MassHealth / Commonwealth Care Prior Authorization Forms and Clinical Guidelines

BMC HealthNet Plan members and providers can search the BMC HealthNet Plan Formulary for coverage of specific medications. If the provider feels that it is medically necessary for a member to take a medication belonging to a pharmacy program, he/she may submit a prior authorization request to the Plan by fax or online submission using the appropriate form below. 

• If the request meets criteria, BMC HealthNet Plan will cover the drug.
• If the request is denied, the member and the authorized appeal representative have the right to appeal the decision. 

Please review clinical guidelines before submitting prior authorization requests. Be sure to provide complete information on the form. Contact us with questions about guidelines, submitting forms, or to request a printed version of any guideline or form.

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Medical Drug Name	Clinical Criteria	Prior Authorization Form
Abatacept	Biologic DMARDs	Biologic DMARDs PA Form
Abilify	Antipsychotics	Antipsychotics PA Form
Abilify DiscMelt	Antipsychotics	Antipsychotics PA Form
AbobotulinumtoxinA	Botulinum Toxin	Botulinum Toxin PA Form
Abstral	Opioids	Opioids PA Form
Acanya	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Accolate	Leukotriene Modifiers	Leukotriene Modifiers PA Form
Accu-Chek	Blood Glucose Test Strips	Blood Glucose Test Strips PA Form
Aciphex	Proton Pump Inhibitors	Proton Pump Inhibitors PA Form
Actemra	Biologic DMARDs	Biologic DMARDs PA Form
Acthar Gel, H.P.	Acthar Gel	Acthar HP Gel PA Form
Actiq	Opioids	Opioids PA Form
Actonel	Bisphosphonates	Bisphosphonates PA Form
Actonel with Calcium	Bisphosphonates	Bisphosphonates PA Form
Acular	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Acular PF	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Acuvail	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Aczone	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Adalimumab	Biologic DMARDs	Biologic DMARDs PA Form
Adapalene	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Adapalene and Benzoyl Peroxide	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Adcirca	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Adderall XR	ADHD Medications	ADHD Medications PA Form
Advair Diskus	ICS-LABAs	ICS-LABAs PA Form
Advair HFA	ICS-LABAs	ICS-LABAs PA Form
Advate rAHF-PFM	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Advicor	HMG CoA Reductase Inhibitors	HMG CoA Reductase Inhibitors PA Form
Advocate	Blood Glucose Test Strips	Blood Glucose Test Strips PA Form
Akne-Mycin	Brand Name Topical Medications	Brand Name Topical PA Form
Alamast	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Alefacept	Biologic DMARDs	Biologic DMARDs PA Form
Alendronate	Bisphosphonates	Bisphosphonates PA Form
Alendronate and Cholecalciferol	Bisphosphonates	Bisphosphonates PA Form
Alfuzosin	BPH Medications	BPH Medications PA Form
Aliskiren	Direct Renin Inhibitors	Direct Renin Inhibitors PA Form
Allegra (OTC)	Antihistamines	Antihistamines PA Form
Almotriptan	Migraine-Specific Medications (Triptans)	Migraine-Specific Medications (Triptans) PA Form
Alocril	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Alomide	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Aloxi	Antiemetics	Antiemetics PA Form
Alphanate, Alphanate VWF	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Alphanine SD	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Alrex	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Altabax	Altabax	Altabax PA Form
Altoprev	HMG CoA Reductase Inhibitors	HMG CoA Reductase Inhibitors PA Form
Ambien CR	Insomnia Agents	Insomnia Agents PA Form
Ambrisentan	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Amerge	Migraine-Specific Medications (Triptans)	Migraine-Specific Medications (Triptans) PA Form
Amevive	Biologic DMARDs	Biologic DMARDs PA Form
Amitiza	Amitiza	Amitiza PA Form
Amlodipine-Atorvastatin	HMG CoA Reductase Inhibitors	HMG CoA Reductase Inhibitors PA Form
Amoxicillin-Clarithromycin-Lansoprazole	Proton Pump Inhibitors	Proton Pump Inhibitors PA Form
Amphetamine and Dextroamphetamine	ADHD Medications	ADHD Medications PA Form
Ampyra	Multiple Sclerosis	Multiple Sclerosis PA Form
Amrix	Skeletal Muscle Relaxants	Skeletal Muscle Relaxants PA Form
Amturnide	Direct Renin Inhibitors	Direct Renin Inhibitors PA Form
Anadrol	Anabolic Steroids	Anabolic Steroids PA Form
Anakinra	Biologic DMARDs	Biologic DMARDs PA Form
Antara	Fibric Acid Derivatives	Fibric Acid Derivatives PA Form
Antihemophilic Factor	Antihemophilic Medications	Antihemophilic Medications PA Form
Antihemophilic Factor-von Willebrand Factor	Antihemophilic Medications	Antihemophilic Medications PA Form
Anzemet	Antiemetics	Antiemetics PA Form
Aplenzin	Antidepressants	Antidepressants PA Form
Aprepitant	Antiemetics	Antiemetics PA Form
Aranesp	Erythropoiesis Stimulating Agents	Erythropoiesis Stimulating Agents PA Form
Arcalyst	IL-1 Antagonists	IL-1 Antagonists PA Form
Aripiprazole ODT	Antipsychotics	Antipsychotics PA Form
Armodafanil	Provigil-Nuvigil	Provigi-lNuvigil PA Form
Asenapine	Antipsychotics	Antipsychotics PA Form
Aspirin-Pravastatin	HMG CoA Reductase Inhibitors	HMG CoA Reductase Inhibitors PA Form
Astelin	Nasal Antihistamines	Nasal Antihistamines PA Form
Astepro	Nasal Antihistamines	Nasal Antihistamines PA Form
Atacand, Atacand HCT	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Atelvia	Bisphosphonates	Bisphosphonates PA Form
Atomoxetine	ADHD Medications	ADHD Medications PA Form
Atorvastatin	HMG CoA Reductase Inhibitors	HMG CoA Reductase Inhibitors PA Form
Atralin	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Avalide	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Avapro	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Avinza	Opioids	Opioids PA Form
Avita	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Avodart	BPH-Medications	BPH-Medications PA Form
Axert	Migraine-Specific Medications (Triptans)	Migraine-Specific Medications (Triptans) PA Form
AzaSite	Ophthalmic Antibiotics	Ophthalmic Antibiotics PA Form
Azelaic Acid	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Azelastine Nasal	Nasal Antihistamines	Nasal Antihistamines PA Form
Azelastine Ophthalmic	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Azelex	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Azilsartan Medoxomil	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Azithromycin Ophthalmic	Ophthalmic Antibiotics	Ophthalmic Antibiotics PA Form

