Medicare Part D Prior Authorization Directory

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A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

A

Abacavir No - No PA Required ABACAVIR and LAMIVUDINE No - No PA Required Abacavir and Lamivudine No - No PA Required Abacavir Sulfate No - No PA Required ABIGALE LO, ABIGALE No - No PA Required ABILIFY No - No PA Required Abilify Asimtufii No - No PA Required ABILIFY MAINTENA No - No PA Required Abilify MyCite No - No PA Required Abiraterone No - No PA Required Abiraterone Acetate No - No PA Required abiraterone acetate No - No PA Required Abiraterone acetate No - No PA Required Abiraterone Acetate, ABIRATERONE ACETATE No - No PA Required Abirtega No - No PA Required ABRILADA Yes - PA Required Absorica LD, Absorica No - No PA Required acamprosate calcium No - No PA Required Acamprosate Calcium No - No PA Required Acanya No - No PA Required Acarbose No - No PA Required ACCUTANE No - No PA Required Acebutolol Hydrochloride No - No PA Required ACETAMINOPHEN No - No PA Required Acetaminophen and Codeine No - No PA Required ACETAMINOPHEN AND CODEINE No - No PA Required ACETAMINOPHEN AND CODEINE PHOSPHATE No - No PA Required Acetaminophen and Codeine Phosphate No - No PA Required acetazolamide No - No PA Required AcetaZOLAMIDE No - No PA Required ACETAZOLAMIDE No - No PA Required Acetazolamide No - No PA Required acetaZOLAMIDE No - No PA Required ACETAZOLAMIDE EXTENDED-RELEASE No - No PA Required Acetic Acid No - No PA Required ACETIC ACID No - No PA Required acetylcysteine No - No PA Required ACETYLCYSTEINE No - No PA Required Acetylcysteine No - No PA Required Aciphex No - No PA Required ACITRETIN No - No PA Required Acitretin No - No PA Required Acthar Yes - PA Required Activella No - No PA Required Actonel No - No PA Required Actoplus Met No - No PA Required Actos No - No PA Required Acular No - No PA Required ACULAR LS No - No PA Required ACUVAIL No - No PA Required ACYCLOVIR No - No PA Required Acyclovir No - No PA Required acyclovir No - No PA Required Acyclovir Sodium No - No PA Required Acyclovir suspension No - No PA Required ACZONE No - No PA Required Aczone No - No PA Required Adalimumab Yes - PA Required Adalimumab-aacf No - No PA Required Adalimumab-adbm No - No PA Required Adalimumab-bwwd No - No PA Required Adalimumab-ryvk No - No PA Required Adapalene No - No PA Required ADAPALENE No - No PA Required adapalene No - No PA Required Adapalene and benzoyl peroxide No - No PA Required ADAPALENE and BENZOYL PEROXIDE No - No PA Required Adapalene and Benzoyl Peroxide No - No PA Required ADAPALENE AND BENZOYL PEROXIDE No - No PA Required adapalene and benzoyl peroxide No - No PA Required Adapalene and Benzoyl Peroxide Gel, 0.1%/2.5% No - No PA Required Adapalene Gel USP, 0.3% No - No PA Required Adbry Yes - PA Required ADCIRCA No - No PA Required Adderall No - No PA Required Adderall XR No - No PA Required Adefovir dipivoxil No - No PA Required Adempas Varies by Plan ADMELOG No - No PA Required ADVAIR DISKUS No - No PA Required ADVAIR HFA No - No PA Required Adzenys XR-ODT No - No PA Required AGAMREE Yes - PA Required Agrylin No - No PA Required AIMOVIG Yes - PA Required AIRSUPRA No - No PA Required AJOVY Yes - PA Required AKEEGA No - No PA Required AKLIEF Varies by Plan Ala-Scalp No - No PA Required Albendazole No - No PA Required Albendazole 200 mg No - No PA Required Albuterol No - No PA Required Albuterol Sulate HFA No - No PA Required Albuterol Sulfate No - No PA Required ALBUTEROL SULFATE No - No PA Required albuterol sulfate No - No PA Required Albuterol sulfate No - No PA Required Albuterol Sulfate HFA No - No PA Required albuterol sulfate HFA No - No PA Required Albuterol Sulfate Inhalation No - No PA Required Albuterol Sulfate Inhalation Solution No - No PA Required Albuterol Sulfate Inhalation Solution, 0.5% No - No PA Required Alclometasone dipropionate No - No PA Required Alclometasone Dipropionate No - No PA Required Aldactone No - No PA Required ALECENSA Varies by Plan Alfuzosin hydrochloride No - No PA Required Alfuzosin Hydrochloride No - No PA Required Alfuzosin Hydrochloride extended release No - No PA Required Aliskiren No - No PA Required Alkindi Sprinkle No - No PA Required Allopurinol No - No PA Required ALLOPURINOL No - No PA Required almotriptan No - No PA Required Almotriptan Malate No - No PA Required Alogliptin No - No PA Required alogliptin and metformin hydrochloride No - No PA Required Alogliptin and Pioglitazone No - No PA Required Alosetron No - No PA Required Alosetron Hydrochloride No - No PA Required ALPHAGAN P No - No PA Required Alprazolam No - No PA Required Alprazolam C-IV No - No PA Required Alprazolam Extended Release No - No PA Required Alprazolam ODT C-IV No - No PA Required Alprazolam XR No - No PA Required Alrex No - No PA Required ALTAVERA No - No PA Required Altreno No - No PA Required Alunbrig Varies by Plan ALVAIZ No - No PA Required Alvesco Varies by Plan ALYACEN 1/35 No - No PA Required ALYACEN 1/35, ALYACEN 7/7/7 No - No PA Required ALYFTREK Varies by Plan ALYQ No - No PA Required amantadine No - No PA Required Amantadine No - No PA Required Amantadine HCL No - No PA Required Amantadine HCl No - No PA Required amantadine hydrochloride No - No PA Required Amantadine Hydrochloride No - No PA Required AMANTADINE HYDROCHLORIDE No - No PA Required Ambien No - No PA Required Ambien CR No - No PA Required AmBisome No - No PA Required Ambrisentan No - No PA Required ambrisentan No - No PA Required Amcinonide No - No PA Required Amikacin Sulfate No - No PA Required amiloride hydrochloride No - No PA Required Amiloride Hydrochloride No - No PA Required Amiloride Hydrochloride and Hydrochlorothiazide No - No PA Required AMIODARONE HCI No - No PA Required Amiodarone Hydrochloride No - No PA Required Amiodarone hydrochloride No - No PA Required AMIODARONE HYDROCHLORIDE No - No PA Required Amitiza No - No PA Required AMITRIPTYLINE HCL No - No PA Required Amitriptyline HCL No - No PA Required AMITRIPTYLINE HYDROCHLORIDE No - No PA Required Amitriptyline Hydrochloride No - No PA Required AMJEVITA Yes - PA Required Amlodipine and atorvastatin No - No PA Required Amlodipine and Atorvastatin No - No PA Required Amlodipine and Benazepril Hydrochloride No - No PA Required Amlodipine and olmesartan Medoxomil No - No PA Required AMLODIPINE AND OLMESARTAN MEDOXOMIL No - No PA Required Amlodipine and Olmesartan Medoxomil No - No PA Required AMLODIPINE and OLMESARTAN medoxomil No - No PA Required Amlodipine and Valsartan No - No PA Required amlodipine and valsartan No - No PA Required Amlodipine and valsartan No - No PA Required Amlodipine Besylate No - No PA Required Amlodipine besylate No - No PA Required amlodipine besylate No - No PA Required AMLODIPINE BESYLATE No - No PA Required AMLODIPINE BESYLATE 10 mg No - No PA Required AMLODIPINE BESYLATE 10 mg, AMLODIPINE BESYLATE 2.5 mg, AMLODIPINE BESYLATE 5 mg No - No PA Required AMLODIPINE BESYLATE 2.5 mg No - No PA Required AMLODIPINE BESYLATE 2.5 mg, AMLODIPINE BESYLATE 5 mg, AMLODIPINE BESYLATE 10 mg No - No PA Required AMLODIPINE BESYLATE 5 mg No - No PA Required Amlodipine Besylate and Benazepril Hydrochloride No - No PA Required amlodipine besylate and olmesartan medoxomil No - No PA Required Amlodipine besylate and Olmesartan medoxomil No - No PA Required Amlodipine besylate and Olmesartran medoxomil No - No PA Required AMLODIPINE BESYLATE, AMLODIPINE AND BENAZEPRIL HYDROCHLORIDE No - No PA Required Ammonium Lactate No - No PA Required Amnesteem No - No PA Required Amoxapine No - No PA Required Amoxicillin No - No PA Required AMOXICILLIN No - No PA Required Amoxicillin 500 mg No - No PA Required Amoxicillin and Clavulanate Potassium No - No PA Required Amoxicillin and Clavulanate potassium No - No PA Required amoxicillin and clavulanate potassium No - No PA Required Amoxicillin and clavulanate potassium No - No PA Required AMOXICILLIN AND CLAVULANATE POTASSIUM No - No PA Required Amphetamine No - No PA Required Amphetamine Extended-Release No - No PA Required Amphetamine sulfate No - No PA Required Amphetamine Sulfate No - No PA Required AMPHETAMINE SULFATE No - No PA Required Amphotericin B No - No PA Required Amphotericin B liposome No - No PA Required AMPICILLIN No - No PA Required Ampicillin No - No PA Required ampicillin No - No PA Required Ampicillin and Sulbactam No - No PA Required ampicillin and sulbactam No - No PA Required Ampicillin Sodium No - No PA Required Ampicillin sodium No - No PA Required ampicillin sodium and sulbactam sodium No - No PA Required Ampicillin Sodium and Sulbactam Sodium No - No PA Required AMPYRA No - No PA Required AMRIX No - No PA Required AMZEEQ No - No PA Required ANAFRANIL No - No PA Required anagrelide No - No PA Required Anagrelide No - No PA Required Analpram HC No - No PA Required Anastrozole No - No PA Required ANASTROZOLE No - No PA Required ANCOBON No - No PA Required ANDEMBRY Yes - PA Required Angeliq Varies by Plan Annovera No - No PA Required Anoro Ellipta No - No PA Required Anusol HC No - No PA Required Anzupgo Varies by Plan Apixaban Varies by Plan Aplenzin Varies by Plan apomorphine hydrocloride No - No PA Required Apraclonidine No - No PA Required APREPITANT No - No PA Required Aprepitant No - No PA Required Apri 28 Day Varies by Plan APRISO No - No PA Required APTENSIO XR No - No PA Required Aptiom No - No PA Required Aptivus Varies by Plan AQNEURSA Yes - PA Required AQVESME Varies by Plan Aranelle No - No PA Required ARANESP Yes - PA Required Arava No - No PA Required Arazlo No - No PA Required ARBLI No - No PA Required Arcalyst Yes - PA Required Arformoterol tartrate No - No PA Required arformoterol tartrate No - No PA Required Arformoterol Tartrate No - No PA Required Arformoterol Tartrate Inhalation No - No PA Required Arformoterol Tartrate Inhalation Solution No - No PA Required Aricept No - No PA Required ARIKAYCE Yes - PA Required ARIMIDEX No - No PA Required Aripiprazole No - No PA Required aripiprazole No - No PA Required ARIPIPRAZOLE No - No PA Required ARISTADA Yes - PA Required ARISTADA INITIO Yes - PA Required Arixtra No - No PA Required Armodafinil No - No PA Required ARMODAFINIL No - No PA Required Arnuity Ellipta No - No PA Required Aromasin No - No PA Required ARTHROTEC No - No PA Required Ascomp with Codeine No - No PA Required Ascorbic Acid No - No PA Required ASENAPINE No - No PA Required Asenapine No - No PA Required Ashlyna No - No PA Required ASMANEX No - No PA Required ASMANEX HFA No - No PA Required Aspirin and Dipyridamole No - No PA Required Aspirin and Extended - Release Dipyridamole Capsules, 25 mg / 200 mg No - No PA Required Aspirin and Extended-Release Dipyridamole No - No PA Required ASPIRIN AND EXTENDED-RELEASE DIPYRIDAMOLE No - No PA Required ASTAGRAF XL No - No PA Required ATACAND No - No PA Required ATACAND HCT No - No PA Required Atazanavir No - No PA Required Atazanavir Sulfate No - No PA Required Atelvia No - No PA Required Atenolol No - No PA Required atenolol No - No PA Required Atenolol 29300-411 No - No PA Required Atenolol and Chlorthalidone No - No PA Required ATENOLOL AND CHLORTHALIDONE No - No PA Required Ativan No - No PA Required atomoxetine No - No PA Required Atomoxetine No - No PA Required Atomoxetine Hydrochloride No - No PA Required ATORVALIQ No - No PA Required Atorvastatin calcium No - No PA Required atorvastatin calcium No - No PA Required Atorvastatin Calcium No - No PA Required ATORVASTATIN CALCIUM No - No PA Required Atovaquone No - No PA Required atovaquone No - No PA Required ATOVAQUONE No - No PA Required Atovaquone and Proguanil HCl No - No PA Required Atovaquone and Proguanil Hydrochloride No - No PA Required Atovaquone and Proguanil Hydrochloride Pediatric, Atovaquone and Proguanil Hydrochloride No - No PA Required Atovaquone Oral Suspension No - No PA Required Atralin No - No PA Required Atropine No - No PA Required ATROPINE No - No PA Required Atropine sulfate No - No PA Required Atropine Sulfate No - No PA Required ATROPINE SULFATE No - No PA Required ATROPINE SULFATE Unknown atropine sulfate No - No PA Required ATROPINE SULFATE Unknown Atrovent HFA No - No PA Required Attruby Varies by Plan Aubagio No - No PA Required Aubra EQ No - No PA Required Augmentin No - No PA Required AUGMENTIN ES-600 No - No PA Required Augtyro Varies by Plan Auranofin Varies by Plan AUVELITY No - No PA Required AUVI-Q No - No PA Required Auvi-Q No - No PA Required Avalide No - No PA Required Avapro No - No PA Required Aveed Yes - PA Required Aviane No - No PA Required AVMAPKI FAKZYNJA CO-PACK Varies by Plan AVODART No - No PA Required AVYCAZ Yes - PA Required Ayvakit Varies by Plan AZACITIDINE Varies by Plan Azacitidine Varies by Plan AZACTAM No - No PA Required Azasan No - No PA Required AZASITE No - No PA Required Azathioprine No - No PA Required AZATHIOPRINE No - No PA Required Azathioprine Sodium No - No PA Required Azelaic Acid No - No PA Required azelaic acid No - No PA Required Azelaic Acid Gel No - No PA Required Azelastine No - No PA Required AZELASTINE HYDROCHLORIDE No - No PA Required Azelastine Hydrochloride No - No PA Required AZELASTINE HYDROCHLORIDE AND FLUTICASONE PROPIONATE No - No PA Required Azelastine hydrochloride and Fluticasone propionate No - No PA Required Azelastine Hydrochloride and Fluticasone Propionate No - No PA Required Azelastine Hydrochloride Ophthalmic Solution 0.05% No - No PA Required AZELEX No - No PA Required Azilect No - No PA Required azithromycin No - No PA Required AZITHROMYCIN No - No PA Required Azithromycin No - No PA Required azithromycin dihydrate No - No PA Required AZITHROMYCIN DIHYDRATE No - No PA Required Azithromycin Dihydrate No - No PA Required Azithromycin monohydrate No - No PA Required Azopt No - No PA Required Azor No - No PA Required AZSTARYS Varies by Plan Aztreonam No - No PA Required Azulfidine No - No PA Required Azulfidine EN-tabs No - No PA Required Azurette Varies by Plan

B

Bacitracin No - No PA Required Bacitracin Zinc and Polymyxin B Sulfate No - No PA Required BACLOFEN No - No PA Required Baclofen No - No PA Required Baclofen (Intrathecal) No - No PA Required BAFIERTAM Varies by Plan Balcoltra No - No PA Required balsalazide disodium No - No PA Required Balsalazide Disodium No - No PA Required BALVERSA Varies by Plan Balziva No - No PA Required Banzel No - No PA Required Baqsimi Yes - PA Required BARACLUDE No - No PA Required Baricitinib Varies by Plan BASAGLAR KwikPen, BASAGLAR Tempo Pen No - No PA Required Baxdela Yes - PA Required BELBUCA No - No PA Required BELSOMRA Varies by Plan Benazepril hydrochloride No - No PA Required BENAZEPRIL HYDROCHLORIDE No - No PA Required Benazepril Hydrochloride No - No PA Required benazepril hydrochloride and hydrochlorothiazide No - No PA Required Benazepril Hydrochloride and Hydrochlorothiazide No - No PA Required Benicar No - No PA Required Benicar HCT No - No PA Required BENLYSTA Yes - PA Required Benzamycin No - No PA Required BENZTROPINE MESYLATE No - No PA Required Benztropine Mesylate No - No PA Required Bepotastine Besilate No - No PA Required Bepreve No - No PA Required Besivance Yes - PA Required Betaine No - No PA Required BETAMETHASONE DIPROPIONATE Varies by Plan Betamethasone Dipropionate Varies by Plan Betamethasone dipropionate Varies by Plan Betamethasone Dipropionate USP, 0.05% No - No PA Required Betamethasone Sodium Phosphate and Betamethasone Acetate No - No PA Required Betamethasone Valerate No - No PA Required BETAMETHASONE VALERATE No - No PA Required Betamethasone valerate No - No PA Required Betaxolol Hydrochloride No - No PA Required Bethanechol Chloride No - No PA Required BETHKIS No - No PA Required BETIMOL No - No PA Required Betoptic S No - No PA Required BEVESPI AEROSPHERE No - No PA Required bexarotene No - No PA Required Bexarotene No - No PA Required Beyaz Varies by Plan Bicalutamide No - No PA Required bicalutamide No - No PA Required BICILLIN C-R 900/300 Yes - PA Required BICILLIN CR Yes - PA Required BICILLIN L-A Yes - PA Required BiDil No - No PA Required Bijuva No - No PA Required Biktarvy Varies by Plan BILDYOS Yes - PA Required Bilprevda Yes - PA Required Bimatoprost No - No PA Required BIMATOPROST No - No PA Required bimatoprost No - No PA Required Bimzelx Yes - PA Required Binosto No - No PA Required Bismuth Subcitrate Potassium, Metronidazole and Tetracycline Hydrochloride No - No PA Required BISMUTH SUBCITRATE POTASSIUM, METRONIDAZOLE, AND TETRACYCLINE HYDROCHLORIDE No - No PA Required Bismuth subcitrate potassium, Metronidazole, Tetracycline hydrochloride No - No PA Required Bisoprolol No - No PA Required Bisoprolol fumarate No - No PA Required BISOPROLOL FUMARATE No - No PA Required Bisoprolol Fumarate No - No PA Required Bisoprolol Fumarate and Hydrochlorothiazide No - No PA Required bisoprolol fumarate and hydrochlorothiazide No - No PA Required Blisovi 24 Fe No - No PA Required BLISOVI FE 1.5/30 No - No PA Required Blisovi Fe 1/20 No - No PA Required Blujepa Varies by Plan BOMYNTRA Yes - PA Required BONJESTA No - No PA Required Bonsity No - No PA Required Bosentan No - No PA Required bosentan No - No PA Required BOSULIF Varies by Plan BRAFTOVI Varies by Plan BREKIYA No - No PA Required Breo Ellipta No - No PA Required Brexpiprazole Varies by Plan BREYNA No - No PA Required BREZTRI No - No PA Required BRIELLYN No - No PA Required BRILINTA No - No PA Required BRIMONIDINE No - No PA Required Brimonidine No - No PA Required Brimonidine Tartrate No - No PA Required BRIMONIDINE TARTRATE No - No PA Required Brimonidine tartrate No - No PA Required Brimonidine Tartrate and Timolol Maleate No - No PA Required BRIMONIDINE TARTRATE and TIMOLOL MALEATE No - No PA Required Brimonidine tartrate and Timolol maleate No - No PA Required Brimonidine Tartrate ophthalmic solution, 0.15% No - No PA Required Brimonidine Tartrate/Timolol Maleate No - No PA Required Brimonidine Tartrate/Timolol Maleate Ophthalmic Solution No - No PA Required Brinsupri Varies by Plan BRINZOLAMIDE No - No PA Required Brinzolamide No - No PA Required Brivaracetam Varies by Plan BRIVARACETAM Varies by Plan brivaracetam Varies by Plan Brivaracetam oral Solution Varies by Plan Brivaracetam Oral Solution Varies by Plan Briviact Varies by Plan Bromfenac No - No PA Required BROMFENAC No - No PA Required bromfenac 0.075% No - No PA Required bromfenac ophthalmic solution No - No PA Required Bromfenac Ophthalmic Solution 0.09% No - No PA Required Bromfenac Ophthalmic Solution, 0.07% No - No PA Required bromfenac sodium No - No PA Required BROMFENAC SODIUM No - No PA Required Bromocriptine Mesylate No - No PA Required Bromocriptine mesylate No - No PA Required BROMSITE 0.075% No - No PA Required BRUKINSA Varies by Plan Bryhali No - No PA Required BRYNOVIN No - No PA Required Bucapsol No - No PA Required Budesonide No - No PA Required BUDESONIDE No - No PA Required budesonide No - No PA Required Budesonide and Formoterol Fumarate Dihydrate No - No PA Required budesonide inhalation No - No PA Required Budesonide Inhalation No - No PA Required Budesonide Inhalation Suspension No - No PA Required Bumetanide No - No PA Required bumetanide No - No PA Required BUMETANIDE No - No PA Required BUPRENORPHINE No - No PA Required Buprenorphine No - No PA Required Buprenorphine and Naloxone No - No PA Required Buprenorphine and Naloxone Sublingual Film No - No PA Required Buprenorphine HCl No - No PA Required Buprenorphine HCl and Naloxone HCl No - No PA Required buprenorphine hydrochloride No - No PA Required Buprenorphine Hydrochloride No - No PA Required Buprenorphine Hydrochloride and Naloxone Hydrochloride Dihydrate No - No PA Required buprenorphine hydrochloride and naloxone hydrochloride dihydrate No - No PA Required BUPRENORPHINE HYDROCHLORIDE and NALOXONE HYDROCHLORIDE DIHYDRATE No - No PA Required Buprenorphine Sublingual No - No PA Required Buprenorphine Sublingual C-III No - No PA Required buprenorphine transdermal system No - No PA Required bupropion No - No PA Required Bupropion HCL No - No PA Required Bupropion HCL ER (XL) No - No PA Required Bupropion hydrochloride No - No PA Required Bupropion Hydrochloride No - No PA Required bupropion hydrochloride No - No PA Required BuPROPion Hydrochloride No - No PA Required BUPROPION HYDROCHLORIDE No - No PA Required bupropion Hydrochloride No - No PA Required BUPROPION HYDROCHLORIDE (SR) No - No PA Required Bupropion Hydrochloride (SR) No - No PA Required Bupropion Hydrochloride (XL) No - No PA Required BUPROPION HYDROCHLORIDE (XL) No - No PA Required Bupropion hydrochloride (XL) No - No PA Required BUPROPION HYDROCHLORIDE SR No - No PA Required Bupropion Hydrochloride SR No - No PA Required bupropion hydrochloride SR No - No PA Required buPropion Hydrochloride XL No - No PA Required Bupropion Hydrochloride XL No - No PA Required Buspirone Hcl No - No PA Required busPIRone HCl No - No PA Required Buspirone HCL No - No PA Required buspirone hydrochloride No - No PA Required BUSPIRONE HYDROCHLORIDE No - No PA Required Buspirone hydrochloride No - No PA Required Buspirone Hydrochloride No - No PA Required Butorphanol Tartrate No - No PA Required Butrans No - No PA Required BYLVAY Varies by Plan Bylvay Varies by Plan Bystolic No - No PA Required

