)

FENOFIBRATE 48MG, 54MG, 145MG, 160MG TABLET (ORAL)

FENOFIBRATE 67MG, 134MG, 200MG CAPSULE (ORAL)

FENSOLVI SYRINGE (SUBCUTANEOUS)*

FERATE OTC (ORAL)

FERRALET 90 DUAL-IRON (ORAL)

FERROUS FUMARATE TABLET OTC (ORAL)

FERROUS FUMARATE/ASCORBIC ACID/B12-IF/FA CAPSULE (ORAL)

FERROUS GLUCONATE OTC (ORAL)

FERROUS SULFATE 65 MG TABLET OTC (ORAL)

FERROUS SULFATE DROPS (ORAL)

FERROUS SULFATE OTC (ORAL)

FERROUS SULFATE SOLUTION OTC (ORAL)

FERROUS SULFATE TABLET ER OTC (ORAL)

FERROUS SULFATE, DRIED TABLET ER OTC (ORAL)

FEXOFENADINE 30 MG/5 ML SUSP (OTC) (ORAL)

FEXOFENADINE-D TABLET (OTC) (ORAL)

FINASTERIDE 5 MG TABLET (not 1 MG) (ORAL)

FIRVANQ (ORAL)

FISH OIL SOFTGEL (OTC) (ORAL)

FLOVENT DISKUS, FLOVENT HFA (INHALATION)

FLUCONAZOLE SUSPENSION, TABLET (ORAL)

FLUOROMETHOLONE 0.1% DROP (OPHTHALMIC)

FLUOXETINE 20 MG/5 ML SOLUTION (ORAL)

FLUOXETINE CAPSULE (not 90 MG) (ORAL)

FLUOXETINE TABLET (ORAL) 10 MG only

FLUPHENAZINE DECANOATE (INJECTION)

FLUPHENAZINE ELIXIR/SOLN, TABLET (ORAL)

FLURAZEPAM CAPSULE (ORAL)

FLUTAMIDE CAPSULE (ORAL)

FLUTICASONE PROP 50 MCG SPRAY (RX & OTC) (NASAL)

FLUTICASONE PROPIONATE 0.005% OINTMENT (TOPICAL)

FLUTICASONE PROPIONATE 0.05% CREAM (TOPICAL)

FLUVOXAMINE TABLET (IR) (ORAL)

FML FORTE 0.25% DROP (not LIQUIFILM) (OPHTHALMIC)

FOCALIN XR CAPSULE (ORAL) (DX CODE REQ.)

DIAGNOSIS CODE REQ

FOLIVANE-OB CAPSULE (ORAL)

FOTIVDA CAPSULE (ORAL)*

FULPHILA SYRINGE (SUBCUTANEOUS)

GABAPENTIN CAPSULE (ORAL)

GABAPENTIN TABLET (ORAL)

GABITRIL TABLET (ORAL)

GAVRETO CAPSULE (ORAL)*

GEMFIBROZIL TABLET (ORAL)

GENOTROPIN CARTRIDGE (INJECTION)*

GENOTROPIN MINIQUICK (INJECTION)*

GENTAK 0.3% OINTMENT (OPHTHALMIC)

GENTAMICIN 0.1% CREAM (TOPICAL)

GENTAMICIN 0.1% OINTMENT (TOPICAL)

GENTAMICIN 0.3% SOLUTION (OPHTHALMIC)

GIANVI 3 MG-0.02 MG (ORAL)

GILOTRIF TABLET (ORAL)

GLIPIZIDE-METFORMIN TABLET (ORAL)

GLUCAGON (INJECTION)

GLUCAGON EMERGENCY KIT (LILLY) (INJECTION)

GLYBURIDE-METFORMIN TABLET (ORAL)

GLYSET TABLET (ORAL)

GLYXAMBI TABLET (ORAL)

GRISEOFULVIN SUSPENSION (not TABLET) (ORAL)

GUANFACINE ER TABLET (ORAL)

Updated July 1, 2021

Brand Name

BRAND PREFFERED

BRAND PREFFERED BRAND PREFFERED BRAND PREFFERED

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Preferred Drug

Diagnosis Code Link

GUANFACINE TABLET (ORAL)

HALOBETASOL PROPIONATE 0.05% CREAM (TOPICAL)

HALOPERIDOL DECANOATE, LACTATE (INJECTION)

HALOPERIDOL LACTATE CONC (ORAL)

HALOPERIDOL TABLET (ORAL)

HEATHER 0.35 MG TABLET (ORAL)

HELIXATE FS (INTRAVEN.)