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Bactroban	Brand Name Topical Medications	Brand Name Topical PA Form
Bebulin VH	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Beclomethasone Nasal	Nasal Corticosteroids	Nasal Corticosteroids PA Form
Beconase, Beconase AQ	Nasal Corticosteroids	Nasal Corticosteroids PA Form
Belimumab	Biologic DMARDs	Biologic DMARDs PA Form
BeneFIX	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Benicar, Benicar HCT	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Benlysta	Biologic DMARDs	Biologic DMARDs PA Form
Benzamycin Gel Pak	Polypills-Convenience Packaging Medications	Polypills-Convenience Packaging Medications PA Form
Benzoyl Peroxide and Clindamycin Phosphate	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Bepotastine Ophthalmic	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Bepreve	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Berinert	Hereditary Angioedema	Hereditary Angioedema PA Form
Besifloxacin Ophthalmic	Ophthalmic Antibiotics	Ophthalmic Antibiotics PA Form
Besivance	Ophthalmic Antibiotics	Ophthalmic Antibiotics PA Form
Betamethasone	Brand Name Topical Medications	Brand Name Topical PA Form
Boceprevir	Hepatitis C	Hepatitis C PA Form
Boniva	Bisphosphonates	Bisphosphonates PA Form
Bosentan	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Botox	Botulinum Toxin	Botulinum Toxin PA Form
Botulinum Toxin	Botulinum Toxin	Botulinum Toxin PA Form
Brevoxyl Kit Complex	Polypills-Convenience Packaging Medications	Polypills-Convenience Packaging Medications PA Form
Bromday	Ophthalmic-Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Bromfenac	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Bromocriptine	Antidiabetic Agents - Miscellaneous	Antidiabetic Agents - Miscellaneous PA Form
Budesonide Nasal	Nasal Corticosteroids	Nasal Corticosteroids PA Form
Buprenorphine Sublingual	Suboxone-Buprenorphine HCL	Suboxone-Buprenorphine HCL PA Form
BuPROPion Extended Release	Antidepressants	Antidepressants PA Form
Bupropion Hydrobromide	Antidepressants	Antidepressants PA Form
Butrans	Opioids	Opioids PA Form
Bystolic	Bystolic-Coreg CR-Nexiclon XR	Bystolic-Coreg CRNexiclon XR PA Form