C

Cabergoline No - No PA Required CABERGOLINE No - No PA Required Cablivi Yes - PA Required CABOMETYX Varies by Plan Cabtreo No - No PA Required Caduet No - No PA Required Caffeine Citrate No - No PA Required caffeine citrate No - No PA Required CAFFEINE CITRATE No - No PA Required Caffeine Citrate Oral Solution No - No PA Required Calcipotriene No - No PA Required calcipotriene No - No PA Required Calcipotriene and Betamethasone Dipropionate No - No PA Required calcipotriene and betamethasone dipropionate No - No PA Required calcitriol No - No PA Required Calcitriol No - No PA Required CALCITRIOL No - No PA Required calcium acetate No - No PA Required Calcium Acetate No - No PA Required Calcium Chloride No - No PA Required calcium chloride No - No PA Required CALCIUM CHLORIDE No - No PA Required Calcium Chloride Dihydrate No - No PA Required calcium gluconate No - No PA Required CALCIUM GLUCONATE No - No PA Required Calcium Gluconate No - No PA Required Calcium Gluconate in Sodium Chloride No - No PA Required CALQUENCE Varies by Plan Cambia No - No PA Required CAMILA Varies by Plan CAMZYOS Varies by Plan Canasa No - No PA Required Candesartan No - No PA Required CANDESARTAN CILEXETIL No - No PA Required candesartan cilexetil No - No PA Required Candesartan cilexetil No - No PA Required candesartan cilexetil and hydrochlorothiazide No - No PA Required Candesartan Cilexetil and Hydrochlorothiazide No - No PA Required CAPLYTA Varies by Plan CAPRELSA Varies by Plan Captopril No - No PA Required captopril No - No PA Required CAPTOPRIL AND HYDROCHLOROTHIAZIDE No - No PA Required Carafate No - No PA Required Carbaglu No - No PA Required carbamazepine No - No PA Required CARBAMAZEPINE No - No PA Required Carbamazepine No - No PA Required Carbamazepine ER No - No PA Required CARBAMAZEPINE ER No - No PA Required Carbatrol No - No PA Required Carbidopa No - No PA Required CARBIDOPA No - No PA Required CARBIDOPA AND LEVODOPA No - No PA Required Carbidopa and levodopa No - No PA Required Carbidopa and Levodopa No - No PA Required Carbinoxamine Maleate No - No PA Required CARBINOXAMINE MALEATE No - No PA Required Carbinoxamine Maleate Extended-Release Oral Suspension No - No PA Required CARBZAH No - No PA Required Cardizem No - No PA Required Cardizem CD No - No PA Required Cardizem LA No - No PA Required Cardura No - No PA Required Cardura XL No - No PA Required Carglumic Acid No - No PA Required Carglumic acid No - No PA Required CARISOPRODOL No - No PA Required Carisoprodol No - No PA Required carisoprodol No - No PA Required Carisoprodol Tablets, USP, 350 mg No - No PA Required CARNITOR No - No PA Required Carnitor No - No PA Required Carnitor SF No - No PA Required CaroSpir No - No PA Required Carteolol Hydrochloride No - No PA Required Cartia XT No - No PA Required CARTIA XT No - No PA Required Carvedilol No - No PA Required CARVEDILOL No - No PA Required Carvedilol Phosphate No - No PA Required CASODEX No - No PA Required Caspofungin Acetate No - No PA Required CASPOFUNGIN ACETATE No - No PA Required Cayston No - No PA Required Cefaclor No - No PA Required Cefadroxil No - No PA Required CEFADROXIL No - No PA Required CEFAZOLIN No - No PA Required Cefazolin No - No PA Required Cefazolin Sodium No - No PA Required CEFDINIR No - No PA Required cefdinir No - No PA Required Cefdinir No - No PA Required Cefepime No - No PA Required Cefepime Hydrochloride No - No PA Required CEFEPIME HYDROCHLORIDE AND DEXTROSE No - No PA Required Cefixime No - No PA Required CEFIXIME No - No PA Required Cefixime 400 mg No - No PA Required Cefotetan No - No PA Required Cefoxitin No - No PA Required Cefoxitin and Dextrose No - No PA Required Cefpodoxime Proxetil No - No PA Required CEFPODOXIME PROXETIL No - No PA Required CEFPROZIL No - No PA Required Cefprozil No - No PA Required Ceftaroline Fosamil Yes - PA Required Ceftazidime No - No PA Required Ceftriaxone No - No PA Required ceftriaxone No - No PA Required CEFTRIAXONE AND DEXTROSE No - No PA Required Ceftriaxone Sodium No - No PA Required Cefuroxime No - No PA Required Cefuroxime and Dextrose No - No PA Required Cefuroxime Axetil No - No PA Required Cefuroxime axetil No - No PA Required Cefuroxime sodium No - No PA Required CELEBREX No - No PA Required celecoxib No - No PA Required Celecoxib No - No PA Required CELECOXIB No - No PA Required Celexa No - No PA Required CellCept No - No PA Required Celontin No - No PA Required cephalexin No - No PA Required Cephalexin No - No PA Required CEQUA No - No PA Required Cerdelga Varies by Plan Cetirizine hydrochloride No - No PA Required Cetirizine Hydrochloride No - No PA Required CETIRIZINE HYDROCHLORIDE No - No PA Required Cetirizine Hydrochloride Oral Solution No - No PA Required CEVIMELINE No - No PA Required Cevimeline No - No PA Required cevimeline hydrochloride No - No PA Required CEVIMELINE HYDROCHLORIDE No - No PA Required Cevimeline Hydrochloride No - No PA Required CHANTIX No - No PA Required Chemet Varies by Plan Chenodal Varies by Plan Chlordiazepoxide and Amitriptyline Hydrochloride No - No PA Required CHLORDIAZEPOXIDE HCL AND CLIDINIUM BROMIDE No - No PA Required Chlordiazepoxide Hydrochloride No - No PA Required CHLORDIAZEPOXIDE HYDROCHLORIDE No - No PA Required Chlordiazepoxide Hydrochloride and Clidinium Bromide No - No PA Required CHLORDIAZEPOXIDE HYDROCHLORIDE AND CLIDINIUM BROMIDE No - No PA Required chlordiazepoxide hydrochloride and clidinium bromide No - No PA Required Chlordiazepoxide hydrochloride and clidinium bromide No - No PA Required CHLORHEXIDINE GLUCONATE No - No PA Required Chlorhexidine Gluconate No - No PA Required Chlorhexidine Gluconate 0.12% Oral Rinse No - No PA Required Chlorhexidine Gluconate Oral Rinse No - No PA Required Chlorhexidine Gluconate, 0.12% Oral Rinse No - No PA Required Chlorhexidine Gluconate, 0.12% Oral Rinse Solution No - No PA Required Chloroquine Phosphate No - No PA Required CHLOROQUINE PHOSPHATE No - No PA Required Chlorpromazine No - No PA Required CHLORPROMAZINE HCI No - No PA Required CHLORPROMAZINE HYDROCHLORIDE No - No PA Required Chlorpromazine Hydrochloride No - No PA Required ChlorproMAZINE Hydrochloride No - No PA Required Chlorpromazine hydrochloride No - No PA Required chlorpromazine hydrochloride No - No PA Required Chlorthalidone No - No PA Required CHLORTHALIDONE No - No PA Required CHLORTHALIDONE CHLORTHALIDONE No - No PA Required chlorzoxazone No - No PA Required Chlorzoxazone No - No PA Required CHLORZOXAZONE No - No PA Required Cholbam Varies by Plan CHOLBAM Varies by Plan CHOLESTYRAMINE No - No PA Required Cholestyramine No - No PA Required Cholestyramine for Oral Suspension No - No PA Required CHOLESTYRAMINE LIGHT No - No PA Required Cholestyramine Light No - No PA Required cholestyramine powder for suspension No - No PA Required Cialis No - No PA Required CIBINQO Varies by Plan Cibinqo Varies by Plan ciclopirox No - No PA Required CICLOPIROX No - No PA Required Ciclopirox No - No PA Required Ciclopirox olamine No - No PA Required Ciclopirox Olamine No - No PA Required CILOSTAZOL No - No PA Required cilostazol No - No PA Required Cilostazol No - No PA Required CILOXAN No - No PA Required CIMDUO No - No PA Required CIMETIDINE No - No PA Required Cimetidine No - No PA Required CIMETIDINE HYDROCHLORIDE No - No PA Required Cimetidine Hydrochloride No - No PA Required Cimzia Yes - PA Required CINACALCET No - No PA Required Cinacalcet No - No PA Required Cinacalcet Hydrochloride No - No PA Required Cipro No - No PA Required CIPRO HC No - No PA Required CIPROFLOXACIN No - No PA Required Ciprofloxacin No - No PA Required ciprofloxacin No - No PA Required Ciprofloxacin and Dexamethasone No - No PA Required Ciprofloxacin and dexamethasone No - No PA Required Ciprofloxacin HCL No - No PA Required Ciprofloxacin HCl Ophthalmic No - No PA Required CIPROFLOXACIN HYDROCHLORIDE No - No PA Required Ciprofloxacin Hydrochloride No - No PA Required ciprofloxacin hydrochloride and hydrocortisone No - No PA Required Ciprofloxacin in Dextrose No - No PA Required Ciprofloxacin Otic No - No PA Required Ciprofloxacin Otic Solution, 0.2% No - No PA Required citalopram No - No PA Required CITALOPRAM No - No PA Required Citalopram No - No PA Required Citalopram Hydrobromide No - No PA Required CITALOPRAM HYDROBROMIDE No - No PA Required Cladribine No - No PA Required Claravis No - No PA Required Clarinex No - No PA Required CLARINEX-D 12 HOUR No - No PA Required clarithromycin No - No PA Required Clarithromycin No - No PA Required CLARITHROMYCIN No - No PA Required Clemastine Fumarate No - No PA Required CLEMASTINE FUMARATE No - No PA Required CLEMSZA No - No PA Required CLENPIQ Varies by Plan Cleocin No - No PA Required Cleocin Hydrochloride No - No PA Required Cleocin Pediatric No - No PA Required CLEOCIN PHOSPHATE No - No PA Required Cleocin Phosphate No - No PA Required Cleocin T No - No PA Required Climara No - No PA Required Climara Pro No - No PA Required Clindacin ETZ No - No PA Required Clindacin P No - No PA Required Clindagel No - No PA Required Clindamycin No - No PA Required clindamycin and benzoyl peroxide No - No PA Required Clindamycin and Benzoyl Peroxide No - No PA Required CLINDAMYCIN AND BENZOYL PEROXIDE No - No PA Required Clindamycin HCL No - No PA Required CLINDAMYCIN HYDROCHLORIDE No - No PA Required clindamycin hydrochloride No - No PA Required Clindamycin Hydrochloride No - No PA Required Clindamycin hydrochloride No - No PA Required Clindamycin in 5 percent Dextrose No - No PA Required Clindamycin in 5 Percent Dextrose No - No PA Required Clindamycin Palmitate Hydrochloride No - No PA Required clindamycin palmitate hydrochloride No - No PA Required Clindamycin Palmitate Hydrochloride (Pediatric) No - No PA Required CLINDAMYCIN PALMITATE HYDROCHLORIDE (Pediatric) No - No PA Required Clindamycin Phoaphate Topical Solution USP, 1% No - No PA Required Clindamycin Phoaphate Topical USP, 1% No - No PA Required clindamycin phosphate No - No PA Required CLINDAMYCIN PHOSPHATE No - No PA Required Clindamycin phosphate No - No PA Required Clindamycin Phosphate No - No PA Required Clindamycin Phosphate 1.2% and Tretinoin 0.025% No - No PA Required clindamycin phosphate and benzoyl peroxide No - No PA Required Clindamycin Phosphate and Benzoyl Peroxide No - No PA Required Clindamycin phosphate and benzoyl peroxide No - No PA Required CLINDAMYCIN PHOSPHATE AND BENZOYL PEROXIDE No - No PA Required CLINDAMYCIN PHOSPHATE AND BENZOYL PEROXIDE CLINDAMYCIN PHOSPHATE AND BENZOYL PEROXIDE No - No PA Required Clindamycin Phosphate and Tretinoin No - No PA Required Clindamycin Phosphate and Tretinoin Gel 1.2%/0.025% No - No PA Required Clindesse No - No PA Required CLINIMIX Yes - PA Required CLINIMIX E Yes - PA Required Clinisol Yes - PA Required Clinolipid Yes - PA Required CLOBAZAM No - No PA Required Clobazam No - No PA Required clobetasol propionate No - No PA Required CLOBETASOL PROPIONATE No - No PA Required Clobetasol Propionate No - No PA Required Clobetasol Propionate (emollient) No - No PA Required Clobetasol Propionate ANDA No - No PA Required Clobetasol Propionate Cream 0.05% Clobetasol Propionate Cream 0.05% No - No PA Required Clobetasol Propionate Cream USP, 0.05% Clobetasol Propionate Cream USP, 0.05% No - No PA Required Clobetasol Propionate Cream, 0.05% Clobetasol Propionate Cream, 0.05% No - No PA Required clobetasol propionate emollient formulation No - No PA Required Clobex No - No PA Required CLOBEX No - No PA Required Clocortolone Pivalate No - No PA Required CLOMIPRAMINE HYDROCHLORIDE No - No PA Required Clomipramine hydrochloride No - No PA Required Clomipramine Hydrochloride No - No PA Required CLONAZEPAM No - No PA Required Clonazepam No - No PA Required Clonidine No - No PA Required CLONIDINE HCI No - No PA Required Clonidine Hydrochloride No - No PA Required CLONIDINE HYDROCHLORIDE No - No PA Required clonidine hydrochloride No - No PA Required Clonidine hydrochloride No - No PA Required Clonidine transdermal system No - No PA Required Clonidine Transdermal System USP, 0.1 mg/day, Clonidine Transdermal System USP, 0.2 mg/day, Clonidine Transdermal System USP, 0.3 mg/day No - No PA Required Clopidogrel No - No PA Required CLOPIDOGREL No - No PA Required Clopidogrel bisulfate No - No PA Required Clopidogrel Bisulfate No - No PA Required CLORAZEPATE DIPOTASSIUM No - No PA Required Clorazepate Dipotassium No - No PA Required CLOTRIMAZOLE No - No PA Required Clotrimazole No - No PA Required Clotrimazole and Betamethasone Dipropionate No - No PA Required CLOTRIMAZOLE AND BETAMETHASONE DIPROPIONATE No - No PA Required Clotrimazole Topical Solution USP, 1% No - No PA Required CLOZAPINE No - No PA Required Clozapine No - No PA Required Clozaril No - No PA Required COARTEM Varies by Plan Cobenfy No - No PA Required Codeine Sulfate No - No PA Required Codeine sulfate No - No PA Required colchicine No - No PA Required Colchicine No - No PA Required COLCHICINE No - No PA Required COLESEVELAM No - No PA Required Colesevelam No - No PA Required Colesevelam HCL No - No PA Required Colesevelam hydrochloride No - No PA Required COLESEVELAM HYDROCHLORIDE No - No PA Required colesevelam hydrochloride No - No PA Required Colesevelam Hydrochloride No - No PA Required Colestid No - No PA Required Colestipol hydrochloride No - No PA Required COLESTIPOL HYDROCHLORIDE No - No PA Required Colestipol Hydrochloride No - No PA Required COLLAGENASE SANTYL Varies by Plan COMBIGAN No - No PA Required CombiPatch (estradiol/norethindrone acetate transdermal system) No - No PA Required Combivent Respimat No - No PA Required COMETRIQ Varies by Plan COMPLERA No - No PA Required Compro No - No PA Required CONCERTA No - No PA Required CONEXXENCE Yes - PA Required Constulose No - No PA Required ConZip No - No PA Required Copaxone No - No PA Required COPIKTRA Varies by Plan CORDRAN No - No PA Required Coreg No - No PA Required Coreg CR No - No PA Required Corlanor No - No PA Required CORTEF No - No PA Required Cosentyx Yes - PA Required COSENTYX Yes - PA Required COSOPT No - No PA Required COSOPT PF No - No PA Required Cotellic Varies by Plan Cotempla XR-ODT No - No PA Required COZAAR No - No PA Required Crenessity Varies by Plan Creon Varies by Plan CRESEMBA Varies by Plan Crestor No - No PA Required CREXONT No - No PA Required Crinone No - No PA Required cromolyn sodium No - No PA Required Cromolyn Sodium No - No PA Required CROMOLYN SODIUM No - No PA Required Cromolyn Sodium Inhalation Solution No - No PA Required Cromolyn Sodium Oral Solution (Concentrate) No - No PA Required Crotan No - No PA Required Cryselle No - No PA Required CTEXLI Varies by Plan Cuprimine No - No PA Required Cuvposa No - No PA Required CUVRIOR Varies by Plan Cyclobenzaprine HCL No - No PA Required Cyclobenzaprine HCL ER No - No PA Required CYCLOBENZAPRINE HYDROCHLORIDE No - No PA Required Cyclobenzaprine Hydrochloride No - No PA Required Cyclobenzaprine hydrochloride No - No PA Required CYCLOPHOSPHAMIDE No - No PA Required Cyclophosphamide No - No PA Required Cycloserine No - No PA Required CYCLOSET No - No PA Required Cyclosporine No - No PA Required CYCLOSPORINE No - No PA Required Cyclosporine Modified No - No PA Required Cyltezo No - No PA Required CYPROHEPTADINE No - No PA Required CYPROHEPTADINE HYDROCHLORIDE No - No PA Required Cyproheptadine Hydrochloride No - No PA Required cyproheptadine hydrochloride solution No - No PA Required Cyred EQ Varies by Plan Cystadane No - No PA Required CYSTADROPS Varies by Plan Cystagon Varies by Plan CYSTARAN Varies by Plan Cytomel No - No PA Required Cytotec No - No PA Required