HEMLIBRA (SUBCUTANE.)

HUMALOG 100 UNIT/ML CARTRIDGE (SUBCUTANEOUS)

HUMALOG MIX 50-50 KWIKPEN, VIAL

HUMALOG MIX 75-25 VIAL (SUBCUTANEOUS)

HUMATE-P KIT (INTRAVEN.)

HUMIRA KIT, PEN INJ KIT (INJECTION)

HUMULIN 70/30 KWIKPEN OTC (SUBCUTANE.)

HUMULIN 70/30 VIAL (SUBCUTANEOUS)

HUMULIN N 100 UNITS/ML VIAL (SUBCUTANEOUS)

HUMULIN R 100 UNITS/ML VIAL (SUBCUTANEOUS)

HUMULIN R 500 UNITS/ML PEN, VIAL (SUBCUTANEOUS)

HYCAMTIN CAPSULE (ORAL)

HYDROCODONE / APAP SOLUTION (ORAL)

HYDROCODONE / APAP TABLET (ORAL)

HYDROCORTISONE (PROCTO) RECTAL CREAM 2.5% (TOPICAL)

HYDROCORTISONE 0.5% CREAM (not ACETATE) (TOPICAL)

HYDROCORTISONE 1% CREAM (not ACETATE) (TOPICAL)

HYDROCORTISONE 1% OINTMENT (TOPICAL)

HYDROCORTISONE 2.5% CREAM (TOPICAL)

HYDROCORTISONE 2.5% LOTION (TOPICAL)

HYDROCORTISONE 2.5% OINTMENT (TOPICAL)

HYDROCORTISONE TABLET (ORAL)

HYDROMORPHONE TABLET (IR) (ORAL)

HYDROXYUREA CAPSULE (ORAL)

IBANDRONATE TABLETS (ORAL)

IBRANCE CAPSULE (not TABLET) (ORAL)

IBUPROFEN SUSPENSION, TABLET (ORAL)

ICLUSIG TABLET (ORAL)

IDHIFA TABLET (ORAL)

IFEREX 150 FORTE (ORAL)

ILEVRO 0.3% DROP (OPHTHALMIC)

IMATINIB TABLET (ORAL)

IMBRUVICA CAPSULE, TABLET (ORAL)

IMIQUIMOD 5% CREAM PACKET (not 3.75%) (TOPICAL)

IMITREX NASAL SPRAY (NASAL)*

INCRELEX VIAL (SUBCUTANEOUS)

INDOMETHACIN CAPSULE (IR) (not ER 75 MG) (ORAL)

INLYTA TABLET (ORAL)

INQOVI TABLET (ORAL)*

INREBIC CAPSULE (ORAL)

INSULIN ASPART 100 UNIT/ML CARTRIDGE, PEN, VIAL (SUBCUTANEOUS)*

INSULIN ASPART PROT (MIX70-30) FLEXPEN, VIAL (SUBCUTANEOUS)*

INSULIN LISPRO 100 UNIT/ML PEN (SUBCUTANEOUS)*

INSULIN LISPRO 100 UNIT/ML VIAL (SUBCUTANEOUS)*

INSULIN LISPRO JR 100 UNIT/ML KWIKPEN (SUBCUTANEOUS)*

INSULIN LISPRO MIX 75-25 KWIKPEN (SUBCUTANEOUS)*

INVEGA SUSTENNA (INTRAMUSC)

INVEGA TRINZA (INTRAMUSC)

INVOKAMET TABLET (not XR) (ORAL)

INVOKANA TABLET (ORAL)

IPRATROPIUM 0.03%, 0.06% SPRAY (NASAL)

IPRATROPIUM BR 0.02% SOLUTION (INHALATION)

IRBESARTAN, IRBESARTAN / HCTZ (ORAL)