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Caduet	HMG CoA Reductase Inhibitors	HMG CoA Reductase Inhibitors PA Form
Calcium Carbonate and Risedronate	Bisphosphonates	Bisphosphonates PA Form
Cambia	NSAIDs-COX2	NSAID-Cox2 PA Form
Canakinumab	IL-1 Antagonists	IL-1 Antagonists PA Form
Candesartan	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Capex	Brand Name Topical Medications	Brand Name Topical PA Form
Capsaicin	Qutenza	Qutenza PA Form
Cardura XL	BPH Medications	BPH Medications PA Form
Carimune	IVIG, IgG	Medical Benefit PA Form
Carisoprodol	Skeletal Muscle Relaxants	BPH Medications PA Form
Carvidilol Extened Release	Bystolic-Coreg CR-Nexiclon XR	Bystolic-Coreg CRNexiclon XR PA Form
Celebrex	NSAIDs-COX2	NSAID-Cox2 PA Form
Celecoxib	NSAIDs-COX2	NSAID-Cox2 PA Form
Certolizumab	Biologic DMARDs	Biologic DMARDs PA Form
Cervarix	HPV Vaccines	Medical Benefit PA Form
Cesamet	Antiemetics	Antiemetics PA Form
Cetirizine	Antihistamines	Antihistamines PA Form
cetirizine (OTC)	Antihistamines	Antihistamines PA Form
Cialis	BPH Medications	BPH Medications
Ciclesonide Nasal	Nasal Corticosteroids	Nasal Corticosteroids PA Form
Ciclopirox Topical	Antifungal Agents	Antifungal Agents PA Form
Ciloxan Ointment	Ophthalmic Antibiotics	Ophthalmic Antibiotics PA Form
Cimzia	Biologic DMARDs	Biologic DMARDs PA Form
Cinryze	Hereditary Angioedema	Hereditary Angioedema PA Form
Ciprofloxacin	Ophthalmic Antibiotics	Ophthalmic Antibiotics PA Form
Claravis	Acne and Rosacea (Oral)	Acne and Rosacea (Oral) PA Form
Clarinex, Clarinex-D, Clarinex Redi-Tabs	Antihistamines	Antihistamines PA Form
CleverChek	Blood Glucose Test Strips	Blood Glucose Test Strips PA Form
Clindamycin/tretinoin	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Clindareach Kit	Polypills-Convenience Packaging Medications	Polypills-Convenience Packaging Medications PA Form
Clobetaplus Kit	Polypills-Convenience Packaging Medications	Polypills-Convenience Packaging Medications PA Form
Clobex	Brand Name Topical Medications	Brand Name Topical PA Form
Clonidine Hydrochloride	ADHD Medications	ADHD Medications PA Form
Coagulation factor IX	Antihemophilic Medications	Antihemophilic Medications PA Form
Coagulation factor VIIa	Antihemophilic Medications	Antihemophilic Medications PA Form
Collagenase Clostridium Histolyticum	Xiaflex	Xiaflex PA Form
Colyte	Brand Name PEG Products	Brand Name PEG Products PA Form
Complement C1esterase inhibitor	Hereditary Angioedema	Hereditary Angioedema PA Form
Concerta	ADHD Medications	ADHD Medications PA Form
Condylox	Brand Name Topical Medications	Brand Name Topical PA Form
Copegus	Hepatitis C	Hepatitis C PA Form
Coreg CR	Bystolic-Coreg CR-Nexiclon XR	Bystolic-Coreg CRNexiclon XR PA Form
Corifact	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Corticotropin	Acthar Gel	Acthar HP Gel PA Form
Cozaar	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Crestor	HMG CoA Reductase Inhibitors	HMG CoA Reductase Inhibitors PA Form
Cromolyn	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Cutivate	Brand Name Topical Medications	Brand Name Topical PA Form
Cyclobenzaprine	Skeletal Muscle Relaxants	Skeletal Muscle Relaxants PA Form
Cyclobenzaprine Extended-Release	Skeletal Muscle Relaxants	Skeletal Muscle Relaxants PA Form
Cycloset	Antidiabetic Agents - Miscellaneous	Antidiabetic Agents - Miscellaneous PA Form
Cyclosporine Ophthalmic	Restasis	Restasis PA Form
Cymbalta	Antidepressants	Antidepressants PA Form