D

DABIGATRAN No - No PA Required Dabigatran etexilate No - No PA Required dabigatran etexilate No - No PA Required Dabigatran Etexilate No - No PA Required DABIGATRAN ETEXILATE No - No PA Required Dalbavancin No - No PA Required DALBAVANCIN HYDROCHLORIDE No - No PA Required Dalfampridine No - No PA Required DALFAMPRIDINE No - No PA Required Daliresp No - No PA Required DALVANCE No - No PA Required Danazol No - No PA Required Dantrium No - No PA Required Dantrolene No - No PA Required dantrolene sodium No - No PA Required Dantrolene Sodium No - No PA Required DANZITEN No - No PA Required DAPAGLIFLOZIN No - No PA Required dapagliflozin and metformin hydrochloride No - No PA Required dapsone No - No PA Required Dapsone No - No PA Required DAPSONE No - No PA Required Dapsone 100 mg, Dapsone 25 mg No - No PA Required DAPTOMYCIN No - No PA Required Daptomycin No - No PA Required daptomycin No - No PA Required Daptomycin in Sodium Chloride No - No PA Required Daraprim No - No PA Required Darifenacin No - No PA Required DARIFENACIN No - No PA Required Darunavir No - No PA Required DARUNAVIR No - No PA Required Darunavir 600 and 800 mg No - No PA Required DASATINIB No - No PA Required Dasatinib No - No PA Required dasatinib No - No PA Required Daurismo Varies by Plan DAWNZERA Yes - PA Required Daytrana No - No PA Required DAYVIGO Varies by Plan DDAVP No - No PA Required DEBLITANE Varies by Plan deferasirox No - No PA Required Deferasirox No - No PA Required DEFERASIROX No - No PA Required Deferasirox oral No - No PA Required Deferasirox Oral Granules No - No PA Required Deferiprone No - No PA Required DEFERIPRONE No - No PA Required Deflazacort No - No PA Required Deflazacort Oral Suspension No - No PA Required Delestrogen No - No PA Required DELSTRIGO Varies by Plan Demeclocycline Hydrochloride No - No PA Required DEMEROL No - No PA Required Demser No - No PA Required Denavir No - No PA Required Denosumab-BMWO Yes - PA Required Depakote No - No PA Required Depakote ER No - No PA Required Depakote Sprinkles No - No PA Required Depen No - No PA Required Depo-Estradiol Yes - PA Required Depo-Provera No - No PA Required Depo-SubQ Provera No - No PA Required Depo-Testosterone No - No PA Required DERMOTIC No - No PA Required DESCOVY No - No PA Required Desipramine HCL No - No PA Required DESIPRAMINE HYDROCHLORIDE No - No PA Required Desipramine Hydrochloride No - No PA Required Desloratadine No - No PA Required DESLORATADINE No - No PA Required Desloratadine Oral Solution No - No PA Required Desmopressin acetate No - No PA Required Desmopressin Acetate No - No PA Required desmopressin acetate No - No PA Required DESMOPRESSIN ACETATE No - No PA Required Desogestrel and Ethinyl Estradiol Varies by Plan desogestrel and ethinyl estradiol Varies by Plan DESOGESTREL AND ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL Varies by Plan Desonide No - No PA Required DESONIDE No - No PA Required Desonide Ointment, 0.05% No - No PA Required DESOXIMETASONE No - No PA Required desoximetasone No - No PA Required Desoximetasone No - No PA Required Desvenlafaxine No - No PA Required desvenlafaxine No - No PA Required DESVENLAFAXINE No - No PA Required Desvenlafaxine ER No - No PA Required DESVENLAFAXINE ER No - No PA Required Desvenlafaxine Succinate No - No PA Required DEXAMETHASONE No - No PA Required dexamethasone No - No PA Required Dexamethasone No - No PA Required Dexamethasone 1.5 mg No - No PA Required Dexamethasone Intensol, Dexamethasone No - No PA Required DEXAMETHASONE SODIUM PHOSPHATE No - No PA Required Dexamethasone Sodium Phosphate No - No PA Required Dexamethasone sodium phosphate No - No PA Required DEXEDRINE SPANSULE No - No PA Required Dexilant No - No PA Required Dexlansoprazole No - No PA Required Dexlansoprazole delayed release No - No PA Required Dexmethylphenidate hydrochloride No - No PA Required DEXMETHYLPHENIDATE HYDROCHLORIDE No - No PA Required Dexmethylphenidate Hydrochloride No - No PA Required Dexmethylphenidate Hydrochloride Extended-Release Varies by Plan Dextroamphetamine No - No PA Required Dextroamphetamine Saccharate and Amphetamine Aspartate and Dextroamphetamine Sulfate and Amphetamine Sulfate No - No PA Required dextroamphetamine saccharate, amphetamine aspartate monohydrate, dextroamphetamine sulfate and amphetamine sulfate No - No PA Required DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE MONOHYDRATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE No - No PA Required Dextroamphetamine Saccharate, Amphetamine Aspartate Monohydrate, Dextroamphetamine Sulfate and Amphetamine Sulfate No - No PA Required Dextroamphetamine saccharate, amphetamine aspartate monohydrate, dextroamphetamine sulfate, amphetamine sulfate No - No PA Required Dextroamphetamine Saccharate, Amphetamine Aspartate Monohydrate, Dextroamphetamine Sulfate, Amphetamine Sulfate Extended-Release No - No PA Required dextroamphetamine saccharate, amphetamine aspartate monohydrate, dextroamphetamine sulfate, and amphetamine sulfate No - No PA Required Dextroamphetamine Saccharate, Amphetamine Aspartate Monohydrate, Dextroamphetamine Sulfate, and Amphetamine Sulfate No - No PA Required Dextroamphetamine Saccharate, Amphetamine Aspartate Monohydrate, Dextroamphetamine Sulfate, and Amphetamine Sulfate Extended-Release No - No PA Required Dextroamphetamine Saccharate, Amphetamine Aspartate, Dextroamphetamine Sulfate and Amphetamine Sulfate No - No PA Required DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE No - No PA Required Dextroamphetamine Saccharate, Amphetamine Aspartate, Dextroamphetamine Sulfate, Amphetamine Sulfate No - No PA Required Dextroamphetamine Saccharate, Amphetamine Aspartate, Dextroamphetamine Sulfate, Amphetamine Sulfate Tablets,CII No - No PA Required Dextroamphetamine Saccharate, Amphetamine Aspartate, Dextroamphetamine Sulfate, and Amphetamine Sulfate No - No PA Required Dextroamphetamine saccharate, amphetamine aspartate, dextroamphetamine sulfate, and amphetamine sulfate No - No PA Required DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE, AND AMPHETAMINE SULFATE No - No PA Required dextroamphetamine sulfate No - No PA Required Dextroamphetamine Sulfate No - No PA Required DEXTROAMPHETAMINE SULFATE No - No PA Required Dextroamphetamine Sulfate Extended-Release No - No PA Required Dextromethorphan hydrobromide and quinidine sulfate Varies by Plan Dhivy No - No PA Required DIAZEPAM No - No PA Required Diazepam No - No PA Required Diazepam Intensol No - No PA Required Diazoxide No - No PA Required Dibasic Sodium Phosphate, Monobasic Potassium Phosphate and Monobasic Sodium Phosphate Yes - PA Required Dichlorphenamide No - No PA Required DICLEGIS No - No PA Required Diclofenac No - No PA Required Diclofenac DR No - No PA Required diclofenac epolamine No - No PA Required Diclofenac Epolamine No - No PA Required DICLOFENAC POTASSIUM No - No PA Required diclofenac potassium No - No PA Required Diclofenac potassium No - No PA Required Diclofenac Potassium No - No PA Required DICLOFENAC SODIUM No - No PA Required Diclofenac sodium No - No PA Required diclofenac sodium No - No PA Required Diclofenac Sodium No - No PA Required Diclofenac Sodium 1.5% No - No PA Required Diclofenac sodium and Misoprostol No - No PA Required Diclofenac Sodium and Misoprostol No - No PA Required Diclofenac sodium and Misoprostol DR No - No PA Required Diclofenac Sodium Delayed Release No - No PA Required Diclofenac Sodium DR No - No PA Required Diclofenac Sodium ER No - No PA Required Diclofenac Sodium Gel No - No PA Required Diclofenac Sodium Misoprostol No - No PA Required Diclofenac Sodium Topical Solution No - No PA Required Diclofenac Sodium/Misoprostol diclofenac-sodium-misoprostol No - No PA Required Diclofenac Sodium/Misoprostol DICLOFENAC-SODIUM-MISOPROSTOL No - No PA Required DICLOXACILLIN SODIUM No - No PA Required Dicloxacillin Sodium No - No PA Required Dicyclomine No - No PA Required Dicyclomine Hydrochloride No - No PA Required Dicyclomine hydrochloride No - No PA Required DICYCLOMINE HYDROCHLORIDE No - No PA Required Differin No - No PA Required DIFFERIN No - No PA Required Diflorasone Diacetate No - No PA Required Diflucan No - No PA Required Diflunisal No - No PA Required diflunisal No - No PA Required Difluprednate No - No PA Required DIFLUPREDNATE No - No PA Required Difluprednate Ophthalmic No - No PA Required Difluprednate Ophthalmic Emulsion No - No PA Required Digoxin No - No PA Required DIGOXIN No - No PA Required Dihydroergotamine mesylate No - No PA Required Dihydroergotamine Mesylate No - No PA Required Dihydroergotamine Mesylate Nasal No - No PA Required Dilantin No - No PA Required DILANTIN No - No PA Required Dilantin Infatabs No - No PA Required Dilaudid No - No PA Required DILTIAZEM HCI No - No PA Required Diltiazem HCL ER No - No PA Required diltiazem hydrochloride No - No PA Required Diltiazem Hydrochloride No - No PA Required DILTIAZEM HYDROCHLORIDE No - No PA Required Diltiazem hydrochloride No - No PA Required DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE No - No PA Required Diltiazem Hydrochloride EXTENDED RELEASE No - No PA Required Diltiazem Hydrochloride Extended-Release No - No PA Required DILTIAZEM HYDROCHLORIDE in SODIUM CHLORIDE No - No PA Required dimethyl fumarate No - No PA Required Dimethyl Fumarate No - No PA Required Dimethyl fumarate No - No PA Required DIMETHYL FUMARATE No - No PA Required Dimethyl fumarate, Dimethyl Fumarate No - No PA Required Dimethyl Fumarate, DIMETHYL FUMARATE No - No PA Required Diovan No - No PA Required Diovan HCT No - No PA Required Dipentum Varies by Plan DIPROLENE No - No PA Required Dipyridamole No - No PA Required DIPYRIDAMOLE No - No PA Required DISOPYRAMIDE PHOSPHATE No - No PA Required Disopyramide Phosphate No - No PA Required Disulfiram No - No PA Required Divalproex Sodium No - No PA Required divalproex sodium No - No PA Required Divalproex sodium No - No PA Required Divalproex Sodium D/R No - No PA Required Divalproex Sodium ER No - No PA Required DIVIGEL No - No PA Required DOFETILIDE No - No PA Required Dofetilide No - No PA Required Dofetilide 0.125mg, Dofetilide 0.25mg, Dofetilide 0.5mg No - No PA Required DOJOLVI Varies by Plan Dolishale No - No PA Required Dolobid No - No PA Required Donepezil No - No PA Required donepezil hydrochloride No - No PA Required Donepezil hydrochloride No - No PA Required DONEPEZIL HYDROCHLORIDE No - No PA Required Donepezil Hydrochloride No - No PA Required Doptelet Sprinkle, DOPTELET Varies by Plan DORYX MPC No - No PA Required Dorzolamide and Timolol No - No PA Required Dorzolamide HCl No - No PA Required DORZOLAMIDE HYDROCHLORIDE No - No PA Required Dorzolamide hydrochloride No - No PA Required Dorzolamide Hydrochloride No - No PA Required DORZOLAMIDE HYDROCHLORIDE and TIMOLOL MALEATE No - No PA Required DORZOLAMIDE HYDROCHLORIDE AND TIMOLOL MALEATE No - No PA Required Dorzolamide hydrochloride and timolol maleate No - No PA Required Dorzolamide Hydrochloride and Timolol Maleate No - No PA Required Dorzolamide Hydrochloride and Timolol Maleate Ophthalmic Solution No - No PA Required Dorzolamide Hydrochloride and Timolol Maleate ophthalmic Solution No - No PA Required Dorzolamide Hydrochloride and Timolol Maleate Preservative Free No - No PA Required Dorzolamide Hydrochloride Ophthalmic No - No PA Required Dorzolamide Hydrochloride Ophthalmic Solution No - No PA Required DORZOLAMIDE HYDROCHLORIDE TIMOLOL MALEATE No - No PA Required DORZOLAMIDE HYDROCHLORIDE TIMOLOL MALETAE No - No PA Required DOTTI No - No PA Required Dovato Yes - PA Required Doxazosin No - No PA Required DOXAZOSIN No - No PA Required Doxazosin mesylate No - No PA Required Doxazosin Mesylate No - No PA Required doxepin No - No PA Required Doxepin No - No PA Required DOXEPIN No - No PA Required Doxepin HCL No - No PA Required doxepin hydrochloride No - No PA Required Doxepin Hydrochloride No - No PA Required DOXEPIN HYDROCHLORIDE No - No PA Required Doxepin hydrochloride No - No PA Required Doxercalciferol No - No PA Required DOXERCALCIFEROL No - No PA Required Doxy 100 No - No PA Required DOXY 100(TM) DOXYCYCLINE No - No PA Required DOXYCYCLINE No - No PA Required doxycycline No - No PA Required Doxycycline No - No PA Required DOXYCYCLINE DOXYCYCLINE No - No PA Required Doxycycline Hyclate No - No PA Required DOXYCYCLINE HYCLATE No - No PA Required doxycycline hyclate No - No PA Required Doxycycline hyclate No - No PA Required DOXYCYCLINE HYCLATE DELAYED RELEASE No - No PA Required Doxycycline Hyclate, Doxycycline No - No PA Required Doxycycline Monohydrate No - No PA Required Doxylamine succinate and pyridoxine hydrochloride No - No PA Required Doxylamine succinate and Pyridoxine hydrochloride No - No PA Required Doxylamine Succinate and Pyridoxine Hydrochloride No - No PA Required DRIZALMA SPRINKLE No - No PA Required DRONABINOL No - No PA Required Dronabinol No - No PA Required DROSPIRENONE AND ETHINYL ESTRADIOL Varies by Plan drospirenone and ethinyl estradiol Varies by Plan Drospirenone and Ethinyl Estradiol Varies by Plan Drospirenone and ethinyl estradiol Varies by Plan DROXIA No - No PA Required Droxidopa No - No PA Required droxidopa No - No PA Required DROXIDOPA No - No PA Required DUAKLIR PRESSAIR Varies by Plan Duavee Varies by Plan Duetact No - No PA Required Dulera No - No PA Required duloxetine No - No PA Required DULOXETINE No - No PA Required Duloxetine No - No PA Required Duloxetine D/R No - No PA Required Duloxetine Delayed-Release No - No PA Required DULOXETINE DELAYED-RELEASE No - No PA Required Duloxetine DR No - No PA Required Duloxetine HCL DR No - No PA Required DULOXETINE HYDROCHLORIDE No - No PA Required Duloxetine Hydrochloride No - No PA Required Duloxetine hydrochloride No - No PA Required Duobrii No - No PA Required Duopa No - No PA Required Dupixent Yes - PA Required DUREZOL No - No PA Required DUTASTERIDE No - No PA Required Dutasteride No - No PA Required Dutasteride and Tamsulosin Hydrochloride No - No PA Required Dutasteride and tamsulosin hydrochloride No - No PA Required DUVYZAT Yes - PA Required Dyanavel XR, DYANAVEL XR No - No PA Required DYMISTA No - No PA Required Dyrenium No - No PA Required

E

EBGLYSS Yes - PA Required Econazole Nitrate No - No PA Required Edaravone Yes - PA Required edaravone Yes - PA Required Edarbi Varies by Plan Edarbyclor Varies by Plan EDECRIN No - No PA Required Edluar No - No PA Required EFAVIRENZ No - No PA Required Efavirenz No - No PA Required Effexor XR No - No PA Required Effient No - No PA Required EGRIFTA SV Yes - PA Required EGRIFTA WR Yes - PA Required EKTERLY Varies by Plan ELESTRIN No - No PA Required Eletriptan HBR No - No PA Required eletriptan hydrobromide No - No PA Required Eletriptan hydrobromide No - No PA Required Eletriptan Hydrobromide No - No PA Required ELIGARD No - No PA Required Eligard No - No PA Required ELIMITE No - No PA Required ELIQUIS Varies by Plan ELMIRON Varies by Plan eltrombopag No - No PA Required ELTROMBOPAG No - No PA Required Eltrombopag No - No PA Required Eltrombopag Olamine No - No PA Required Eltrombopag olamine No - No PA Required EluRyng No - No PA Required ELYXYB - celecoxib No - No PA Required EMEND No - No PA Required EMFLAZA No - No PA Required EMGALITY Yes - PA Required Empaveli Yes - PA Required EMROSI No - No PA Required EMSAM Varies by Plan emtricitabine No - No PA Required Emtricitabine and tenofovir disoproxil fumarate No - No PA Required Emtricitabine and Tenofovir Disoproxil Fumarate No - No PA Required EMTRICITABINE AND TENOFOVIR DISOPROXIL FUMARATE No - No PA Required Emtriva No - No PA Required ENALAPRIL MALEATE No - No PA Required Enalapril Maleate No - No PA Required Enalapril maleate No - No PA Required Enalapril Maleate and Hydrochlorothiazide No - No PA Required Enalapril maleate oral solution No - No PA Required Enalapril Maleate Oral Solution No - No PA Required ENBREL Yes - PA Required Enbrel Yes - PA Required Enbumyst No - No PA Required Endari No - No PA Required EnilloRing No - No PA Required ENOBY Yes - PA Required ENOXAPARIN SODIUM No - No PA Required Enoxaparin sodium No - No PA Required Enoxaparin Sodium No - No PA Required ENSACOVE Varies by Plan ENSKYCE Varies by Plan Enspryng Yes - PA Required ENSTILAR Varies by Plan Entacapone No - No PA Required ENTACAPONE No - No PA Required Entecavir No - No PA Required ENTECAVIR No - No PA Required ENTRESTO No - No PA Required Entyvio Yes - PA Required Enulose No - No PA Required Envarsus XR No - No PA Required Eohilia No - No PA Required Epclusa No - No PA Required Epidiolex Varies by Plan EPIDUO No - No PA Required epiduo forte No - No PA Required EPINASTINE HYDROCHLORIDE No - No PA Required EPINEPHRINE No - No PA Required Epinephrine No - No PA Required epinephrine No - No PA Required Epinephrine 0.15 Pediatrics No - No PA Required Epinephrine 0.3 Adults No - No PA Required Epinephrine Convenience Kit No - No PA Required Epinephrine Pediatrics No - No PA Required Epinephrine Professional No - No PA Required EPIPEN No - No PA Required EPIVIR No - No PA Required EPLERENONE No - No PA Required Eplerenone No - No PA Required EPOGEN Yes - PA Required Eprontia No - No PA Required Epsolay No - No PA Required EPSOLAY No - No PA Required EQUETRO No - No PA Required ERAXIS Yes - PA Required Ergomar Sublingual Varies by Plan ergotamine tartrate and caffeine Varies by Plan ERIVEDGE Varies by Plan ERLEADA Varies by Plan ERLOTINIB No - No PA Required Erlotinib No - No PA Required Erlotinib Hydrochloride No - No PA Required ERLOTINIB HYDROCHLORIDE No - No PA Required ERMEZA No - No PA Required ERRIN Varies by Plan Ertaczo Varies by Plan Ertapenem No - No PA Required ERTAPENEM No - No PA Required ERTAPENEM SODIUM No - No PA Required ertapenem sodium No - No PA Required Ery No - No PA Required Erythrocin Lactobionate Yes - PA Required Erythromycin No - No PA Required ERYTHROMYCIN No - No PA Required erythromycin No - No PA Required Erythromycin and Benzoyl Peroxide No - No PA Required Erythromycin Ethylsuccinate No - No PA Required ERYTHROMYCIN ETHYLSUCCINATE No - No PA Required Erythromycin Lactobionate Yes - PA Required erythromycin lactobionate Yes - PA Required erythromycin topical solution 2% No - No PA Required Erzofri extended-release Yes - PA Required ESBRIET No - No PA Required Escitalopram No - No PA Required escitalopram No - No PA Required Escitalopram Oral Solution No - No PA Required escitalopram oxalate No - No PA Required Escitalopram Oxalate No - No PA Required ESCITALOPRAM OXALATE No - No PA Required Escitalopram oxalate No - No PA Required Eslicarbazepine acetate No - No PA Required Eslicarbazepine Acetate No - No PA Required esomeprazole No - No PA Required Esomeprazole DR No - No PA Required Esomeprazole magnesium No - No PA Required ESOMEPRAZOLE MAGNESIUM No - No PA Required Esomeprazole Magnesium No - No PA Required esomeprazole magnesium No - No PA Required Esomeprazole Magnesium DR No - No PA Required Esomeprazole Magnesium for delayed-release oral suspension No - No PA Required Esomeprazole Sodium No - No PA Required ESOMEPRAZOLE STRONTIUM No - No PA Required Estarylla No - No PA Required Estazolam No - No PA Required ESTRACE No - No PA Required estradiol No - No PA Required Estradiol No - No PA Required ESTRADIOL No - No PA Required Estradiol / Norethindrone Acetate No - No PA Required Estradiol and Norethindrone Acetate No - No PA Required ESTRADIOL AND NORETHINDRONE ACETATE No - No PA Required Estradiol Gel No - No PA Required Estradiol Transdermal System No - No PA Required ESTRADIOL VAGINAL No - No PA Required Estradiol Vaginal No - No PA Required ESTRADIOL VAGINAL INSERTS No - No PA Required ESTRADIOL VALERATE No - No PA Required Estradiol Valerate No - No PA Required Estradiol valerate No - No PA Required Estradiol Valerate and Estradiol Valerate/Dienogest No - No PA Required Estring No - No PA Required ESZOPICLONE No - No PA Required Eszopiclone No - No PA Required Ethacrynic acid No - No PA Required Ethacrynic Acid No - No PA Required ethacrynic acid No - No PA Required Ethambutol Hydrochloride No - No PA Required ETHAMBUTOL HYDROCHLORIDE No - No PA Required ETHOSUXIMIDE No - No PA Required Ethosuximide No - No PA Required etodolac No - No PA Required Etodolac No - No PA Required Etodolac ER No - No PA Required Etonogestrel and Ethinyl Estradiol Vaginal Yes - PA Required Etonogestrel and Ethinyl Estradiol Vaginal Ring Yes - PA Required Etravirine No - No PA Required ETRAVIRINE No - No PA Required etravirine No - No PA Required Eucrisa Varies by Plan Eulexin Varies by Plan Evamist No - No PA Required Evekeo No - No PA Required Evenity Varies by Plan Everolimus No - No PA Required everolimus No - No PA Required EVEROLIMUS No - No PA Required Evista No - No PA Required EVOTAZ No - No PA Required Evoxac No - No PA Required EVRYSDI Varies by Plan Exelderm Varies by Plan Exelon No - No PA Required EXEMESTANE No - No PA Required Exemestane No - No PA Required Exenatide No - No PA Required Exforge No - No PA Required Exforge HCT No - No PA Required Exjade No - No PA Required EXXUA Varies by Plan Eysuvis No - No PA Required ezetimibe No - No PA Required EZETIMIBE No - No PA Required Ezetimibe No - No PA Required ezetimibe and simvastatin No - No PA Required Ezetimibe and Simvastatin No - No PA Required

F

FABHALTA Varies by Plan Falmina No - No PA Required Famciclovir No - No PA Required FAMCICLOVIR No - No PA Required FAMOTIDINE No - No PA Required Famotidine No - No PA Required famotidine No - No PA Required FANAPT Varies by Plan FARXIGA No - No PA Required FASENRA Yes - PA Required FEBUXOSTAT No - No PA Required febuxostat No - No PA Required Febuxostat No - No PA Required FEIRZA 1.5/30 TM No - No PA Required FEIRZA 1/20 No - No PA Required Felbamate No - No PA Required Felbatol No - No PA Required Felodipine No - No PA Required FELODIPINE No - No PA Required Femara No - No PA Required FEMLYV No - No PA Required Femring No - No PA Required fenofibrate No - No PA Required FENOFIBRATE No - No PA Required Fenofibrate No - No PA Required Fenofibric acid No - No PA Required FENOFIBRIC ACID No - No PA Required Fenofibric Acid No - No PA Required FENOFIBRIC ACID DELAYED-RELEASE No - No PA Required Fenoprofen Calcium No - No PA Required FENOPROFEN CALCIUM No - No PA Required FENOPRON TM No - No PA Required FENTANYL No - No PA Required Fentanyl Citrate No - No PA Required FENTANYL CITRATE No - No PA Required Fentanyl system No - No PA Required FENTANYL TRANSDERMAL No - No PA Required FERRIPROX No - No PA Required fesoterodine fumarate No - No PA Required FESOTERODINE FUMARATE No - No PA Required Fesoterodine fumarate No - No PA Required Fesoterodine Fumarate No - No PA Required Fetzima Varies by Plan Fexmid No - No PA Required Fidaxomicin No - No PA Required FILSPARI Varies by Plan FILSUVEZ Varies by Plan FINACEA FOAM No - No PA Required Finasteride No - No PA Required Fingolimod No - No PA Required fingolimod No - No PA Required FINGOLIMOD No - No PA Required FINGOLIMOD HYDROCHLORIDE No - No PA Required Fintepla Varies by Plan Finzala No - No PA Required Fioricet No - No PA Required Firazyr No - No PA Required Firdapse Varies by Plan FIRMAGON Yes - PA Required FIRVANQ No - No PA Required Flac Otic Oil No - No PA Required Flarex Yes - PA Required Flavoxate Hydrochloride No - No PA Required Flecainide Acetate No - No PA Required FLECTOR No - No PA Required FLEQSUVY No - No PA Required fluconazole No - No PA Required Fluconazole No - No PA Required FLUCONAZOLE No - No PA Required Fluconazole in Sodium Chloride No - No PA Required Flucytosine No - No PA Required FLUCYTOSINE No - No PA Required Fludrocortisone Acetate No - No PA Required Fludrocortisone acetate No - No PA Required FLUDROCORTISONE ACETATE No - No PA Required Flunisolide No - No PA Required Fluocinolone acetonide No - No PA Required fluocinolone acetonide No - No PA Required FLUOCINOLONE ACETONIDE No - No PA Required Fluocinolone Acetonide No - No PA Required FLUOCINOLONE ACETONIDE Oil No - No PA Required Fluocinolone Acetonide Oil No - No PA Required Fluocinolone Acetonide Topical No - No PA Required Fluocinolone Acetonide Topical Solution USP, 0.01% No - No PA Required Fluocinonide No - No PA Required FLUOCINONIDE No - No PA Required fluocinonide No - No PA Required Fluocinonide Cream No - No PA Required FLUOROMETHOLONE Yes - PA Required Fluorouracil No - No PA Required fluorouracil No - No PA Required FLUOROURACIL No - No PA Required Fluoxetine No - No PA Required fluoxetine No - No PA Required FLUOXETINE No - No PA Required FLUOXETINE HCL No - No PA Required Fluoxetine HCl No - No PA Required Fluoxetine HCL No - No PA Required Fluoxetine hydrochloride No - No PA Required Fluoxetine Hydrochloride No - No PA Required FLUOXETINE HYDROCHLORIDE No - No PA Required fluoxetine hydrochloride No - No PA Required FLUPHENAZINE DECANOATE No - No PA Required Fluphenazine Decanoate No - No PA Required fluphenazine decanoate No - No PA Required FLUPHENAZINE HYDROCHLORIDE No - No PA Required Fluphenazine hydrochloride No - No PA Required Fluphenazine Hydrochloride No - No PA Required fluphenazine hydrochloride No - No PA Required Fluphenazine Hydrochoride No - No PA Required Flurandrenolide No - No PA Required Flurazepam Hydrochloride No - No PA Required Flurbiprofen No - No PA Required Flurbiprofen Sodium No - No PA Required Fluticasone No - No PA Required FLUTICASONE No - No PA Required Fluticasone Furoate and Vilanterol No - No PA Required Fluticasone Furoate Ellipta No - No PA Required FLUTICASONE PROPIONATE No - No PA Required Fluticasone Propionate No - No PA Required Fluticasone Propionate and Salmeterol No - No PA Required fluticasone propionate and salmeterol No - No PA Required Fluticasone Propionate and Salmeterol DISKUS No - No PA Required Fluticasone Propionate and Salmeterol HFA No - No PA Required FLUTICASONE PROPIONATE DISKUS No - No PA Required Fluticasone Propionate HFA No - No PA Required Fluticasone Propionate spray, metered No - No PA Required Fluvastatin No - No PA Required Fluvastatin Sodium No - No PA Required FLUVASTATIN SODIUM ER No - No PA Required Fluvoxamine maleate No - No PA Required fluvoxamine maleate No - No PA Required Fluvoxamine Maleate No - No PA Required FML No - No PA Required Focalin No - No PA Required Focalin XR No - No PA Required Fondaparinux Sodium No - No PA Required fondaparinux sodium No - No PA Required FONDAPARINUX SODIUM No - No PA Required formoterol fumarate No - No PA Required Formoterol fumarate No - No PA Required Formoterol Fumarate No - No PA Required FORMOTEROL FUMARATE No - No PA Required Formoterol Fumarate Inhalation Solution No - No PA Required Forteo No - No PA Required FORZINITY Yes - PA Required FOSAMAX No - No PA Required FOSAMAX PLUS D No - No PA Required Fosamprenavir Calcium No - No PA Required Fosfomycin tromethamine No - No PA Required FOSFOMYCIN TROMETHAMINE No - No PA Required Fosfomycin Tromethamine No - No PA Required Fosinopril Sodium No - No PA Required Fosinopril sodium No - No PA Required Fosinopril Sodium and Hydrochlorothiazide No - No PA Required Fosrenol No - No PA Required FOTIVDA Varies by Plan Fragmin Yes - PA Required FROVATRIPTAN No - No PA Required Frovatriptan No - No PA Required frovatriptan succinate No - No PA Required Fruzaqla Varies by Plan Fulphila Yes - PA Required FUROSCIX No - No PA Required FUROSEMIDE No - No PA Required Furosemide No - No PA Required Fyavolv No - No PA Required Fycompa No - No PA Required FYLNETRA Yes - PA Required