Updated July 1, 2021

Brand Name

BRAND PREFERRED

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Preferred Drug

Diagnosis Code Link

IRESSA TABLET (ORAL)

IRON 45 MG TABLET OTC (ORAL)

IRON POLYSACCHARIDES COMPLEX OTC (ORAL)

IRON PS CMPLX/VIT B12/FA (ORAL)

IRON,CARBONYL/ASCORBIC ACID OTC (ORAL)

ISIBLOOM (ORAL)

ISOSORBIDE DINITRATE 10MG, 20MG, 30MG TABLETS (ORAL)*

ISOSORBIDE DINITRATE 40 MG TAB (only 70710-1152-01) (ORAL)*

ISOSORBIDE DINITRATE 5MG TABLETS (not 68682-0193-01) (ORAL)*

ISOSORBIDE MONONITRATE ER/SR TABLET (ORAL)

ISOSORBIDE MONONITRATE TABLET (ORAL)

IVERMECTIN TABLET (ORAL)

JAKAFI TABLET (ORAL)

JANUMET TABLET (ORAL)

JANUMET XR TABLET (ORAL)

JANUVIA TABLET (ORAL)

JARDIANCE TABLET (ORAL)

JENCYCLA 0.35 MG (ORAL)

JENTADUETO TABLET (IR) (not XR) (ORAL)

JULEBER-28 (ORAL)

JUNEL 1/20 MCG, JUNEL 1.5/30 MCG (ORAL)

JUNEL FE 1/20, JUNEL FE 1.5/30 (not 24) (ORAL)

KETOCONAZOLE 2% SHAMPOO (TOPICAL)

KETOCONAZOLE CREAM (TOPICAL)

KETOROLAC 0.5% SOLUTION (not 0.4%) (OPHTHALMIC)

KITABIS PAK 300 MG/5 ML (INHALATION)

KOSELUGO CAPSULE (ORAL)*

KURVELO (ORAL)

LABETALOL TABLET (ORAL)

LAMOTRIGINE CHEW DISPERS TAB (not ODT) (ORAL)

LAMOTRIGINE TABLET (IR) (not ER) (ORAL)

LANTUS SOLOSTAR (SUBCUTANEOUS)

LANTUS VIAL (SUBCUTANEOUS)

LARIN FE 1/20, LARIN FE 1.5/30 (ORAL) (not 24)

LARISSIA (ORAL)

LATANOPROST 0.005% DROP (OPHTHALMIC)

LATUDA TABLET (ORAL)

LENVIMA CAPSULE, DAILY DOSE (ORAL)

LESSINA-28 (ORAL)

LETAIRIS TABLET (ORAL)*

LETROZOLE TABLET (ORAL)

LEUKERAN TABLET (ORAL)

LEUPROLIDE ACETATE KIT, VIAL (SUBCUTANEOUS)

LEVEMIR FLEXTOUCH, VIAL (SUBCUTANEOUS)

LEVETIRACETAM SOLUTION, IR TABLET (not ER) (ORAL)

LEVOBUNOLOL 0.5% DROP (OPHTHALMIC)

LEVOCETIRIZINE TABLETS (RX & OTC) (ORAL)

LEVOFLOXACIN TABLET (ORAL)

LEVONOR-ETH ESTRADIOL-28 0.1/0.02 (ORAL) (not 91)

LEVONOR-ETH ESTRADIOL-28 0.15/0.03 (ORAL) (not 91)

LEVORA-28 (ORAL)

LIALDA DR TABLET (ORAL)

LIDODERM (TOPICAL)

LILLOW-28 TABLET (ORAL)

LINZESS CAPSULE (ORAL)

LISINOPRIL, LISINOPRIL / HCTZ (ORAL)

LOESTRIN 21 1/20, LOESTRIN 21 1.5/30 (ORAL)

LOESTRIN FE 1/20, LOESTRIN FE 1/5.30 (ORAL)

LOKELMA POWDER PACKET (ORAL)

LONSURF TABLET (ORAL)

Updated July 1, 2021

Brand Name

BRAND PREFFERED CHEWABLE OPTION BRAND PREFFERED BRAND PREFFERED BRAND PREFFERED BRAND PREFFERED BRAND PREFFERED BRAND PREFFERED

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