G

gabapentin No - No PA Required Gabapentin No - No PA Required GABAPENTIN No - No PA Required GABARONE No - No PA Required Galafold Varies by Plan Galantamine No - No PA Required Galantamine Hydrobromide No - No PA Required GALBRIELA No - No PA Required Gallifrey No - No PA Required Ganciclovir Varies by Plan ganciclovir Varies by Plan ganciclovir sodium Varies by Plan Gastrocrom No - No PA Required Gatifloxacin No - No PA Required GATIFLOXACIN No - No PA Required Gatifloxacin Ophthalmic Solution 0.5% No - No PA Required Gattex Yes - PA Required GAVILYTE-N No - No PA Required Gavreto Varies by Plan Gefitinib No - No PA Required Gemfibrozil No - No PA Required GEMFIBROZIL No - No PA Required Gemmily No - No PA Required GEMTESA Varies by Plan Generlac No - No PA Required GENOTROPIN Yes - PA Required Gentamicin No - No PA Required GENTAMICIN SULFATE No - No PA Required gentamicin sulfate No - No PA Required Gentamicin Sulfate No - No PA Required Gentamicin Sulfate in Sodium Chloride No - No PA Required Gentamicin Sulfate Opth Solution No - No PA Required Genvoya Varies by Plan Geodon No - No PA Required Gilenya No - No PA Required Gilotrif Varies by Plan GIMOTI No - No PA Required GLATIRAMER ACETATE No - No PA Required Glatiramer Acetate No - No PA Required Glatopa No - No PA Required Gleevec No - No PA Required Gleostine No - No PA Required Glimepiride No - No PA Required Glimepiride 3 mg No - No PA Required Glipizide No - No PA Required Glipizide and Metformin HCl No - No PA Required Glipizide and metformin hcl No - No PA Required Glipizide and Metformin Hydrochloride No - No PA Required GLIPIZIDE ER No - No PA Required Gloperba No - No PA Required Glucagon Yes - PA Required GLUCAGON Yes - PA Required Glucose No - No PA Required Glucose and Sodium Chloride No - No PA Required Glucotrol XL No - No PA Required GLYBURIDE No - No PA Required Glyburide No - No PA Required glyburide No - No PA Required glyburide and metformin hydrochloride No - No PA Required Glyburide and Metformin Hydrochloride No - No PA Required Glycate No - No PA Required Glycerol Phenylbutyrate No - No PA Required glycerol phenylbutyrate No - No PA Required Glycopyrrolate No - No PA Required GLYCOPYRROLATE No - No PA Required glycopyrrolate No - No PA Required GLYCOPYRROLATE 1ML No - No PA Required Glycopyrrolate Oral Solution No - No PA Required Glyxambi Varies by Plan GOCOVRI Varies by Plan GoLYTELY No - No PA Required Gomekli Yes - PA Required Gralise No - No PA Required Granisetron Hydrochloride No - No PA Required GRANIX Yes - PA Required Griseofulvin No - No PA Required Griseofulvin MICROSIZE No - No PA Required GRISEOFULVIN MICROSIZE No - No PA Required Guanfacine No - No PA Required GUANFACINE No - No PA Required guanfacine No - No PA Required Guanfacine ER No - No PA Required Guanfacine extended-release No - No PA Required Guanfacine Extended-Release No - No PA Required Guanfacine Hydrochloride No - No PA Required GUANFACINE HYDROCHLORIDE No - No PA Required Gvoke HypoPen 0.5 mg Auto-Injector, Gvoke HypoPen 1 mg Auto-Injector, Gvoke PFS 1 mg Pre-filled Syringe, Gvoke Kit Yes - PA Required Gvoke VialDx Yes - PA Required

H

HADLIMA No - No PA Required Hadlima No - No PA Required Hailey 1.5/30 No - No PA Required Hailey 24 Fe No - No PA Required Hailey Fe 1.5/30 No - No PA Required HAILEY Fe 1/20 No - No PA Required HALCINONIDE No - No PA Required Halcinonide Topical Solution No - No PA Required Halcion No - No PA Required Halobetasol Propionate No - No PA Required Halobetasol propionate No - No PA Required HALOG No - No PA Required Halog No - No PA Required Haloperidol No - No PA Required HALOPERIDOL No - No PA Required haloperidol No - No PA Required HALOPERIDOL DECANOATE No - No PA Required Haloperidol decanoate No - No PA Required Haloperidol Decanoate No - No PA Required HALOPERIDOL LACTATE No - No PA Required Haloperidol Lactate No - No PA Required HARLIKU No - No PA Required Harvoni No - No PA Required HEATHER Varies by Plan Hemady No - No PA Required HEMICLOR No - No PA Required HERNEXEOS Varies by Plan Horizant Varies by Plan HULIO No - No PA Required HUMALOG No - No PA Required Humalog KwikPen No - No PA Required Humalog KwikPen, Humalog Junior KwikPen, Humalog, Humalog Tempo Pen, Sterile Diluent No - No PA Required Humalog Mix50/50 KwikPen No - No PA Required Humalog Mix75/25, Humalog Mix75/25 KwikPen No - No PA Required Humatin Varies by Plan HUMATROPE Yes - PA Required Humira Yes - PA Required HUMIRA Yes - PA Required Hydralazine No - No PA Required hydrALAZINE Hydrochloride No - No PA Required Hydralazine Hydrochloride No - No PA Required HYDRALAZINE HYDROCHLORIDE No - No PA Required HydrALAZINE hydrochloride No - No PA Required HydrALAZINE Hydrochloride No - No PA Required HYDREA No - No PA Required HYDROCHLOROTHIAZIDE No - No PA Required hydrochlorothiazide No - No PA Required Hydrochlorothiazide No - No PA Required Hydrocodone APAP No - No PA Required Hydrocodone Bitartrate No - No PA Required HYDROCODONE BITARTRATE AND ACETAMINOPHEN No - No PA Required hydrocodone bitartrate and acetaminophen No - No PA Required Hydrocodone Bitartrate and Acetaminophen No - No PA Required Hydrocodone Bitartrate and Homatropine Methylbromide No - No PA Required Hydrocodone Bitartrate and Ibuprofen No - No PA Required Hydrocodone Polistirex and Chlorpheniramine Polistirex extended-release No - No PA Required HYDROCORTISONE No - No PA Required hydrocortisone No - No PA Required Hydrocortisone No - No PA Required Hydrocortisone Acetate No - No PA Required HYDROCORTISONE ACETATE No - No PA Required Hydrocortisone Acetate Cream No - No PA Required hydrocortisone acetate pramoxine hcl No - No PA Required Hydrocortisone Acetate Pramoxine Hcl No - No PA Required hydrocortisone acetate pramoxine HCl No - No PA Required Hydrocortisone Acetate, Iodoquinol No - No PA Required hydrocortisone and acetic acid No - No PA Required Hydrocortisone and Acetic Acid No - No PA Required Hydrocortisone Butyrate No - No PA Required HYDROCORTISONE BUTYRATE No - No PA Required Hydrocortisone Cream No - No PA Required Hydrocortisone Rectal Suspension (Retention) No - No PA Required Hydrocortisone sodium succinate No - No PA Required HYDROCORTISONE VALERATE No - No PA Required Hydrocortisone Valerate No - No PA Required hydrocortisone valerate cream No - No PA Required Hydromorphone Hydrochloride No - No PA Required HYDROMORPHONE HYDROCHLORIDE No - No PA Required hydromorphone hydrochloride No - No PA Required Hydroxychloroquine No - No PA Required Hydroxychloroquine Sulfate No - No PA Required Hydroxychloroquine sulfate No - No PA Required HYDROXYCHLOROQUINE SULFATE No - No PA Required Hydroxyurea No - No PA Required HYDROXYUREA No - No PA Required Hydroxyzine No - No PA Required Hydroxyzine HCL No - No PA Required HYDROXYZINE HYDROCHLORIDE No - No PA Required Hydroxyzine hydrochloride No - No PA Required Hydroxyzine Hydrochloride No - No PA Required HydrOXYzine Hydrochloride No - No PA Required HYDROXYZINE PAMOATE No - No PA Required hydroxyzine pamoate No - No PA Required Hydroxyzine Pamoate No - No PA Required Hydroxyzine pamoate No - No PA Required HYFTOR No - No PA Required HYRIMOZ No - No PA Required HYRNUO Varies by Plan Hysingla ER No - No PA Required HYZAAR No - No PA Required

I

Ibrance Varies by Plan IBSRELA Varies by Plan IBTROZI Varies by Plan IBU No - No PA Required ibuprofen No - No PA Required Ibuprofen No - No PA Required IBUPROFEN No - No PA Required IBUPROFEN AND FAMOTIDINE No - No PA Required Ibuprofen and Famotidine No - No PA Required Ibuprofen and famotidine No - No PA Required Ibuprofen Famotidine No - No PA Required Ibuprofen Lysine No - No PA Required Icatibant No - No PA Required ICATIBANT No - No PA Required Iclevia No - No PA Required Iclusig Varies by Plan Icosapent No - No PA Required Icosapent ethyl No - No PA Required icosapent ethyl No - No PA Required ICOSAPENT ETHYL No - No PA Required Icosapent Ethyl No - No PA Required Idhifa Varies by Plan ILEVRO Yes - PA Required ILOPERIDONE Varies by Plan ILUMYA Yes - PA Required Imatinib No - No PA Required Imatinib Mesylate No - No PA Required Imatinib mesylate No - No PA Required imatinib mesylate No - No PA Required IMATINIB MESYLATE No - No PA Required Imatinib mesylate 400 mg No - No PA Required Imbruvica Yes - PA Required Imipramine Hydrochloride No - No PA Required Imipramine hydrochloride No - No PA Required Imipramine Pamoate No - No PA Required Imiquimod No - No PA Required IMIQUIMOD No - No PA Required IMITREX No - No PA Required IMKELDI No - No PA Required IMPAVIDO Varies by Plan IMURAN No - No PA Required IMVEXXY No - No PA Required Imvexxy No - No PA Required Inbrija Varies by Plan Incassia Varies by Plan Increlex Yes - PA Required Incruse Ellipta No - No PA Required Indapamide No - No PA Required INDERAL LA No - No PA Required Inderal XL No - No PA Required Indocin No - No PA Required INDOCIN No - No PA Required INDOMETHACIN No - No PA Required indomethacin No - No PA Required Indomethacin No - No PA Required Indomethacin ER No - No PA Required Inluriyo Varies by Plan INLYTA Varies by Plan InnoPran XL No - No PA Required INPEFA Varies by Plan INQOVI Varies by Plan Inrebic Varies by Plan Inspra No - No PA Required Insulin Aspart Yes - PA Required Insulin Aspart Protamine and Insulin Aspart Mix 70/30 Yes - PA Required Insulin Degludec Yes - PA Required INSULIN DILUTING MEDIUM FOR Kirsty, KIRSTY Yes - PA Required Insulin Diluting Medium for NovoLog, NOVOLOG Yes - PA Required INSULIN GLARGINE No - No PA Required Insulin Glargine No - No PA Required Insulin Glargine Solostar Yes - PA Required Insulin Glargine Solostar, Insulin Glargine Yes - PA Required Insulin glargine U-300 Max, Insulin glargine U-300 Yes - PA Required Insulin Lispro No - No PA Required Insulin Lispro Protamine and Insulin Lispro Injectable Suspension Mix75/25 KwikPen Yes - PA Required Insulin Lispro, Insulin Lispro Junior KwikPen, Insulin Lispro KwikPen Yes - PA Required Intelence No - No PA Required Intralipid Yes - PA Required Intrarosa Varies by Plan INTROVALE No - No PA Required Intuniv No - No PA Required INVANZ No - No PA Required INVEGA Yes - PA Required INVEGA HAFYERA Yes - PA Required INVEGA SUSTENNA Yes - PA Required INVEGA TRINZA Yes - PA Required Inveltys No - No PA Required INVOKANA Varies by Plan INZIRQO No - No PA Required IOPIDINE 1% No - No PA Required Ipratropium Bromide No - No PA Required IPRATROPIUM BROMIDE No - No PA Required Ipratropium bromide No - No PA Required IPRATROPIUM BROMIDE AND ALBUTEROL SULFATE No - No PA Required Ipratropium Bromide and Albuterol Sulfate No - No PA Required IQIRVO Varies by Plan IRBESARTAN No - No PA Required Irbesartan No - No PA Required Irbesartan and Hydrochlorothiazide No - No PA Required IRBESARTAN AND HYDROCHLOROTHIAZIDE No - No PA Required IRESSA No - No PA Required ISENTRESS Yes - PA Required Isibloom Varies by Plan Isolyte S No - No PA Required Isoniazid No - No PA Required isoniazid No - No PA Required Isosorbide No - No PA Required Isosorbide dinitrate No - No PA Required ISOSORBIDE DINITRATE No - No PA Required Isosorbide Dinitrate No - No PA Required isosorbide dinitrate and hydralazine hydrochloride No - No PA Required Isosorbide dinitrate and hydralazine hydrochloride No - No PA Required Isosorbide Mononitrate No - No PA Required ISOSORBIDE MONONITRATE No - No PA Required isosorbide mononitrate No - No PA Required Isotretinoin No - No PA Required ISOTRETINOIN No - No PA Required Isradipine No - No PA Required Istalol No - No PA Required Isturisa Varies by Plan Itovebi Varies by Plan Itraconazole No - No PA Required itraconazole No - No PA Required ITRACONAZOLE No - No PA Required Ivabradine No - No PA Required IVABRADINE No - No PA Required ivabradine No - No PA Required IVERMECTIN No - No PA Required ivermectin No - No PA Required Ivermectin No - No PA Required iwilfin Varies by Plan IYUZEH No - No PA Required

J

Jadenu No - No PA Required JAIMIESS No - No PA Required JAKAFI Varies by Plan Jalyn No - No PA Required Jantoven No - No PA Required JANUMET No - No PA Required JANUMET XR No - No PA Required JANUVIA No - No PA Required Jardiance Varies by Plan JARDIANCE Varies by Plan JASCAYD Varies by Plan Jasmiel Varies by Plan Jatenzo Yes - PA Required JAVYGTOR No - No PA Required JAYPIRCA Varies by Plan JAYTHARI No - No PA Required JAYTHARI Oral Suspension No - No PA Required Jentadueto Varies by Plan Jentadueto XR Varies by Plan Joenja Varies by Plan JORNAY PM Extended-Release No - No PA Required JOURNAVX Varies by Plan Joyeaux No - No PA Required JUBBONTI Yes - PA Required JUBLIA Varies by Plan Juleber Varies by Plan Juluca Yes - PA Required Junel 21 Day No - No PA Required Junel 21 Day, Junel Fe 28 Day No - No PA Required Junel FE No - No PA Required Junel Fe 1.5/30 No - No PA Required Junel Fe 1/20 No - No PA Required JUNEL FE 28 DAY No - No PA Required Junel Fe 28 Day No - No PA Required Juxtapid Varies by Plan JYLAMVO No - No PA Required

K

Kaitlib Fe No - No PA Required Kaletra No - No PA Required Kalydeco Varies by Plan Karbinal ER No - No PA Required Kariva Varies by Plan Katerzia No - No PA Required Kelnor 1/35 No - No PA Required Keppra No - No PA Required Keppra XR No - No PA Required Kerendia Varies by Plan KESIMPTA Yes - PA Required Ketoconazole No - No PA Required KETOCONAZOLE No - No PA Required ketoconazole No - No PA Required Ketoconazole Cream No - No PA Required Ketodan No - No PA Required Ketoprofen No - No PA Required Ketorolac Tromethamine No - No PA Required KETOROLAC TROMETHAMINE No - No PA Required ketorolac tromethamine No - No PA Required Ketorolac tromethamine No - No PA Required Keveyis No - No PA Required KEVZARA Yes - PA Required Khindivi No - No PA Required Kineret Yes - PA Required Kionex No - No PA Required KISQALI Varies by Plan KISQALI FEMARA CO-PACK No - No PA Required Kitabis Pak No - No PA Required Klaron No - No PA Required Klisyri Varies by Plan Klonopin No - No PA Required KLOR-CON No - No PA Required KLOR-CON M No - No PA Required KLOXXADO No - No PA Required Konvomep No - No PA Required Korlym No - No PA Required KOSELUGO Varies by Plan KOURZEQ No - No PA Required KRAZATI Varies by Plan Krintafel Varies by Plan KRISTALOSE No - No PA Required Kurvelo No - No PA Required Kuvan No - No PA Required Kyleena Varies by Plan KYMBEE No - No PA Required

L

Labetalol HCL No - No PA Required Labetalol Hydrochloride No - No PA Required Labetalol hydrochloride No - No PA Required LABETALOL HYDROCHLORIDE No - No PA Required Labetalol Hydrochloride, Labetalol HCl in Sodium Chloride, Labetalol HCl in Dextrose No - No PA Required LACOSAMIDE No - No PA Required lacosamide No - No PA Required Lacosamide No - No PA Required Lacosamide Oral Solution No - No PA Required Lactulose No - No PA Required LACTULOSE No - No PA Required LACTULOSE Crystalline No - No PA Required Lactulose Solution No - No PA Required LAGEVRIO Varies by Plan LAMICTAL XR No - No PA Required lamivudine No - No PA Required Lamivudine No - No PA Required LAMIVUDINE No - No PA Required Lamivudine and Zidovudine No - No PA Required LAMIVUDINE and ZIDOVUDINE No - No PA Required LAMIVUDINE AND ZIDOVUDINE No - No PA Required lamotrigine No - No PA Required Lamotrigine No - No PA Required LAMOTRIGINE No - No PA Required Lamotrigine ER No - No PA Required Lamotrigine Extended-Release No - No PA Required LAMOTRIGINE Kit, LAMOTRIGINE No - No PA Required LAMPIT Varies by Plan LANOXIN No - No PA Required Lansoprazole No - No PA Required LANSOPRAZOLE No - No PA Required lansoprazole No - No PA Required Lansoprazole DR No - No PA Required Lanthanum carbonate No - No PA Required Lanthanum Carbonate No - No PA Required Lantus No - No PA Required LANTUS SOLOSTAR No - No PA Required Lantus Solostar No - No PA Required Lantus Solostar, Lantus No - No PA Required Lapatinib No - No PA Required Larin 1.5/30 No - No PA Required Larin 1/20 No - No PA Required Larin 24 Fe No - No PA Required Larin Fe 1.5/30 No - No PA Required Larin Fe 1/20 No - No PA Required Lasix No - No PA Required LASIX ONYU No - No PA Required LATANOPROST No - No PA Required Latanoprost No - No PA Required latanoprost No - No PA Required Latanoprost Ophthalmic Solution No - No PA Required Latanoprostene Bunod Ophthalmic Solution, 0.024% Varies by Plan Latuda No - No PA Required LAZCLUZE Varies by Plan Ledipasvir and Sofosbuvir No - No PA Required Leflunomide No - No PA Required leflunomide No - No PA Required LEFLUNOMIDE No - No PA Required lenalidomide No - No PA Required Lenalidomide No - No PA Required LENALIDOMIDE No - No PA Required Lenvima Varies by Plan LEQSELVI Varies by Plan Lescol XL No - No PA Required Lessina No - No PA Required Letairis No - No PA Required Letrozole No - No PA Required LETROZOLE No - No PA Required leucovorin calcium No - No PA Required Leucovorin calcium No - No PA Required LEUCOVORIN CALCIUM No - No PA Required Leucovorin Calcium No - No PA Required LEUKERAN Varies by Plan Leukine Yes - PA Required LEUPROLIDE ACETATE No - No PA Required leuprolide acetate No - No PA Required Leuprolide Acetate No - No PA Required LEUPROLIDE ACETATE DEPOT No - No PA Required Levalbuterol No - No PA Required levalbuterol inhalation No - No PA Required Levalbuterol Inhalation Solution No - No PA Required Levalbuterol tartrate HFA inhalation No - No PA Required levetiracetam No - No PA Required LEVETIRACETAM No - No PA Required Levetiracetam No - No PA Required Levetiracetam ER No - No PA Required Levetiracetam Extended-Release No - No PA Required LEVETIRACETAM Extended-release No - No PA Required Levetiracetam Levetiracetam No - No PA Required LEVETIRACETAM solution No - No PA Required Levobunolol Hydrochloride No - No PA Required Levocarnitine No - No PA Required levocarnitine No - No PA Required LEVOCETIRIZINE DIHYDROCHLORIDE No - No PA Required levocetirizine dihydrochloride No - No PA Required Levocetirizine Dihydrochloride No - No PA Required LEVOFLOXACIN No - No PA Required levofloxacin No - No PA Required Levofloxacin No - No PA Required Levonest No - No PA Required Levonorgestrel and Ethinyl Estradiol Varies by Plan levonorgestrel and ethinyl estradiol Varies by Plan LEVONORGESTREL AND ETHINYL ESTRADIOL Varies by Plan Levonorgestrel and Ethinyl Estradiol and Ethinyl Estradiol Varies by Plan LEVONORGESTREL AND ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL Varies by Plan Levora No - No PA Required LEVORPHANOL TARTRATE No - No PA Required Levorphanol Tartrate No - No PA Required levothyroxine sodium No - No PA Required Levothyroxine Sodium No - No PA Required LEVOTHYROXINE SODIUM No - No PA Required Levothyroxine sodium No - No PA Required LEVOXYL No - No PA Required Lexapro No - No PA Required LEXETTE No - No PA Required Lialda No - No PA Required Librax No - No PA Required LICART No - No PA Required Lidocaine No - No PA Required LIDOCAINE No - No PA Required lidocaine No - No PA Required Lidocaine 5% No - No PA Required Lidocaine 5% Gel No - No PA Required Lidocaine 5% Patch No - No PA Required LIDOCAINE AND PRILOCAINE No - No PA Required Lidocaine and Prilocaine No - No PA Required Lidocaine and prilocaine No - No PA Required LIDOCAINE AND PRILOCAINE LIDOCAINE AND PRILOCAINE No - No PA Required LIDOCAINE HCI No - No PA Required LIDOCAINE HCI AND DEXTROSE No - No PA Required LIDOCAINE HCI AND EPINEPHRINE No - No PA Required LIDOCAINE HCI AND EPINEPHRINE WITH EPINEPHRINE No - No PA Required LIDOCAINE HCI, LIDOCAINE HCl No - No PA Required Lidocaine HCl - Hydrocortisone Acetate No - No PA Required Lidocaine HCl - Hydrocortisone Acetate with Aloe No - No PA Required Lidocaine HCl 3% and Hydrocortisone Acetate 0.5% Cream No - No PA Required Lidocaine HCl 3% and Hydrocortisone Acetate1% Cream No - No PA Required LIDOCAINE HCl AND EPINEPHRINE No - No PA Required LIDOCAINE HYDROCHLORIDE No - No PA Required Lidocaine Hydrochloride No - No PA Required lidocaine hydrochloride No - No PA Required Lidocaine hydrochloride No - No PA Required Lidocaine Hydrochloride and Dextrose No - No PA Required LIDOCAINE HYDROCHLORIDE AND DEXTROSE No - No PA Required Lidocaine Hydrochloride and Epinephrine No - No PA Required Lidocaine Hydrochloride and Hydrocortisone Acetate No - No PA Required LIDOCAINE HYDROCHLORIDE, HYDROCORTISONE ACETATE No - No PA Required Lidocaine Patch No - No PA Required Lidocaine Viscous No - No PA Required Lidocan No - No PA Required Lidocan III No - No PA Required Lidocan IV No - No PA Required Lidocan V No - No PA Required Lidocan VI No - No PA Required Lidocan VII No - No PA Required Lifitegrast Varies by Plan LILETTA Varies by Plan linagliptin Varies by Plan Linagliptin and metformin hydrochloride Varies by Plan linezolid No - No PA Required Linezolid No - No PA Required Linzess Varies by Plan Liomny No - No PA Required liothyronine sodium No - No PA Required Liothyronine Sodium No - No PA Required Liothyronine sodium No - No PA Required Lipitor No - No PA Required Lipofen No - No PA Required LIRAGLUTIDE No - No PA Required liraglutide No - No PA Required Liraglutide No - No PA Required LISDEXAMFETAMINE DIMESYLATE No - No PA Required Lisdexamfetamine Dimesylate No - No PA Required lisdexamfetamine dimesylate No - No PA Required Lisdexamfetamine dimesylate No - No PA Required LISINOPRIL No - No PA Required lisinopril No - No PA Required Lisinopril No - No PA Required LISINOPRIL AND HYDROCHLOROTHIAZIDE No - No PA Required Lisinopril and Hydrochlorothiazide No - No PA Required LISINOPRIL and HYDROCHLOROTHIAZIDE No - No PA Required Lisinopril and hydrochlorothiazide No - No PA Required Litfulo Varies by Plan Lithium No - No PA Required Lithium carbonate No - No PA Required Lithium Carbonate No - No PA Required lithium carbonate No - No PA Required Lithium Carbonate ER No - No PA Required LITHIUM CARBONATE LITHIUM CARBONATE No - No PA Required LITHOBID No - No PA Required Lithostat Varies by Plan Livalo No - No PA Required Livdelzi Varies by Plan Livmarli Varies by Plan Livtencity Varies by Plan Lo Loestrin Fe No - No PA Required LO LOESTRIN FE No - No PA Required LODOCO No - No PA Required Lodosyn No - No PA Required Loestrin Fe 28 Day, Loestrin 21 Day No - No PA Required LOFENA No - No PA Required Lofexidine No - No PA Required lofexidine hydrochloride No - No PA Required Lofexidine hydrochloride No - No PA Required LoJaimiess No - No PA Required LOJAIMIESS No - No PA Required LOKELMA Yes - PA Required Lomotil No - No PA Required LOMUSTINE No - No PA Required LONSURF Varies by Plan Loperamide Hydrochloride No - No PA Required Loperamide hydrochloride No - No PA Required LOPERAMIDE HYDROCHLORIDE No - No PA Required Lopinavir and ritonavir No - No PA Required Lopinavir and Ritonavir No - No PA Required Lopressor No - No PA Required LOPRESSOR No - No PA Required LORAZEPAM No - No PA Required Lorazepam No - No PA Required Lorbrena Varies by Plan LOREEV XR No - No PA Required Losartan Potassium No - No PA Required LOSARTAN POTASSIUM No - No PA Required Losartan potassium No - No PA Required LOSARTAN POTASSIUM 100 mg No - No PA Required LOSARTAN POTASSIUM 25 mg No - No PA Required LOSARTAN POTASSIUM 25 mg, LOSARTAN POTASSIUM 50 mg, LOSARTAN POTASSIUM 100 mg No - No PA Required LOSARTAN POTASSIUM 50 mg No - No PA Required LOSARTAN POTASSIUM AND HYDROCHLOROTHIAZIDE No - No PA Required Losartan potassium and Hydrochlorothiazide No - No PA Required Losartan Potassium and Hydrochlorothiazide No - No PA Required losartan potassium and hydrochlorothiazide No - No PA Required Losartan potassium Tablets, 100 mg No - No PA Required Losartan potassium Tablets, 25 mg No - No PA Required Losartan potassium Tablets, 25 mg, Losartan potassium Tablets, 50 mg, Losartan potassium Tablets, 100 mg No - No PA Required Losartan potassium Tablets, 50 mg No - No PA Required Lotemax No - No PA Required LOTEMAX No - No PA Required Lotemax SM No - No PA Required Lotensin No - No PA Required Lotensin HCT No - No PA Required LOTEPREDNOL ETABONATE No - No PA Required loteprednol etabonate No - No PA Required Loteprednol Etabonate No - No PA Required Loteprednol etabonate and tobramycin No - No PA Required Loteprednol etabonate and Tobramycin No - No PA Required Lovastatin No - No PA Required Lovenox No - No PA Required Low-Ogestrel No - No PA Required Loxapine No - No PA Required Lubiprostone No - No PA Required LUBIPROSTONE No - No PA Required Lucemyra No - No PA Required LUIZZA 1.5/30 No - No PA Required LUIZZA 1/20 No - No PA Required LULICONAZOLE No - No PA Required LUMAKRAS Varies by Plan LUMIGAN No - No PA Required Lumryz No - No PA Required Lunesta No - No PA Required LUPKYNIS Varies by Plan Lupron Depot No - No PA Required Lupron Depot-PED No - No PA Required Lurasidone HCL No - No PA Required Lurasidone Hydrochloride No - No PA Required lurasidone hydrochloride No - No PA Required LURASIDONE HYDROCHLORIDE No - No PA Required Lurasidone hydrochloride No - No PA Required LURBIRO No - No PA Required Lutera No - No PA Required LUTRATE DEPOT No - No PA Required Luzu No - No PA Required LYBALVI No - No PA Required LYNKUET Varies by Plan Lynparza Varies by Plan Lyrica No - No PA Required Lyrica CR No - No PA Required Lysodren Varies by Plan LYUMJEV Yes - PA Required

M

Magnesium Chloride No - No PA Required Magnesium Sulfate No - No PA Required magnesium sulfate No - No PA Required MAGNESIUM SULFATE No - No PA Required Magnesium Sulfate in Dextrose No - No PA Required MAGNESIUM SULFATE IN DEXTROSE No - No PA Required Magnesium Sulfate in Water No - No PA Required MALARONE No - No PA Required Malathion No - No PA Required Maraviroc No - No PA Required Marinol No - No PA Required MARINOL No - No PA Required MARLISSA No - No PA Required Matulane Varies by Plan Matzim LA No - No PA Required Mavenclad No - No PA Required Mavyret Varies by Plan MAXIDEX No - No PA Required Maxitrol No - No PA Required MAXITROL No - No PA Required MAYZENT Varies by Plan Meclizine Hydrochloride No - No PA Required MECLIZINE HYDROCHLORIDE No - No PA Required Meclizine Hydrocloride No - No PA Required Meclofenamate Sodium No - No PA Required Medrol No - No PA Required Medroxyprogesterone No - No PA Required Medroxyprogesterone Acetate No - No PA Required MEDROXYPROGESTERONE ACETATE No - No PA Required medroxyprogesterone acetate No - No PA Required Medroxyprogesterone Acetate Injectable Suspension No - No PA Required Mefenamic Acid No - No PA Required Mefenamic acid No - No PA Required Mefloquine Hydrochloride No - No PA Required Megestrol Acetate No - No PA Required Mekinist Varies by Plan MEKTOVI Varies by Plan MELEYA Varies by Plan Meloxicam No - No PA Required MELOXICAM No - No PA Required meloxicam No - No PA Required MEMANTINE No - No PA Required Memantine No - No PA Required memantine No - No PA Required Memantine and Donepezil No - No PA Required MEMANTINE AND DONEPEZIL HYDROCHLORIDES No - No PA Required Memantine and Donepezil Hydrochlorides Extended-release No - No PA Required Memantine HCL No - No PA Required memantine hydrochloride No - No PA Required Memantine Hydrochloride No - No PA Required Memantine hydrochloride No - No PA Required MEMANTINE HYDROCHLORIDE No - No PA Required memantine hydrochloride and donepezil hydrochloride No - No PA Required Menostar No - No PA Required Meperidine Hydrochloride No - No PA Required MEPROBAMATE No - No PA Required Meprobamate No - No PA Required MEPRON No - No PA Required Mercaptopurine No - No PA Required MERCAPTOPURINE No - No PA Required MERILOG Yes - PA Required MEROPENEM No - No PA Required Meropenem No - No PA Required Meropenem and Sodium Chloride No - No PA Required Mesalamine No - No PA Required MESALAMINE No - No PA Required mesalamine No - No PA Required Mesalamine Rectal No - No PA Required mesna No - No PA Required MESNA No - No PA Required Mesna No - No PA Required MESNEX No - No PA Required Mestinon No - No PA Required METADATE CD No - No PA Required Metaxalone No - No PA Required METAXALONE No - No PA Required Metformin No - No PA Required Metformin ER 500 mg, Metformin ER 750 mg No - No PA Required Metformin HCL No - No PA Required Metformin HCl No - No PA Required METFORMIN HYDROCHLORIDE No - No PA Required metformin hydrochloride No - No PA Required Metformin Hydrochloride No - No PA Required Metformin hydrochloride No - No PA Required Metformin hydrochloride ER No - No PA Required METFORMIN HYDROCHLORIDE ER No - No PA Required Metformin hydrochloride ER, Metformin hydrochloride No - No PA Required METFORMIN HYDROCHLORIDE EXTENDED RELEASE No - No PA Required METFORMIN HYDROCHLORIDE EXTENDED RELEASE, METFORMIN HYDROCHLORIDE No - No PA Required Metformin Hydrochloride Oral Solution No - No PA Required Metformin hydrochloride, Metformin hydrochloride ER No - No PA Required METHADONE HYDROCHLORIDE No - No PA Required Methadone Hydrochloride No - No PA Required Methadone Hydrocloride No - No PA Required Methadone Hydrocloride dye-free, sugar-free, unflavored No - No PA Required Methamphetamine Hydrochloride No - No PA Required Methazolamide No - No PA Required methazolamide No - No PA Required METHAZOLAMIDE No - No PA Required METHENAMINE HIPPURATE No - No PA Required Methenamine Hippurate No - No PA Required Methenamine hippurate No - No PA Required Methenamine Mandelate No - No PA Required Methimazole No - No PA Required methimazole No - No PA Required METHITEST No - No PA Required methocarbamol No - No PA Required Methocarbamol No - No PA Required METHOCARBAMOL No - No PA Required Methocarbamol Tablets, USP, 500 mg No - No PA Required Methocarbamol Tablets, USP, 500 mg, Methocarbamol Tablets, USP, 750 mg No - No PA Required Methocarbamol Tablets, USP, 750 mg No - No PA Required METHOTREXATE No - No PA Required Methotrexate No - No PA Required Methotrexate Sodium No - No PA Required Methoxsalen No - No PA Required Methscopolamine Bromide No - No PA Required METHSCOPOLAMINE BROMIDE No - No PA Required Methsuximide No - No PA Required Methyldopa No - No PA Required Methylin No - No PA Required Methylphenidate No - No PA Required Methylphenidate HCl No - No PA Required Methylphenidate hydrochloride No - No PA Required methylphenidate hydrochloride No - No PA Required METHYLPHENIDATE HYDROCHLORIDE No - No PA Required Methylphenidate Hydrochloride No - No PA Required Methylphenidate Hydrochloride (LA) No - No PA Required methylphenidate hydrochloride CD No - No PA Required METHYLPHENIDATE HYDROCHLORIDE EXTENDED RELEASE No - No PA Required Methylphenidate Hydrochloride Extended-Release No - No PA Required Methylphenidate Transdermal System No - No PA Required Methylprednisolone No - No PA Required MethylPREDNISolone No - No PA Required methylprednisolone No - No PA Required METHYLPREDNISOLONE No - No PA Required METHYLPREDNISOLONE ACETATE No - No PA Required Methylprednisolone acetate No - No PA Required Methylprednisolone Acetate No - No PA Required METHYLPREDNISOLONE ACETATE, Methylprednisolone Acetate No - No PA Required Methylprednisolone Sodium Succinate No - No PA Required Methylprednisolone sodium succinate No - No PA Required Methyltestosterone No - No PA Required MethylTESTOSTERone No - No PA Required Metoclopramide No - No PA Required METOCLOPRAMIDE No - No PA Required metoclopramide hydrochloride No - No PA Required METOCLOPRAMIDE hydrochloride No - No PA Required Metolazone No - No PA Required METOLAZONE No - No PA Required Metoprolol No - No PA Required Metoprolol Succinate No - No PA Required METOPROLOL SUCCINATE No - No PA Required metoprolol succinate No - No PA Required Metoprolol succinate No - No PA Required Metoprolol Succinate ER No - No PA Required METOPROLOL SUCCINATE ER No - No PA Required METOPROLOL TARTRATE No - No PA Required Metoprolol Tartrate No - No PA Required Metoprolol tartrate No - No PA Required METOPROLOL TARTRATE AND HYDROCHLOROTHIAZIDE No - No PA Required Metoprolol Tartrate and Hydrochlorothiazide No - No PA Required MetroCream No - No PA Required METROGEL No - No PA Required Metronidazole No - No PA Required metronidazole No - No PA Required METRONIDAZOLE No - No PA Required metronidazole vaginal No - No PA Required Metronidazole Vaginal Gel No - No PA Required Metronidazole Vaginal Gel, 0.75% No - No PA Required Metyrosine No - No PA Required METYROSINE No - No PA Required Mexiletine Hydrochloride No - No PA Required MEXILETINE HYDROCHLORIDE No - No PA Required Mexiletine hydrochloride No - No PA Required Mibelas 24 Fe No - No PA Required MICAFUNGIN No - No PA Required Micafungin No - No PA Required Micafungin in Sodium Chloride No - No PA Required Microgestin 1.5/30 No - No PA Required Microgestin 1/20 No - No PA Required Microgestin 24 Fe No - No PA Required Microgestin Fe 1.5/30 No - No PA Required Microgestin Fe 1/20 No - No PA Required midazolam Varies by Plan MIDAZOLAM Varies by Plan Midazolam Varies by Plan Midazolam Hydrochloride Varies by Plan Midazolam hydrochloride Varies by Plan MIDAZOLAM IN 0.8% SODIUM CHLORIDE Varies by Plan Midazolam In Sodium Chloride Varies by Plan Midazolam in Sodium Chloride Varies by Plan Midodrine Hydrochloride No - No PA Required Midodrine hydrochloride No - No PA Required MIDODRINE HYDROCHLORIDE No - No PA Required MIEBO Varies by Plan Mifepristone No - No PA Required MIGERGOT No - No PA Required Miglustat No - No PA Required MIGLUSTAT No - No PA Required Mili No - No PA Required Milnacipran hydrochloride, Savella Varies by Plan Mimvey No - No PA Required Minivelle No - No PA Required minocycline hydrochloride No - No PA Required Minocycline hydrochloride No - No PA Required MINOCYCLINE HYDROCHLORIDE No - No PA Required Minocycline Hydrochloride No - No PA Required MINOXIDIL No - No PA Required Minoxidil No - No PA Required MINZOYA No - No PA Required MIRABEGRON No - No PA Required Mirabegron No - No PA Required Mircera Yes - PA Required Mirena Varies by Plan Mirtazapine No - No PA Required Mirvaso No - No PA Required misoprostol No - No PA Required MISOPROSTOL No - No PA Required Misoprostol No - No PA Required MITIGARE No - No PA Required Modafinil No - No PA Required modafinil No - No PA Required MODEYSO Varies by Plan Moexipril Hydrochloride No - No PA Required Molindone Hydrochloride No - No PA Required MOMETASONE FUROATE No - No PA Required Mometasone Furoate No - No PA Required Montelukast No - No PA Required MONTELUKAST No - No PA Required Montelukast Sodium No - No PA Required MONTELUKAST SODIUM No - No PA Required montelukast sodium No - No PA Required Morphine Sulfate No - No PA Required Morphine sulfate No - No PA Required MORPHINE SULFATE No - No PA Required Morphine Sulfate ER No - No PA Required Morphine Sulfate Extended Release No - No PA Required Morphine Sulfate, Morphine sulfate No - No PA Required MOTEGRITY No - No PA Required MOTPOLY XR No - No PA Required MOVANTIK Varies by Plan MoviPrep No - No PA Required Moxifloxacin No - No PA Required MOXIFLOXACIN No - No PA Required MOXIFLOXACIN HYDROCHLORIDE No - No PA Required Moxifloxacin Hydrochloride No - No PA Required Moxifloxacin Hydrochloride Tablets, 400 mg No - No PA Required Moxifloxacin ophthalmic solution No - No PA Required Moxifloxacin Ophthalmic Solution No - No PA Required MS Contin No - No PA Required Mulpleta Varies by Plan Multaq Varies by Plan Mupirocin No - No PA Required mupirocin No - No PA Required MUPIROCIN No - No PA Required Myalept Yes - PA Required Mycapssa No - No PA Required Mycophenolate Mofetil No - No PA Required Mycophenolate mofetil No - No PA Required MYCOPHENOLATE MOFETIL No - No PA Required mycophenolate mofetil No - No PA Required mycophenolate mofetil, Mycophenolate Mofetil No - No PA Required Mycophenolate Mofetil, mycophenolate mofetil No - No PA Required Mycophenolic Acid No - No PA Required MYCOPHENOLIC ACID No - No PA Required mycophenolic acid No - No PA Required MYDAYIS No - No PA Required Myfembree No - No PA Required Myfortic No - No PA Required MYHIBBIN No - No PA Required MYQORZO Varies by Plan Myrbetriq No - No PA Required Mysoline No - No PA Required MYTESI Varies by Plan

N

NABUMETONE No - No PA Required Nabumetone No - No PA Required Nabumetone 500 mg, Nabumetone 750 mg, Nabumetone 1000 mg No - No PA Required Nadolol No - No PA Required NADOLOL No - No PA Required Nafcillin No - No PA Required NAFCILLIN No - No PA Required NAFCILLIN SODIUM No - No PA Required Naftifine Hydrochloride No - No PA Required Naftin No - No PA Required NALMEFENE HYDROCHLORIDE Yes - PA Required nalmefene hydrochloride Yes - PA Required Nalocet No - No PA Required NALOXONE HCI No - No PA Required naloxone hydrochloride No - No PA Required NALOXONE HYDROCHLORIDE No - No PA Required Naloxone Hydrochloride No - No PA Required Naloxone Hydrochloride Injection, USP, Auto-Injector No - No PA Required Naltrexone Hydrochloride No - No PA Required NALTREXONE HYDROCHLORIDE No - No PA Required Namzaric No - No PA Required Naprelan No - No PA Required Naproxen No - No PA Required NAPROXEN No - No PA Required Naproxen and esomeprazole magnesium No - No PA Required Naproxen Oral Suspension No - No PA Required Naproxen sodium No - No PA Required Naproxen Sodium No - No PA Required Naproxen Sodium, Naproxen No - No PA Required Naproxen Sodium, Naproxen sodium No - No PA Required Naratriptan No - No PA Required naratriptan No - No PA Required Nardil No - No PA Required NATACYN Yes - PA Required Natazia Varies by Plan NATEGLINIDE No - No PA Required Nateglinide No - No PA Required Natroba No - No PA Required Nayzilam Varies by Plan Nebivolol No - No PA Required nebivolol No - No PA Required NEBIVOLOL No - No PA Required NebuPent No - No PA Required Necon No - No PA Required Nefazodone Hydrochloride No - No PA Required neffy No - No PA Required NEMLUVIO Yes - PA Required Neo-Synalar No - No PA Required Neomycin and Polymyxin B Sulfates No - No PA Required Neomycin and Polymyxin B Sulfates and Bacitracin Zinc No - No PA Required NEOMYCIN AND POLYMYXIN B SULFATES AND DEXAMETHASONE No - No PA Required Neomycin and Polymyxin B Sulfates and Dexamethasone No - No PA Required NEOMYCIN AND POLYMYXIN B SULFATES AND GRAMICIDIN No - No PA Required NEOMYCIN AND POLYMYXIN B SULFATES AND HYDROCORTISONE No - No PA Required Neomycin and Polymyxin B Sulfates and Hydrocortisone No - No PA Required Neomycin and Polymyxin B Sulfates and Hydrocortisone Otic Suspension No - No PA Required Neomycin and Polymyxin B Sulfates, Bacitracin Zinc and Hydrocortisone No - No PA Required Neomycin Polymyxin B Sulfates and Dexamethasone No - No PA Required NEOMYCIN POLYMYXIN B SULFATES AND DEXAMETHASONE No - No PA Required Neomycin Sulfate No - No PA Required neomycin sulfate, polymyxin b sulfate and dexamethasone No - No PA Required Nerlynx Varies by Plan NEUPOGEN Yes - PA Required Neupro Varies by Plan Neurontin No - No PA Required NEVANAC Yes - PA Required NEVIRAPINE No - No PA Required Nevirapine No - No PA Required Nexavar No - No PA Required Nexiclon XR No - No PA Required NEXIUM No - No PA Required Nexletol Varies by Plan Nexlizet Varies by Plan Nexplanon Yes - PA Required Nextstellis Varies by Plan Ngenla Yes - PA Required NIACIN No - No PA Required Niacin No - No PA Required Nicardipine hydrochloride No - No PA Required NICARDIPINE HYDROCHLORIDE No - No PA Required Nicardipine Hydrochloride No - No PA Required nicardipine hydrochloride No - No PA Required Nicardipine Hydrochloride in Sodium Chloride No - No PA Required Nicotrol Varies by Plan NIFEdipine No - No PA Required nifedipine No - No PA Required NIFEDIPINE No - No PA Required Nifedipine No - No PA Required Nifedipine ER No - No PA Required Nikki Varies by Plan nilotinib No - No PA Required Nilotinib No - No PA Required Nilutamide No - No PA Required nimodipine No - No PA Required Nimodipine No - No PA Required NINLARO Varies by Plan Nisoldipine No - No PA Required Nitazoxanide No - No PA Required Nitisinone No - No PA Required NITRO-BID No - No PA Required NITRO-DUR No - No PA Required NITROFURANTOIN No - No PA Required nitrofurantoin No - No PA Required Nitrofurantoin No - No PA Required nitrofurantoin (macrocrystals) No - No PA Required Nitrofurantoin (monohydrate/macrocrystals) No - No PA Required NITROFURANTOIN (monohydrate/macrocrystals) No - No PA Required nitrofurantoin macrocrystals No - No PA Required Nitrofurantoin macrocrystals No - No PA Required Nitrofurantoin Macrocrystals No - No PA Required Nitrofurantoin Mono No - No PA Required NITROFURANTOIN MONOHYDRATE MACROCRYSTALLINE No - No PA Required Nitrofurantoin Monohydrate/ Macrocrystalline No - No PA Required Nitrofurantoin Monohydrate/Macrocrystal No - No PA Required Nitrofurantoin Oral Suspension No - No PA Required Nitroglycerin No - No PA Required NITROGLYCERIN No - No PA Required nitroglycerin No - No PA Required Nitroglycerin In Dextrose No - No PA Required NITROGLYCERIN IN DEXTROSE No - No PA Required NITROGLYCERIN LINGUAL No - No PA Required Nitroglycerin Transdermal Infusion System No - No PA Required NITROLINGUAL No - No PA Required NITROSTAT No - No PA Required Nitrostat No - No PA Required NITYR No - No PA Required Nivestym Yes - PA Required NIZATIDINE No - No PA Required Nizatidine No - No PA Required Norditropin Yes - PA Required Norethindrone No - No PA Required NORETHINDRONE No - No PA Required Norethindrone acetate No - No PA Required Norethindrone Acetate No - No PA Required NORETHINDRONE ACETATE AND ETHINYL ESTRADIOL No - No PA Required Norethindrone Acetate and Ethinyl Estradiol No - No PA Required norethindrone acetate and ethinyl estradiol and ferrous fumarate No - No PA Required Norethindrone Acetate and Ethinyl Estradiol and Ferrous Fumarate No - No PA Required Norethindrone and ethinyl estradiol No - No PA Required Norethindrone and ethinyl estradiol and ferrous fumarate No - No PA Required Norgesic No - No PA Required Norgesic Forte No - No PA Required Noritate No - No PA Required NORLIQVA No - No PA Required Norpace CR, Norpace No - No PA Required Norpramin No - No PA Required Northera No - No PA Required Nortrel 28 Day No - No PA Required Nortrel 28 Day, Nortrel 21 Day No - No PA Required Nortrel 7/7/7 (28 Day Regimen) No - No PA Required Nortriptyline HCL No - No PA Required Nortriptyline Hydrochloride No - No PA Required NORTRIPTYLINE HYDROCHLORIDE No - No PA Required Norvasc No - No PA Required Norvir No - No PA Required NOURIANZ Varies by Plan NOXAFIL No - No PA Required NUBEQA Varies by Plan Nucala Yes - PA Required Nucynta Varies by Plan Nucynta ER Varies by Plan Nuedexta Varies by Plan NUEDEXTA Varies by Plan NUPLAZID Varies by Plan NURTEC ODT Varies by Plan NutriLipid I.V. Fat Emulsion Yes - PA Required NUVARING No - No PA Required NuvaRing No - No PA Required Nuvigil No - No PA Required NUZYRA Yes - PA Required Nyamyc No - No PA Required Nylia 7/7/7 No - No PA Required NYLIA 7/7/7 No - No PA Required Nymalize No - No PA Required nystatin No - No PA Required NYSTATIN No - No PA Required Nystatin No - No PA Required Nystatin and triamcinolone acetonide No - No PA Required nystatin and triamcinolone acetonide No - No PA Required Nystatin and Triamcinolone Acetonide No - No PA Required NYSTATIN AND TRIAMCINOLONE ACETONIDE No - No PA Required Nystatin Cream No - No PA Required Nystatin Oral Suspension No - No PA Required Nystatin Topical Powder No - No PA Required Nystop No - No PA Required NYVEPRIA Yes - PA Required

O

Octreotide No - No PA Required Octreotide Acetate No - No PA Required OCTREOTIDE ACETATE No - No PA Required OCUFLOX No - No PA Required ODEFSEY No - No PA Required Odomzo Varies by Plan Ofev Varies by Plan OFLOXACIN No - No PA Required Ofloxacin No - No PA Required ofloxacin No - No PA Required Ofloxacin Ophth Soln No - No PA Required OFLOXACIN OTIC No - No PA Required Ofloxacin Otic No - No PA Required OGSIVEO Varies by Plan Ohtuvayre Yes - PA Required OJEMDA Yes - PA Required Ojjaara Varies by Plan Olanzapine No - No PA Required OLANZAPINE No - No PA Required Olanzapine and Fluoxetine No - No PA Required Olanzapine Intramuscular No - No PA Required Olmesartan Medoxomil No - No PA Required OLMESARTAN MEDOXOMIL No - No PA Required Olmesartan medoxomil No - No PA Required olmesartan medoxomil No - No PA Required olmesartan medoxomil / amlodipine besylate / hydrochlorothiazide No - No PA Required Olmesartan medoxomil Amlodipine and Hydrochlorothiazide No - No PA Required olmesartan medoxomil and amlodipine besylate and hydrochlorothiazide No - No PA Required OLMESARTAN MEDOXOMIL AND HYDROCHLOROTHIAZIDE No - No PA Required Olmesartan medoxomil and hydrochlorothiazide No - No PA Required OLMESARTAN MEDOXOMIL and HYDROCHLOROTHIAZIDE No - No PA Required Olmesartan Medoxomil and Hydrochlorothiazide No - No PA Required OLMESARTAN MEDOXOMIL, AMLODIPINE and HYDROCHLOROTHIAZIDE No - No PA Required Olmesartan Medoxomil, Amlodipine and Hydrochlorothiazide No - No PA Required Olmesartan medoxomil, amlodipine and hydrochlorothiazide No - No PA Required olmesartan medoxomil-hydrochlorothiazide No - No PA Required OLOPATADINE HYDROCHLORIDE No - No PA Required olopatadine hydrochloride No - No PA Required Olopatadine Hydrochloride No - No PA Required Olumiant Varies by Plan OMEPRAZOLE No - No PA Required Omeprazole No - No PA Required omeprazole No - No PA Required Omeprazole and Sodium Bicarbonate No - No PA Required Omeprazole DR No - No PA Required omeprazole sodium bicarbonate No - No PA Required Omnaris Varies by Plan Omnitrope Yes - PA Required Omvoh Yes - PA Required ONAPGO No - No PA Required ondansetron No - No PA Required Ondansetron No - No PA Required ONDANSETRON No - No PA Required Ondansetron HCL No - No PA Required ONDANSETRON HYDROCHLORIDE No - No PA Required Ondansetron Hydrochloride No - No PA Required ondansetron hydrochloride No - No PA Required ondansetron hydrochloride, ondansetron No - No PA Required Ondansetron ODT No - No PA Required ONEXTON No - No PA Required Onfi No - No PA Required ONGENTYS Varies by Plan ONUREG Varies by Plan ONYDA XR No - No PA Required Onzetra Xsail No - No PA Required OPIPZA No - No PA Required OPSUMIT Varies by Plan OPSYNVI Varies by Plan OPVEE Yes - PA Required OPZELURA Varies by Plan ORACEA No - No PA Required Orapred ODT No - No PA Required ORENCIA Yes - PA Required Orenitram Varies by Plan ORFADIN No - No PA Required Orfadin No - No PA Required Orgovyx Varies by Plan Oriahnn Varies by Plan Orilissa Varies by Plan ORKAMBI Varies by Plan Orladeyo Varies by Plan ORLYNVAH No - No PA Required ORMALVI No - No PA Required Orphenadrine citrate No - No PA Required Orphenadrine Citrate No - No PA Required ORPHENADRINE CITRATE No - No PA Required Orphenadrine Citrate ER No - No PA Required Orphenadrine Citrate, Aspirin and Caffeine No - No PA Required Orquidea Varies by Plan ORSERDU Varies by Plan Orudis No - No PA Required Oseltamivir No - No PA Required OSELTAMIVIR No - No PA Required Oseltamivir Phosphate No - No PA Required oseltamivir phosphate No - No PA Required OSELTAMIVIR PHOSPHATE No - No PA Required Oseltamivir phosphate No - No PA Required Oseltamivir Phosphate for Oral Suspension No - No PA Required Osenvelt Yes - PA Required Osphena Varies by Plan OSPOMYV Yes - PA Required Otezla Varies by Plan Otulfi No - No PA Required Ovide No - No PA Required Oxacillin No - No PA Required OXACILLIN No - No PA Required oxacillin No - No PA Required OXAPROZIN No - No PA Required Oxaprozin No - No PA Required OXAZEPAM No - No PA Required Oxazepam No - No PA Required OXCARBAZEPINE No - No PA Required Oxcarbazepine No - No PA Required oxcarbazepine No - No PA Required OXERVATE Varies by Plan Oxiconazole Nitrate No - No PA Required Oxistat No - No PA Required OXTELLAR XR No - No PA Required oxybutynin No - No PA Required oxybutynin chloride No - No PA Required OXYBUTYNIN CHLORIDE No - No PA Required Oxybutynin Chloride No - No PA Required Oxybutynin Chloride Extended Release No - No PA Required oxycodone and acetaminophen No - No PA Required OXYCODONE AND ACETAMINOPHEN No - No PA Required Oxycodone and Acetaminophen No - No PA Required Oxycodone and Aspirin No - No PA Required Oxycodone HCL No - No PA Required Oxycodone HCl No - No PA Required Oxycodone Hydchloride No - No PA Required oxycodone hydrochloride No - No PA Required Oxycodone Hydrochloride No - No PA Required Oxycodone hydrochloride No - No PA Required OXYCODONE HYDROCHLORIDE No - No PA Required Oxycodone Hydrochloride and Acetaminophen No - No PA Required oxycodone hydrochloride and acetaminophen No - No PA Required Oxycodone Hydrochloride Oral Solution No - No PA Required OXYCODONE HYDROCHLORIDE, OXYCODONE AND ACETAMINOPHEN No - No PA Required OXYCODONE HYDROCHLORIDE, Oxycodone Hydrochloride No - No PA Required OxyContin No - No PA Required OXYMORPHONE HYDROCHLORIDE No - No PA Required Oxymorphone Hydrochloride No - No PA Required Oxymorphone hydrochloride No - No PA Required OXYTROL Varies by Plan Ozempic Yes - PA Required OZEMPIC Yes - PA Required OZOBAX DS No - No PA Required

P

Pacerone No - No PA Required PALIPERIDONE Yes - PA Required Paliperidone Yes - PA Required paliperidone Yes - PA Required PALSONIFY Varies by Plan Palynziq Yes - PA Required PANCREAZE Varies by Plan PANRETIN Varies by Plan Pantoprazole No - No PA Required pantoprazole sodium No - No PA Required Pantoprazole Sodium No - No PA Required Pantoprazole sodium No - No PA Required PANTOPRAZOLE SODIUM No - No PA Required Pantoprazole sodium delayed-release No - No PA Required PANTOPRAZOLE SODIUM DELAYED-RELEASE delayed release No - No PA Required Pantoprazole Sodium DR No - No PA Required PANTOPRAZOLE SODIUM I.V. No - No PA Required PARICALCITOL No - No PA Required Paricalcitol No - No PA Required PARNATE No - No PA Required Paroxetine No - No PA Required PAROXETINE No - No PA Required paroxetine hydrochloride No - No PA Required Paroxetine Hydrochloride No - No PA Required PAROXETINE HYDROCHLORIDE No - No PA Required PAXIL No - No PA Required PAXIL CR No - No PA Required Paxlovid Varies by Plan Pazopanib No - No PA Required pazopanib No - No PA Required PEMAZYRE Varies by Plan Penciclovir No - No PA Required PENCICLOVIR No - No PA Required Penicillamine No - No PA Required penicillamine No - No PA Required Penicillin G Potassium No - No PA Required PENICILLIN G POTASSIUM No - No PA Required Penicillin G Sodium No - No PA Required Penicillin V Potassium No - No PA Required Pentam 300 No - No PA Required PENTAMIDINE ISETHIONATE No - No PA Required Pentamidine Isethionate No - No PA Required pentamidine isethionate No - No PA Required Pentasa No - No PA Required PENTOXIFYLLINE No - No PA Required Pentoxifylline No - No PA Required Pepcid No - No PA Required PERAMPANEL No - No PA Required Perampanel No - No PA Required PERCOCET No - No PA Required Perforomist No - No PA Required Perindopril Erbumine No - No PA Required Periogard Alcohol Free No - No PA Required PERMETHRIN No - No PA Required Permethrin No - No PA Required perphenazine No - No PA Required PERPHENAZINE No - No PA Required Perphenazine No - No PA Required Perphenazine and Amitriptyline Hydrochloride No - No PA Required PERSERIS No - No PA Required PERTZYE Varies by Plan PHEBURANE No - No PA Required Phenelzine Sulfate No - No PA Required phenelzine sulfate No - No PA Required PHENOBARBITAL No - No PA Required Phenobarbital No - No PA Required Phenobarbital Oral Solution No - No PA Required Phenobarbital Sodium No - No PA Required Phenoxybenzamine Hydrochloride No - No PA Required PHENOXYBENZAMINE HYDROCHLORIDE No - No PA Required Phenoxybenzamine hydrochloride No - No PA Required PHENYLEPHRINE HCI No - No PA Required Phenylephrine hydrochloride No - No PA Required phenylephrine hydrochloride No - No PA Required Phenylephrine Hydrochloride No - No PA Required PHENYLEPHRINE HYDROCHLORIDE No - No PA Required phenylephrine hydrochloride injection, solution No - No PA Required Phenylephrine Hydrochloride, IMMPHENTIV No - No PA Required phenylephrine hydrochloride, Phenylephrine Hydrochloride Phenylephrine Hydrochloride No - No PA Required Phenytek No - No PA Required Phenytoin No - No PA Required Phenytoin Infatabs No - No PA Required PHENYTOIN SODIUM No - No PA Required Phenytoin Sodium No - No PA Required Phexx Varies by Plan Phexxi Varies by Plan Phospholine Iodide Varies by Plan PHYRAGO No - No PA Required PIFELTRO Varies by Plan pilocarpine hydrchloride No - No PA Required Pilocarpine hydrochloride No - No PA Required Pilocarpine Hydrochloride No - No PA Required Pilocarpine Hydrochloride Ophthalmic No - No PA Required pimavanserin Varies by Plan Pimecrolimus No - No PA Required Pimozide No - No PA Required Pindolol No - No PA Required PIOGLITAZONE No - No PA Required Pioglitazone No - No PA Required pioglitazone and glimepiride No - No PA Required Pioglitazone and metformin hydrochloride No - No PA Required Pioglitazone HCL and Metformin HCL No - No PA Required PIOGLITAZONE HYDROCHLORIDE No - No PA Required Pioglitazone Hydrochloride and Metformin Hydrochloride No - No PA Required PIPERACILLIN AND TAZOBACTAM No - No PA Required piperacillin and tazobactam No - No PA Required Piperacillin and Tazobactam No - No PA Required Piperacillin and Tazobactam and Sodium Chloride No - No PA Required PIQRAY Varies by Plan Pirfenidone No - No PA Required PIRFENIDONE No - No PA Required Pirfenidone Capsule, 267 mg No - No PA Required PIROXICAM No - No PA Required Piroxicam No - No PA Required Pitavastatin Varies by Plan pitavastatin calcium No - No PA Required Pitavastatin Calcium No - No PA Required Plaquenil No - No PA Required Plavix No - No PA Required Plenamine Yes - PA Required Plenvu No - No PA Required PODOFILOX No - No PA Required POKONZA No - No PA Required POKONZA potassium chloride No - No PA Required Polyethylene Glycol 3350 and electrolytes - Unflavored, Polyethylene Glycol 3350 and electrolytes with Lemon Flavor, Polyethylene Glycol 3350 and electrolyteswith Orange Flavor No - No PA Required Polyethylene Glycol 3350, Sodium Chloride, Sodium Bicarbonate and Potassium Chloride - Unflavored, Polyethylene Glycol 3350, Sodium Chloride, Sodium Bicarbonate and Potassium Chloride with Lemon Flavor, Polyethylene Glycol 3350, Sodium Chloride, Sodium Bicarbonate and Potassium Chloride with Orange Flavor No - No PA Required POLYETHYLENE GLYCOL-3350 AND ELECTROLYTES No - No PA Required POLYMYXIN B No - No PA Required Polymyxin B No - No PA Required Polymyxin B Sulfate and Trimethoprim No - No PA Required polymyxin b sulfate and trimethoprim sulfate No - No PA Required Pomalidomide Varies by Plan Pomalyst Varies by Plan PONVORY Varies by Plan Portia No - No PA Required POSACONAZOLE No - No PA Required Posaconazole No - No PA Required posaconazole No - No PA Required Potassium Acetate No - No PA Required Potassium Chloride No - No PA Required POTASSIUM CHLORIDE No - No PA Required potassium chloride No - No PA Required Potassium chloride No - No PA Required Potassium Chloride ER No - No PA Required POTASSIUM CHLORIDE EXTENDED RELEASE No - No PA Required Potassium chloride extended release No - No PA Required Potassium Chloride Extended-release No - No PA Required Potassium Chloride Extended-Release No - No PA Required Potassium Chloride for Oral Solution No - No PA Required Potassium Chloride in Dextrose No - No PA Required POTASSIUM CHLORIDE IN DEXTROSE No - No PA Required Potassium Chloride in Dextrose and Sodium Chloride No - No PA Required Potassium Chloride in Lactated Ringers and Dextrose No - No PA Required Potassium Chloride in Sodium Chloride No - No PA Required POTASSIUM CHLORIDE IN SODIUM CHLORIDE No - No PA Required POTASSIUM CITRATE No - No PA Required Potassium Citrate No - No PA Required Potassium Citrate and Citric Acid No - No PA Required POTASSIUM CITRATE EXTENDED RELEASE No - No PA Required POTASSIUM IODIDE No - No PA Required Potassium Phosphate No - No PA Required Potassium Phosphates No - No PA Required POTASSIUM PHOSPHATES No - No PA Required Pradaxa No - No PA Required Praluent Yes - PA Required PRAMIPEXOLE No - No PA Required pramipexole dihydrochloride No - No PA Required Pramipexole Dihydrochloride No - No PA Required Pramipexole dihydrochloride No - No PA Required Pramipexole Dihydrochloride Extended-Release No - No PA Required Pramipexole Dihydrochloride Extended-Release, Pramipexole Dihydrochloride No - No PA Required Pramosone No - No PA Required pramosone No - No PA Required Pramosone Cream No - No PA Required PRASUGREL No - No PA Required Prasugrel No - No PA Required Pravastatin sodium No - No PA Required Pravastatin Sodium No - No PA Required PRAVASTATIN SODIUM No - No PA Required PRAZIQUANTEL No - No PA Required Prazosin No - No PA Required Prazosin HCL No - No PA Required Prazosin hydrochloride No - No PA Required prazosin hydrochloride No - No PA Required Prazosin Hydrochloride No - No PA Required PRED FORTE No - No PA Required PRED MILD No - No PA Required PrednisoLONE No - No PA Required Prednisolone No - No PA Required PREDNISOLONE No - No PA Required prednisolone acetate No - No PA Required PREDNISOLONE ACETATE No - No PA Required Prednisolone Acetate No - No PA Required PREDNISOLONE SODIUM PHOSPHATE No - No PA Required prednisoLONE sodium phosphate No - No PA Required Prednisolone Sodium Phosphate No - No PA Required prednisolone sodium phosphate ODT No - No PA Required Prednisolone Sodium Phosphate Oral Solution No - No PA Required Prednisone No - No PA Required prednisone No - No PA Required PREDNISONE No - No PA Required PredniSONE No - No PA Required Prednisone D/P No - No PA Required Prednisone delayed release No - No PA Required PredniSONE Tablets, USP, 10 mg No - No PA Required PredniSONE Tablets, USP, 20 mg No - No PA Required PredniSONE Tablets, USP, 5 mg No - No PA Required PredniSONE Tablets, USP, 5 mg, PredniSONE Tablets, USP, 10 mg, PredniSONE Tablets, USP, 20 mg No - No PA Required Pregabalin No - No PA Required pregabalin No - No PA Required PREGABALIN No - No PA Required PREGABALIN capsules, CV No - No PA Required Pregabalin Extended Release No - No PA Required Premasol - sulfite-free (Amino Acid) Yes - PA Required Pretomanid No - No PA Required Prevalite No - No PA Required PREVYMIS Varies by Plan PREZCOBIX Varies by Plan PREZISTA No - No PA Required Priftin Varies by Plan Prilosec No - No PA Required PRIMAQUINE PHOSPHATE No - No PA Required Primaquine Phosphate No - No PA Required PRIMAXIN IV No - No PA Required PRIMIDONE No - No PA Required Primidone No - No PA Required Pristiq Extended-Release No - No PA Required ProAir Digihaler No - No PA Required ProAir RespiClick No - No PA Required Probenecid No - No PA Required Probenecid and Colchicine No - No PA Required Procardia XL No - No PA Required PROCENTRA No - No PA Required Prochlorperazine No - No PA Required prochlorperazine edisylate No - No PA Required PROCHLORPERAZINE EDISYLATE No - No PA Required Prochlorperazine Edisylate No - No PA Required PROCHLORPERAZINE MALEATE No - No PA Required prochlorperazine maleate No - No PA Required Prochlorperazine Maleate No - No PA Required PROCRIT Yes - PA Required Procto-Med HC No - No PA Required PROCYSBI Varies by Plan PROGESTERONE No - No PA Required Progesterone No - No PA Required Progesterone vaginal insert No - No PA Required Proglycem No - No PA Required Prograf No - No PA Required Prolate No - No PA Required Prolensa No - No PA Required Prolia Yes - PA Required PROMACTA No - No PA Required Promethazine No - No PA Required Promethazine and Phenylephrine HCl, and Codeine Phosphate No - No PA Required Promethazine DM No - No PA Required PROMETHAZINE HCI No - No PA Required PROMETHAZINE HYDROCHLORIDE No - No PA Required promethazine hydrochloride No - No PA Required Promethazine Hydrochloride No - No PA Required Promethazine Hydrochloride and Codeine Phosphate No - No PA Required Promethazine Hydrochloride and Dextromethorphan Hydrobromide No - No PA Required Promethazine Hydrochloride and Dextromethorphan Hydrobromide Oral No - No PA Required Promethazine Hydrochloride and Dextromethorphan Hydrobromide Oral Solution No - No PA Required Promethazine Hydrochloride and Phenylephrine Hydrochloride No - No PA Required PROMETHEGAN No - No PA Required Prometrium No - No PA Required Propafenone HCl No - No PA Required PROPAFENONE HYDROCHLORIDE No - No PA Required propafenone hydrochloride No - No PA Required Propafenone Hydrochloride No - No PA Required Propranolol No - No PA Required PROPRANOLOL No - No PA Required PROPRANOLOL HYDROCHLORIDE No - No PA Required Propranolol hydrochloride No - No PA Required propranolol hydrochloride No - No PA Required Propranolol Hydrochloride No - No PA Required Propranolol Hydrochloride ER No - No PA Required Propranolol Hydrochloride, Propranolol hydrochloride No - No PA Required Propylthiouracil No - No PA Required PROPYLTHIOURACIL No - No PA Required PROSCAR No - No PA Required ProSol Yes - PA Required Protonix Delayed-Release No - No PA Required Protonix I.V. No - No PA Required Protriptyline Hydrochloride No - No PA Required Provera No - No PA Required Provigil No - No PA Required Prozac No - No PA Required prucalopride No - No PA Required Prucalopride No - No PA Required PRUCALOPRIDE No - No PA Required Prucalopride succinate No - No PA Required PRUDOXIN No - No PA Required PULMICORT FLEXHALER No - No PA Required PULMICORT RESPULES No - No PA Required Pulmozyme Varies by Plan PURIXAN No - No PA Required PYLERA No - No PA Required PYQUVI No - No PA Required Pyrazinamide No - No PA Required pyrazinamide No - No PA Required PYRAZINAMIDE No - No PA Required Pyridostigmine Bromide No - No PA Required pyridostigmine bromide No - No PA Required Pyridostigmine bromide No - No PA Required Pyrimethamine No - No PA Required PYRUKYND Varies by Plan PYZCHIVA No - No PA Required

Q

Qbrelis No - No PA Required Qbrexza Varies by Plan QELBREE Varies by Plan QINLOCK Varies by Plan QNASL Varies by Plan QUESTRAN No - No PA Required QUETIAPINE No - No PA Required Quetiapine No - No PA Required Quetiapine Extended Release No - No PA Required Quetiapine Extended-Release No - No PA Required Quetiapine fumarate No - No PA Required Quetiapine Fumarate No - No PA Required QUETIAPINE FUMARATE No - No PA Required Quetiapine Fumarate ER No - No PA Required QuilliChew ER No - No PA Required Quillivant XR No - No PA Required Quinapril No - No PA Required QUINAPRIL No - No PA Required Quinapril and Hydrochlorothiazide No - No PA Required Quinapril and Hydrochlorothiazide 10/12.5, Quinapril and Hydrochlorothiazide 20/12.5, Quinapril and Hydrochlorothiazide 20/25 No - No PA Required Quinapril HCL and Hydrochlorothiazide No - No PA Required QUINAPRIL HYDROCHLORIDE/HYDROCHLOROTHIAZIDE No - No PA Required Quinidine gluconate No - No PA Required Quinidine Gluconate No - No PA Required QUINIDINE SULFATE No - No PA Required Quinine Sulfate No - No PA Required QUININE SULFATE No - No PA Required Qulipta Varies by Plan QUVIVIQ Varies by Plan QVAR REDIHALER Varies by Plan

R

RABEPRAZOLE SODIUM No - No PA Required Rabeprazole sodium No - No PA Required Rabeprazole Sodium No - No PA Required Rabeprazole Sodium DR No - No PA Required RALDESY TM No - No PA Required Raloxifene hydrochloride No - No PA Required Raloxifene Hydrochloride No - No PA Required RAMELTEON No - No PA Required Ramelteon No - No PA Required Ramipril No - No PA Required RANITIDINE No - No PA Required Ranitidine Hydrochloride No - No PA Required Ranolazine No - No PA Required RANOLAZINE No - No PA Required Rasagiline No - No PA Required RASAGILINE No - No PA Required Rasagiline mesylate No - No PA Required Rasuvo No - No PA Required Ravicti No - No PA Required Rayaldee Varies by Plan Reclipsen 28 Day Varies by Plan Recorlev Varies by Plan Rectiv No - No PA Required Reglan No - No PA Required RELENZA Varies by Plan RELEUKO Yes - PA Required RELEXXII No - No PA Required Relistor Yes - PA Required Relpax No - No PA Required Repaglinide No - No PA Required REPATHA Yes - PA Required Respiratory Plus Yes - PA Required RESTASIS No - No PA Required Restasis MultiDose No - No PA Required RESTORIL No - No PA Required RETACRIT Yes - PA Required RETEVMO Varies by Plan Retin-A No - No PA Required Retin-A MICRO No - No PA Required RETROVIR No - No PA Required Revatio No - No PA Required Revcovi Yes - PA Required Revlimid No - No PA Required Revuforj Varies by Plan REXTOVY No - No PA Required Rexulti Varies by Plan REYATAZ No - No PA Required REZDIFFRA Varies by Plan REZLIDHIA Varies by Plan Rezurock Varies by Plan Rezvoglar KwikPen Yes - PA Required REZVOGLAR KWIKPEN Yes - PA Required RHAPSIDO Varies by Plan Rhofade Varies by Plan Rhopressa Varies by Plan RIBAVIRIN No - No PA Required Ribavirin No - No PA Required RIDAURA Varies by Plan Rifabutin No - No PA Required rifampin No - No PA Required Rifampin No - No PA Required RIFAMPIN No - No PA Required Rilpivirine Yes - PA Required Riluzole No - No PA Required Rimantadine Hydrochloride No - No PA Required Rinvoq Varies by Plan RISEDRONATE SODIUM No - No PA Required Risedronate Sodium No - No PA Required risedronate sodium No - No PA Required RISPERDAL CONSTA No - No PA Required RISPERIDONE No - No PA Required Risperidone No - No PA Required risperidone No - No PA Required Ritalin No - No PA Required Ritalin LA No - No PA Required Ritonavir No - No PA Required Ritonavir film coated No - No PA Required Rivaroxaban No - No PA Required RIVAROXABAN No - No PA Required rivaroxaban No - No PA Required rivaroxaban granule No - No PA Required Rivastigmine No - No PA Required RIVASTIGMINE TARTRATE No - No PA Required Rivastigmine Tartrate No - No PA Required Rivastigmine Transdermal System No - No PA Required Rivelsa No - No PA Required RIVFLOZA Yes - PA Required Rizatriptan No - No PA Required rizatriptan benzoate No - No PA Required Rizatriptan Benzoate No - No PA Required RIZATRIPTAN Benzoate No - No PA Required RIZATRIPTAN BENZOATE No - No PA Required Rizatriptan Benzoate ODT No - No PA Required Rocklatan No - No PA Required ROFLUMILAST No - No PA Required roflumilast No - No PA Required Roflumilast No - No PA Required ROMVIMZA Varies by Plan ropinirole No - No PA Required Ropinirole No - No PA Required ROPINIROLE No - No PA Required ROPINIROLE HYDROCHLORIDE No - No PA Required ropinirole hydrochloride No - No PA Required Rosuvastatin No - No PA Required Rosuvastatin Calcium No - No PA Required Rosuvastatin calcium No - No PA Required ROSUVASTATIN CALCIUM No - No PA Required Rosyrah No - No PA Required Rowasa No - No PA Required Roxicodone No - No PA Required RoxyBond No - No PA Required Rozerem No - No PA Required Rozlytrek Varies by Plan Rubraca Varies by Plan RUFINAMIDE No - No PA Required rufinamide No - No PA Required Rufinamide No - No PA Required Rukobia Varies by Plan Ryaltris No - No PA Required RYDAPT Varies by Plan RYTARY No - No PA Required RyVent No - No PA Required

S

SABRIL No - No PA Required Sacubitril and valsartan No - No PA Required Sacubitril and Valsartan No - No PA Required sacubitril and valsartan No - No PA Required Sacubitril and Valsartan Sacubitril and Valsartan No - No PA Required Safyral Varies by Plan SAJAZIR No - No PA Required Salagen No - No PA Required SAMSCA No - No PA Required SANCUSO No - No PA Required Sandimmune No - No PA Required Sandostatin No - No PA Required Sandostatin LAR Depot No - No PA Required SAPHRIS No - No PA Required sapropterin dihydrochloride No - No PA Required Sapropterin dihydrochloride No - No PA Required Sapropterin Dihydrochloride No - No PA Required SAPROPTERIN DIHYDROCHLORIDE No - No PA Required SAVAYSA Varies by Plan Savella Varies by Plan Saxagliptin No - No PA Required SAXAGLIPTIN No - No PA Required Saxagliptin and Metformin No - No PA Required Saxagliptin and Metformin Hydrochloride No - No PA Required SCEMBLIX Varies by Plan scopolamine No - No PA Required Scopolamine No - No PA Required Scopolamine Trandermal System No - No PA Required Scopolamine Transdermal System No - No PA Required SECUADO No - No PA Required SEGLUROMET Varies by Plan Selarsdi No - No PA Required SELARSDI No - No PA Required Selegiline Hydrochloride No - No PA Required SELEGILINE HYDROCHLORIDE No - No PA Required Selenium Sulfide No - No PA Required SELENIUM SULFIDE No - No PA Required SELZENTRY No - No PA Required SEMGLEE No - No PA Required SEREVENT DISKUS Varies by Plan SEROQUEL No - No PA Required SEROQUEL XR No - No PA Required Serostim Yes - PA Required SERTRALINE No - No PA Required Sertraline No - No PA Required Sertraline HCL No - No PA Required Sertraline HCl No - No PA Required sertraline HCl No - No PA Required sertraline hydrochloride No - No PA Required Sertraline Hydrochloride No - No PA Required Sertraline hydrochloride No - No PA Required SERTRALINE HYDROCHLORIDE No - No PA Required SETLAKIN No - No PA Required SEVELAMER CARBONATE No - No PA Required Sevelamer Carbonate No - No PA Required Sevelamer carbonate No - No PA Required sevelamer hydrochloride No - No PA Required Sevelamer Hydrochloride No - No PA Required Sevelamer hydrochloride No - No PA Required Seysara Varies by Plan SHAROBEL Varies by Plan Signifor Yes - PA Required Signifor LAR Yes - PA Required Siklos No - No PA Required SILDENAFIL No - No PA Required sildenafil No - No PA Required Sildenafil No - No PA Required Sildenafil Citrate No - No PA Required sildenafil citrate No - No PA Required sildenafil CITRATE No - No PA Required SILDENAFIL CITRATE No - No PA Required Silenor No - No PA Required Siliq Yes - PA Required SILODOSIN No - No PA Required Silodosin No - No PA Required SILVADENE No - No PA Required Silver Nitrate No - No PA Required Silver Nitrate Applicators No - No PA Required SILVER SULFADIAZINE No - No PA Required Silver Sulfadiazine No - No PA Required SIMBRINZA No - No PA Required Simlandi No - No PA Required Simponi Yes - PA Required SIMPONI ARIA Yes - PA Required simvastatin No - No PA Required Simvastatin No - No PA Required SIMVASTATIN No - No PA Required SINEMET No - No PA Required SINGULAIR No - No PA Required SIROLIMUS No - No PA Required Sirolimus No - No PA Required sirolimus No - No PA Required SIRTURO Varies by Plan Sitagliptin No - No PA Required Sitagliptin and Metformin Hydrochloride No - No PA Required Sitagliptin and metformin hydrochloride No - No PA Required SIVEXTRO Yes - PA Required SKYCLARYS Varies by Plan Skyla Varies by Plan Skyrizi Yes - PA Required Skytrofa Varies by Plan SOAANZ No - No PA Required Sodium Acetate No - No PA Required SODIUM ACETATE No - No PA Required Sodium acetate anhydrous No - No PA Required SODIUM BICARBONATE No - No PA Required Sodium Bicarbonate No - No PA Required Sodium Chloride No - No PA Required SODIUM CHLORIDE No - No PA Required Sodium chloride No - No PA Required sodium chloride No - No PA Required Sodium Chloride for Irrigation No - No PA Required Sodium Citrate 4% w/v Anticoagulant No - No PA Required Sodium Citrate and Citric Acid No - No PA Required Sodium Citrate Blood-Pack Units, (PL 146 Plastic) No - No PA Required Sodium Citrate w/v Anticoagulant No - No PA Required Sodium Ferric Gluconate Complex in Sucrose No - No PA Required Sodium Flouride No - No PA Required Sodium Fluoride No - No PA Required Sodium Fluoride 1.1% No - No PA Required Sodium Fluoride 1.1% Dental Gel BUBBLEGUM No - No PA Required Sodium Fluoride 1.1% Dental Gel MINT No - No PA Required Sodium Fluoride 1.1% Gel No - No PA Required Sodium Fluoride 5000 Plus No - No PA Required Sodium Fluoride 5000 PPM No - No PA Required Sodium Fluoride 5000 ppm Enamel Protect No - No PA Required Sodium Fluoride 5000 ppm Fruit, Sodium Fluoride 5000 ppm Spearmint No - No PA Required Sodium Fluoride and Potassium Nitrate No - No PA Required Sodium Fluoride Chewable No - No PA Required Sodium Fluoride F 18 No - No PA Required Sodium Fluoride F18 No - No PA Required Sodium Fluoride Gel No - No PA Required SODIUM IODIDE I 123 No - No PA Required Sodium Iodide I 123 No - No PA Required Sodium Iodide I 131 Diagnostic No - No PA Required Sodium Iodide I-131 No - No PA Required Sodium Nitrite No - No PA Required Sodium nitroprusside No - No PA Required SODIUM NITROPRUSSIDE No - No PA Required Sodium Nitroprusside No - No PA Required sodium nitroprusside No - No PA Required sodium nitroprusside in 0.9% sodium chloride No - No PA Required Sodium Oxybate No - No PA Required sodium oxybate No - No PA Required SODIUM PHENYLACETATE AND SODIUM BENZOATE No - No PA Required Sodium phenylacetate and Sodium benzoate No - No PA Required Sodium Phenylacetate and sodium benzoate No - No PA Required Sodium Phenylacetate and Sodium Benzoate No - No PA Required SODIUM PHENYLACETATE and SODIUM BENZOATE No - No PA Required sodium phenylbutyrate No - No PA Required Sodium Phenylbutyrate No - No PA Required Sodium Phosphates No - No PA Required Sodium Polystyrene Sulfonate No - No PA Required SODIUM POLYSTYRENE SULFONATE No - No PA Required Sodium sulfacetamide No - No PA Required SODIUM SULFACETAMIDE No - No PA Required Sodium Sulfacetamide No - No PA Required Sodium Sulfacetamide 10 % and Sulfur 2 % Cleanser No - No PA Required Sodium Sulfacetamide 10 Sulfur 2 Cleanser No - No PA Required Sodium Sulfacetamide 10 Sulfur 2 cream No - No PA Required Sodium Sulfacetamide 10 Sulfur 5 Cleanser No - No PA Required Sodium Sulfacetamide 10% and Sulfur 2% Cleanser No - No PA Required Sodium Sulfacetamide 10% and Sulfur 5% Cleanser No - No PA Required SODIUM SULFACETAMIDE 10% AND SULFUR 5% Emollient Cream No - No PA Required Sodium Sulfacetamide 10% wash No - No PA Required Sodium Sulfacetamide 8% and Sulfur 4% No - No PA Required Sodium Sulfacetamide 8% and Sulfur 4% Cleanser No - No PA Required Sodium Sulfacetamide 8% Sulfur 4% CLEANSER No - No PA Required Sodium Sulfacetamide 9 Sulfur 4.5 Wash No - No PA Required Sodium Sulfacetamide 9% - Sulfur 4% No - No PA Required Sodium Sulfacetamide 9% - Sulfur 4.5% Wash No - No PA Required Sodium Sulfacetamide 9% and Sulfur 4% Cleanser No - No PA Required Sodium Sulfacetamide 9% and Sulfur 4.5% Cleanser No - No PA Required Sodium Sulfacetamide 9% and Sulfur 4.5% Wash No - No PA Required Sodium Sulfacetamide 9.8 % and Sulfur 4.8 % Cleanser No - No PA Required Sodium Sulfacetamide 9.8% and Sulfur 4.8% Cleanser No - No PA Required Sodium Sulfacetamide 9.8% Sulfur 4.8% Cleanser No - No PA Required Sodium Sulfacetamide and Sulfer Emulsion No - No PA Required SODIUM SULFACETAMIDE AND SULFUR No - No PA Required Sodium Sulfacetamide and Sulfur No - No PA Required SODIUM SULFACETAMIDE and SULFUR Wash No - No PA Required Sodium Sulfacetamide Wash 10% No - No PA Required Sodium Sulfacetamide, Sulfur No - No PA Required SODIUM SULFACETAMIDE, SULFUR No - No PA Required Sodium Sulfate, Potassium Sulfate and Magnesium Sulfate No - No PA Required SODIUM SULFATE, POTASSIUM SULFATE AND MAGNESIUM SULFATE No - No PA Required Sodium sulfate, potassium sulfate and magnesium sulfate No - No PA Required Sodium Sulfate, Potassium Sulfate and Magnesium Sulfate Oral No - No PA Required sodium sulfate, potassium sulfate, and magnesium sulfate No - No PA Required Sodium Sulfate, Potassium Sulfate, and Magnesium Sulfate Bowel Prep kit No - No PA Required SODIUM SULFATE, POTASSIUM SULFATE, MAGNESIUM SULFATE No - No PA Required Sodium Tetradecyl Sulfate No - No PA Required Sodium Thiosulfate No - No PA Required Sofdra Varies by Plan Sofosbuvir and Velpatasvir No - No PA Required SOGROYA Yes - PA Required SOHONOS Varies by Plan Solifenacin Succinate No - No PA Required SOLIFENACIN SUCCINATE No - No PA Required solifenacin succinate No - No PA Required Soliqua 100/33 No - No PA Required Solosec Varies by Plan SOLTAMOX No - No PA Required Soma No - No PA Required SOMAVERT Yes - PA Required SOOLANTRA No - No PA Required sorafenib No - No PA Required Sorafenib No - No PA Required Sorafenib Tosylate No - No PA Required SORILUX No - No PA Required Sotalol No - No PA Required Sotalol Hydrochloride No - No PA Required SOTALOL HYDROCHLORIDE No - No PA Required Sotalol hydrochloride No - No PA Required SOTYKTU Varies by Plan SOTYLIZE No - No PA Required Sovaldi No - No PA Required SOVUNA No - No PA Required SPEVIGO Yes - PA Required Spinosad No - No PA Required Spiriva HandiHaler No - No PA Required Spiriva Respimat No - No PA Required spironolactone No - No PA Required SPIRONOLACTONE No - No PA Required Spironolactone No - No PA Required Spironolactone and Hydrochlorothiazide No - No PA Required SPORANOX No - No PA Required Sprintec No - No PA Required Spritam No - No PA Required Sprix No - No PA Required SPRYCEL No - No PA Required SRONYX No - No PA Required SSD No - No PA Required Starjemza Yes - PA Required STEGLATRO Varies by Plan STEGLUJAN Varies by Plan Stelara No - No PA Required STIMUFEND Yes - PA Required Stiolto Respimat Varies by Plan Stivarga Varies by Plan Stoboclo Yes - PA Required Streptomycin No - No PA Required Stribild Varies by Plan Striverdi Respimat Varies by Plan STROMECTOL No - No PA Required Suboxone No - No PA Required SUBVENITE No - No PA Required Sucraid Varies by Plan sucralfate No - No PA Required Sucralfate No - No PA Required SUCRALFATE No - No PA Required Sucralfate oral suspension No - No PA Required SUFLAVE No - No PA Required Sular No - No PA Required Sulconazole Nitrate Varies by Plan SULFACETAMIDE SODIUM No - No PA Required Sulfacetamide Sodium No - No PA Required Sulfacetamide Sodium and Prednisolone Sodium Phosphate No - No PA Required sulfacetamide sodium and sulfur Sodium Sulfacetamide - Sulfur No - No PA Required SULFACETAMIDE SODIUM, SULFUR No - No PA Required SULFADIAZINE No - No PA Required sulfADIAZINE No - No PA Required Sulfamethoxazole and Trimethoprim No - No PA Required Sulfamethoxazole and Trimethoprim DS No - No PA Required SULFAMYLON Varies by Plan Sulfasalazine No - No PA Required SULINDAC No - No PA Required Sulindac No - No PA Required Sumatriptan No - No PA Required SUMATRIPTAN No - No PA Required sumatriptan No - No PA Required Sumatriptan and Naproxen Sodium No - No PA Required SUMATRIPTAN SUCCINATE No - No PA Required sumatriptan succinate No - No PA Required Sumatriptan Succinate No - No PA Required Sumatriptan Succinate and Naproxen Sodium No - No PA Required Sunitinib malate No - No PA Required Sunitinib Malate No - No PA Required SUNITINIB MALATE No - No PA Required Sunlenca Varies by Plan SUNOSI Varies by Plan SUTAB No - No PA Required SUTENT No - No PA Required Syeda Varies by Plan SYMBICORT No - No PA Required SYMBRAVO No - No PA Required SYMFI No - No PA Required SYMPAZAN No - No PA Required SYMPROIC Varies by Plan Symtuza Varies by Plan Synalar No - No PA Required Synarel Varies by Plan Synjardy Varies by Plan Synjardy XR Varies by Plan Synthroid No - No PA Required Syprine No - No PA Required

T

TABLOID Varies by Plan TABRECTA Varies by Plan TACLONEX No - No PA Required tacrolimus No - No PA Required Tacrolimus No - No PA Required TADALAFIL No - No PA Required Tadalafil No - No PA Required tadalafil No - No PA Required TADLIQ No - No PA Required Tafinlar Yes - PA Required tafluprost No - No PA Required Tafluprost No - No PA Required Tafluprost Ophthalmic No - No PA Required TAGRISSO Varies by Plan Takhzyro Yes - PA Required TAKHZYRO Yes - PA Required Talicia No - No PA Required TALTZ Yes - PA Required Talzenna Varies by Plan Tamiflu No - No PA Required Tamoxifen Citrate No - No PA Required Tamsulosin hydrochloride No - No PA Required tamsulosin hydrochloride No - No PA Required Tamsulosin Hydrochloride No - No PA Required Tanlor No - No PA Required TAPENTADOL Varies by Plan Tapentadol Hydrochloride Varies by Plan TARGADOX No - No PA Required Targretin No - No PA Required TARINA 24 FE No - No PA Required Tarpeyo No - No PA Required TASCENSO ODT No - No PA Required Tasigna No - No PA Required Tasimelteon No - No PA Required Tasmar No - No PA Required TAVABOROLE No - No PA Required Tavaborole No - No PA Required tavaborole No - No PA Required TAVALISSE Varies by Plan TAVNEOS Varies by Plan Tazarotene No - No PA Required TAZAROTENE No - No PA Required tazarotene No - No PA Required TAZICEF No - No PA Required TAZORAC No - No PA Required Tazorac No - No PA Required TAZVERIK Varies by Plan Teflaro Yes - PA Required Tekturna No - No PA Required telmisartan No - No PA Required TELMISARTAN No - No PA Required Telmisartan No - No PA Required Telmisartan and Amlodipine No - No PA Required Telmisartan and Hydrochlorothiazide No - No PA Required TELMISARTAN AND HYDROCHLOROTHIAZIDE No - No PA Required telmisartan and hydrochlorothiazide No - No PA Required temazepam No - No PA Required TEMAZEPAM No - No PA Required Temazepam No - No PA Required Tencon No - No PA Required Tenofovir Disoproxil Fumarate No - No PA Required TENOFOVIR DISOPROXIL FUMARATE No - No PA Required tenofovir disoproxil fumarate No - No PA Required TENORETIC No - No PA Required TENORMIN No - No PA Required TEPMETKO Varies by Plan Terazosin No - No PA Required terazosin No - No PA Required Terazosin hydrochloride No - No PA Required Terazosin Hydrochloride No - No PA Required Terbinafine No - No PA Required TERBINAFINE No - No PA Required Terbinafine Hydrochloride No - No PA Required TERBINAFINE HYDROCHLORIDE No - No PA Required terbinafine hydrochloride No - No PA Required TERBUTALINE SULFATE No - No PA Required Terbutaline Sulfate No - No PA Required Terconazole No - No PA Required Terconazole Vaginal Cream 0.8% No - No PA Required TERIFLUNOMIDE No - No PA Required teriflunomide No - No PA Required Teriflunomide No - No PA Required teriparatide No - No PA Required Teriparatide No - No PA Required Testim No - No PA Required testosterone No - No PA Required TESTOSTERONE No - No PA Required Testosterone No - No PA Required testosterone cypionate No - No PA Required TESTOSTERONE CYPIONATE No - No PA Required Testosterone Cypionate No - No PA Required TESTOSTERONE ENANTHATE No - No PA Required Testosterone Gel, 1% No - No PA Required tetrabenazine No - No PA Required Tetrabenazine No - No PA Required TETRABENAZINE No - No PA Required Tetracycline Hydrochloride No - No PA Required tetracycline hydrochloride No - No PA Required Texacort No - No PA Required Thalitone No - No PA Required Thalomid Varies by Plan Theo-24 No - No PA Required THEOPHYLLINE No - No PA Required Theophylline No - No PA Required theophylline No - No PA Required Theophylline (Anhydrous) No - No PA Required Theophylline Anhydrous No - No PA Required Thiola No - No PA Required Thiola EC No - No PA Required Thioridazine Hydrochloride No - No PA Required Thiothixene No - No PA Required thiothixene No - No PA Required THYQUIDITY No - No PA Required TIADYLT ER No - No PA Required TIAGABINE HYDROCHLORIDE No - No PA Required Tiagabine Hydrochloride No - No PA Required TIAZAC EXTENDED RELEASE No - No PA Required TIBSOVO Varies by Plan TICAGRELOR No - No PA Required ticagrelor No - No PA Required Ticagrelor No - No PA Required Tigecycline No - No PA Required TIGLUTIK No - No PA Required Tikosyn No - No PA Required Tilia Fe No - No PA Required Timolol GFS No - No PA Required Timolol Hemihydrate No - No PA Required Timolol hemihydrate No - No PA Required timolol maleate No - No PA Required TIMOLOL MALEATE No - No PA Required Timolol maleate No - No PA Required Timolol Maleate No - No PA Required timolol maleate ophthalmic gel forming solution No - No PA Required Timolol Maleate Ophthalmic Gel Forming Solution 0.25%, Timolol Maleate Ophthalmic Gel Forming Solution 0.5% No - No PA Required Timolol Maleate Ophthalmic Gel Forming Solution, 0.25%, Timolol Maleate Ophthalmic Gel Forming Solution, 0.5% No - No PA Required Timoptic No - No PA Required Timoptic in Ocudose No - No PA Required Tinidazole No - No PA Required Tiopronin No - No PA Required TIOPRONIN No - No PA Required Tiotropium Bromide No - No PA Required Tirosint No - No PA Required Tirosint SOL No - No PA Required Tivicay Yes - PA Required tizanidine No - No PA Required Tizanidine No - No PA Required Tizanidine HCl No - No PA Required Tizanidine HCL No - No PA Required tizanidine hydrochloride No - No PA Required Tizanidine Hydrochloride No - No PA Required TIZANIDINE HYDROCHLORIDE No - No PA Required Tizanidine hydrochloride No - No PA Required Tlando Yes - PA Required TOBI No - No PA Required TOBI Podhaler No - No PA Required TobraDex No - No PA Required Tobradex ST No - No PA Required Tobramycin No - No PA Required TOBRAMYCIN No - No PA Required tobramycin No - No PA Required TOBRAMYCIN AND DEXAMETHASONE No - No PA Required Tobramycin and dexamethasone No - No PA Required Tobramycin and Dexamethasone No - No PA Required Tobramycin Inhalation No - No PA Required Tobramycin Inhalation Solution Pak No - No PA Required Tobramycin Ophthalmic Solution No - No PA Required TOBREX No - No PA Required Tolcapone No - No PA Required Tolectin No - No PA Required TOLMETIN SODIUM No - No PA Required Tolmetin Sodium No - No PA Required Tolsura No - No PA Required Tolterodine tartrate No - No PA Required Tolterodine Tartrate No - No PA Required TOLTERODINE TARTRATE No - No PA Required Tolterodine Tartrate Extended Release No - No PA Required tolvaptan No - No PA Required TOLVAPTAN No - No PA Required Tolvaptan No - No PA Required TONMYA No - No PA Required Topamax No - No PA Required Topicort No - No PA Required Topiramate No - No PA Required topiramate No - No PA Required TOPIRAMATE No - No PA Required TOPROL XL No - No PA Required toremifene citrate No - No PA Required TORPENZ No - No PA Required Torsemide No - No PA Required TORSEMIDE No - No PA Required Tosymra No - No PA Required TOSYMRA No - No PA Required TOUJEO No - No PA Required TOUJEO Max No - No PA Required Tovet (emollient formulation) No - No PA Required Toviaz No - No PA Required Tracleer No - No PA Required Tradjenta Varies by Plan Tramadol HCL No - No PA Required Tramadol HCL ER No - No PA Required TRAMADOL HCL ER, TRAMADOL HYDROCHLORIDE No - No PA Required TRAMADOL HYDROCHLORIDE No - No PA Required tramadol hydrochloride No - No PA Required Tramadol Hydrochloride No - No PA Required TRAMADOL HYDROCHLORIDE AND ACETAMINOPHEN No - No PA Required Tramadol Hydrochloride and Acetaminophen No - No PA Required Tramadol Hydrochloride Extended-Release No - No PA Required Trandolapril No - No PA Required Trandolapril and Verapamil Hydrochloride No - No PA Required tranexamic acid No - No PA Required Tranexamic acid No - No PA Required TRANEXAMIC ACID No - No PA Required Tranexamic Acid No - No PA Required tranexamic acid in sodium chloride No - No PA Required Tranexamic Acid in Sodium Chloride No - No PA Required TRANEXAMIC ACID IN SODIUM CHLORIDE No - No PA Required Tranexamic Acid, TRANEXAMIC ACID No - No PA Required Transderm Scop No - No PA Required Tranylcypromine No - No PA Required Tranylcypromine Sulfate No - No PA Required TRANYLCYPROMINE SULFATE No - No PA Required Travasol Yes - PA Required Travatan Z No - No PA Required Travoprost No - No PA Required Travoprost Ophthalmic No - No PA Required Travoprost Ophthalmic Solution No - No PA Required Travoprost ophthalmic solution No - No PA Required Travoprost Ophthalmic Solution, 0.004% No - No PA Required Travoprost Ophthalmic Soluton No - No PA Required TRAZODONE HCL No - No PA Required Trazodone HCL No - No PA Required TRAZODONE HYDROCHLORIDE No - No PA Required Trazodone Hydrochloride No - No PA Required Trelegy Ellipta No - No PA Required Trelstar Yes - PA Required TREMFYA Yes - PA Required Treprostinil Varies by Plan Tresiba Yes - PA Required TRESIBA Yes - PA Required Tretinoin No - No PA Required TRETINOIN No - No PA Required Tretinoin (Microsphere) No - No PA Required Tretinoin Cream No - No PA Required Treximet No - No PA Required Tri-Estarylla No - No PA Required Tri-Legest Fe 28 Day No - No PA Required Tri-Lo- Estarylla No - No PA Required Tri-Mili No - No PA Required Tri-Sprintec No - No PA Required triamcinolone acetonide No - No PA Required Triamcinolone acetonide No - No PA Required Triamcinolone Acetonide No - No PA Required TRIAMCINOLONE ACETONIDE No - No PA Required Triamcinolone acetonide, TRIAMCINOLONE ACETONIDE No - No PA Required Triamterene No - No PA Required TRIAMTERENE AND HYDROCHLOROTHIAZIDE No - No PA Required Triamterene and Hydrochlorothiazide No - No PA Required triamterene and hydrochlorothiazide No - No PA Required Triazolam No - No PA Required Tribenzor No - No PA Required Tridacaine II No - No PA Required Tridacaine III No - No PA Required Tridacaine XL No - No PA Required TRIDERM No - No PA Required TRIENTINE HYDROCHLORIDE No - No PA Required Trientine Hydrochloride No - No PA Required Trientine hydrochloride No - No PA Required Trifluoperazine Hydrochloride No - No PA Required Trifluridine No - No PA Required Trihexyphenidyl Hydrochloride No - No PA Required TRIHEXYPHENIDYL HYDROCHLORIDE No - No PA Required Trijardy XR Varies by Plan Trileptal No - No PA Required Trimethobenzamide Hydrochloride No - No PA Required Trimethoprim No - No PA Required Trimethoprim sulfate and Polymyxin B sulfate No - No PA Required Trimipramine Maleate No - No PA Required Trintellix Varies by Plan Trokendi XR No - No PA Required TrophAmine Yes - PA Required TROSPIUM CHLORIDE No - No PA Required Trospium Chloride No - No PA Required Trospium Chloride ER No - No PA Required Trudhesa No - No PA Required Trulance Immediate release Varies by Plan TRULICITY Yes - PA Required Trulicity Yes - PA Required TRUQAP Varies by Plan Truvada No - No PA Required TRYNGOLZA Yes - PA Required TRYPTYR Varies by Plan TRYVIO Varies by Plan Tudorza Pressair Varies by Plan TUKYSA Varies by Plan Turalio Varies by Plan Turqoz No - No PA Required TWYNEO No - No PA Required Twyneo No - No PA Required Tybost Varies by Plan Tydemy Varies by Plan TYENNE Yes - PA Required Tygacil No - No PA Required TYKERB No - No PA Required Tymlos Yes - PA Required Tyrvaya No - No PA Required TYVASO Varies by Plan Tyvaso DPI Varies by Plan TYZAVAN No - No PA Required

U

UBRELVY Varies by Plan Uceris No - No PA Required UDENYCA Yes - PA Required ULORIC No - No PA Required ULTRAVATE No - No PA Required Umeclidinium and Vilanterol Ellipta No - No PA Required UNASYN No - No PA Required Unithroid No - No PA Required UROCIT-K No - No PA Required Uroxatral No - No PA Required URSODIOL No - No PA Required Ursodiol No - No PA Required Ursodiol 200 mg, Ursodiol 400 mg No - No PA Required ustekinumab No - No PA Required USTEKINUMAB-AAUZ No - No PA Required Ustekinumab-aekn No - No PA Required USTEKINUMAB-TTWE No - No PA Required UZEDY No - No PA Required

V

VABOMERE No - No PA Required Vabrinty No - No PA Required Vagifem No - No PA Required Valacyclovir No - No PA Required Valacyclovir hydrochloride No - No PA Required valacyclovir hydrochloride No - No PA Required Valacyclovir Hydrochloride No - No PA Required VALCHLOR Varies by Plan Valcyte No - No PA Required Valganciclovir No - No PA Required VALGANCICLOVIR No - No PA Required VALGANCICLOVIR HYDROCHLORIDE No - No PA Required Valganciclovir hydrochloride No - No PA Required valganciclovir hydrochloride No - No PA Required Valganciclovir hydrochloride for Oral No - No PA Required Valium No - No PA Required Valproic No - No PA Required valproic acid No - No PA Required Valproic Acid No - No PA Required VALPROIC ACID No - No PA Required Valsartan No - No PA Required VALSARTAN No - No PA Required valsartan No - No PA Required VALSARTAN AND HYDROCHLOROTHIAZIDE No - No PA Required Valsartan and Hydrochlorothiazide No - No PA Required Valtoco No - No PA Required VALTREX No - No PA Required VALTYA 1/35 No - No PA Required VALTYA 1/50 No - No PA Required Vancocin No - No PA Required Vancomycin No - No PA Required VANCOMYCIN HYDROCHLORIDE No - No PA Required Vancomycin Hydrochloride No - No PA Required vancomycin hydrochloride No - No PA Required Vancomycin Hydrochloride for Oral Solution No - No PA Required Vandazole No - No PA Required VANFLYTA Varies by Plan Vanos No - No PA Required VANRAFIA Varies by Plan Varenicline No - No PA Required VARENICLINE No - No PA Required varenicline No - No PA Required varenicline tartrate No - No PA Required VARENICLINE TARTRATE No - No PA Required Varenicline tartrate, Varenicline No - No PA Required VARENICLINE TARTRATE, VARENICLINE No - No PA Required varenicline tartrate, Varenicline tartrate No - No PA Required Varubi Varies by Plan Vascepa No - No PA Required Vaseretic No - No PA Required Vasotec No - No PA Required Vecamyl Varies by Plan Vectical No - No PA Required Velivet Triphasic Regimen Varies by Plan Velphoro Varies by Plan Velsipity Varies by Plan VELTASSA Yes - PA Required VEMLIDY Varies by Plan Venclexta Varies by Plan venlafaxine No - No PA Required VENLAFAXINE No - No PA Required Venlafaxine No - No PA Required Venlafaxine HCL ER No - No PA Required Venlafaxine hydrochloride No - No PA Required Venlafaxine Hydrochloride No - No PA Required VENLAFAXINE HYDROCHLORIDE No - No PA Required venlafaxine hydrochloride No - No PA Required Venlafaxine Hydrochloride ER No - No PA Required Venlafaxine hydrochloride ER No - No PA Required venlafaxine hydrochloride, extended release No - No PA Required VENTOLIN HFA No - No PA Required VENXXIVA No - No PA Required VEOZAH Varies by Plan VERAPAMIL HCI No - No PA Required verapamil hydrochloride No - No PA Required Verapamil Hydrochloride No - No PA Required Verapamil hydrochloride No - No PA Required VERAPAMIL HYDROCHLORIDE No - No PA Required Veregen Varies by Plan Verkazia No - No PA Required VERQUVO Varies by Plan VERSACLOZ No - No PA Required Verzenio Varies by Plan VEVYE No - No PA Required VFEND No - No PA Required Viberzi Varies by Plan Victoza No - No PA Required Vienva No - No PA Required Vienva TM No - No PA Required VIGABATRIN No - No PA Required vigabatrin No - No PA Required Vigabatrin No - No PA Required VIGADRONE No - No PA Required VIGAFYDE No - No PA Required VIGAMOX No - No PA Required VIIBRYD No - No PA Required VIJOICE Varies by Plan Vilazodone Hydrochloride No - No PA Required vilazodone hydrochloride No - No PA Required VILAZODONE HYDROCHLORIDE No - No PA Required Vilazodone Hydrochloride, Vilazodone hydrochloride No - No PA Required Vimpat No - No PA Required Viokace Varies by Plan VIORELE Varies by Plan VIRACEPT Varies by Plan Viread No - No PA Required VITRAKVI Varies by Plan VIVITROL Yes - PA Required VIVJOA Varies by Plan Vizimpro Varies by Plan Vogelxo No - No PA Required Vonjo Varies by Plan VOQUEZNA Varies by Plan VOQUEZNA DUAL PAK, VOQUEZNA TRIPLE PAK Varies by Plan VORANIGO Varies by Plan VORICONAZOLE No - No PA Required Voriconazole No - No PA Required voriconazole No - No PA Required Vosevi No - No PA Required VOTRIENT No - No PA Required VOXZOGO 0.4mg, VOXZOGO 0.56mg, VOXZOGO 1.2mg Yes - PA Required Voydeya Varies by Plan VOYXACT Yes - PA Required Vraylar Varies by Plan VTAMA Varies by Plan VUITY No - No PA Required Vumerity Varies by Plan Vyfemla No - No PA Required VYKAT XR Varies by Plan VyLibra No - No PA Required VYSCOXA No - No PA Required VYTORIN No - No PA Required Vyvanse No - No PA Required VYVGART Hytrulo Yes - PA Required Vyzulta Varies by Plan

W

WAINUA Yes - PA Required Wakix Varies by Plan Warfarin Sodium No - No PA Required WARFARIN SODIUM No - No PA Required WAYRILZ Varies by Plan WEGOVY Yes - PA Required Welchol No - No PA Required WELIREG Varies by Plan WELLBUTRIN SR No - No PA Required WELLBUTRIN XL No - No PA Required WEZLANA Yes - PA Required Winlevi Varies by Plan WINREVAIR Yes - PA Required Wixela Inhub No - No PA Required WYMZYA Fe No - No PA Required WYOST Yes - PA Required

X

XACIATO No - No PA Required XALATAN No - No PA Required Xalkori Varies by Plan Xanax No - No PA Required Xanax XR No - No PA Required XARAH FE No - No PA Required Xarelto No - No PA Required XARELTO No - No PA Required Xatmep No - No PA Required XDEMVY Varies by Plan XELJANZ XR, XELJANZ Varies by Plan Xelria Fe No - No PA Required XELSTRYM Varies by Plan Xenazine No - No PA Required Xerese No - No PA Required Xermelo Varies by Plan XGEVA Yes - PA Required XHANCE No - No PA Required XIFAXAN Varies by Plan XIGDUO XR No - No PA Required Xiidra Varies by Plan Xofluza Varies by Plan XOLREMDI Varies by Plan XOPENEX HFA No - No PA Required Xospata Varies by Plan XPOVIO Varies by Plan XROMI No - No PA Required XTAMPZA ER Varies by Plan Xtandi Varies by Plan XTRENBO Yes - PA Required XULANE No - No PA Required Xultophy 100/3.6 Yes - PA Required XYOSTED No - No PA Required Xyrem No - No PA Required XYWAV Varies by Plan

Y

Yargesa No - No PA Required Yasmin Varies by Plan Yaz Varies by Plan YESINTEK Yes - PA Required YONSA No - No PA Required Yorvipath No - No PA Required Yuflyma No - No PA Required YUPELRI Varies by Plan YUSIMRY Yes - PA Required Yutrepia Varies by Plan YUVAFEM No - No PA Required Yuvafem No - No PA Required

Z

ZAFEMY No - No PA Required Zafirlukast No - No PA Required zaleplon No - No PA Required ZALEPLON No - No PA Required Zaleplon No - No PA Required Zanaflex No - No PA Required Zarontin No - No PA Required ZARXIO Yes - PA Required Zavesca No - No PA Required ZAVZPRET Varies by Plan Zegalogue Yes - PA Required ZEJULA Varies by Plan ZELAPAR No - No PA Required ZELBORAF Varies by Plan ZELSUVMI Varies by Plan Zembrace SymTouch No - No PA Required ZEMBRACE SYMTOUCH No - No PA Required Zemdri (plazomicin) Yes - PA Required Zemplar No - No PA Required ZENATANE No - No PA Required Zenpep Varies by Plan Zenzedi No - No PA Required ZEPOSIA 7-Day Starter Pack, ZEPOSIA, ZEPOSIA Starter Kit Varies by Plan ZERBAXA Yes - PA Required ZERVIATE Varies by Plan Zestoretic No - No PA Required Zestril No - No PA Required Zetia No - No PA Required ZEVTERA Yes - PA Required ZIAGEN No - No PA Required ZIANA No - No PA Required Zidovudine No - No PA Required ZIEXTENZO Yes - PA Required ZILBRYSQ Yes - PA Required Zileuton No - No PA Required ZILXI No - No PA Required ZIOPTAN No - No PA Required Ziprasidone No - No PA Required ziprasidone No - No PA Required Ziprasidone Hydrochloride No - No PA Required ziprasidone hydrochloride No - No PA Required Ziprasidone Mesylate No - No PA Required ziprasidone mesylate No - No PA Required ZIPSOR No - No PA Required ZIRGAN Varies by Plan Zithromax No - No PA Required ZITUVIMET No - No PA Required ZITUVIMET XR No - No PA Required ZITUVIO No - No PA Required ZOCOR No - No PA Required Zokinvy Varies by Plan ZOLINZA Varies by Plan zolmitriptan No - No PA Required Zolmitriptan No - No PA Required Zolmitriptan OD No - No PA Required Zoloft No - No PA Required Zolpidem No - No PA Required Zolpidem tartrate No - No PA Required Zolpidem Tartrate No - No PA Required zolpidem tartrate No - No PA Required ZOLPIDEM TARTRATE No - No PA Required Zolpidem tartrate sublingual No - No PA Required ZOMACTON Yes - PA Required ZOMIG No - No PA Required Zonalon No - No PA Required Zonegran No - No PA Required ZONISADE No - No PA Required zonisamide No - No PA Required Zonisamide No - No PA Required Zortress No - No PA Required ZORYVE No - No PA Required Zosyn No - No PA Required Zosyn in Galaxy Containers No - No PA Required Zovia 1/35 No - No PA Required Zovirax No - No PA Required ZTALMY Yes - PA Required Ztlido No - No PA Required Zubsolv No - No PA Required ZUNVEYL Varies by Plan Zurnai Yes - PA Required ZURZUVAE Varies by Plan Zyclara No - No PA Required Zydelig Varies by Plan ZYKADIA Varies by Plan Zylet No - No PA Required ZYMFENTRA Yes - PA Required ZYPITAMAG Varies by Plan ZYPREXA Relprevv No - No PA Required Zytiga No - No PA Required Zyvox No - No PA Required

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