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Dabigatran	Pradaxa	Pradaxa PA Form
Dalfampridine	Multiple Sclerosis	Multiple Sclerosis PA Form
Dapsone	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Darbepoietin	Erythropoiesis Stimulating Agents	Erythropoiesis Stimulating Agents PA Form
Daytrana	ADHD Medications	ADHD Medications PA Form
Deferasirox	Exjade	Exjade PA Form
Degarelix	GnRH Agents	GnRH Agents PA Form
Denosumab	Forteo-Prolia-Xgeva	Forteo-Prolia-Xgeva PA Form
Depot Ped	GnRH Agents	GnRH Agents PA Form
Derma-Smooth FS (Body + Scalp Oil)	Brand Name Topical Medications	Brand Name Topical PA Form
Dermatop E	Brand Name Topical Medications	Brand Name Topical PA Form
Desirudin	Iprivask	Iprivask PA Form
Desloratadine w/wo Pseudoephedrine	Antihistamines	Antihistamines PA Form
Desonate	Brand Name Topical Medications	Brand Name Topical PA Form
Desonide	Brand Name Topical Medications	Brand Name Topical PA Form
Desvenlafaxine	Antidepressants	Antidepressants PA Form
Dex	Blood Glucose Test Strips	Blood Glucose Test Strips PA Form
Dexilant	Proton Pump Inhibitors	Proton Pump Inhibitors PA Form
Dexlansoprazole	Proton Pump Inhibitors	Proton Pump Inhibitors PA Form
Dialyvite	Brand Name Prescription Vitamins	Brand Name Vitamins PA Form
Diclofenac Gel	NSAIDs-COX2	NSAID-Cox2 PA Form
Diclofenac Sodium Topical Solution	NSAIDs-COX2	NSAID-Cox2 PA Form
Diclofenac Topical	NSAIDs-COX2	NSAID-Cox2 PA Form
Differin	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Dificid	Antibiotics (systemic)	Antibiotics (systemic) PA Form
Difluprednate Ophthalmic	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Diovan, Diovan HCT	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Diprosone	Brand Name Topical Medications	Brand Name Topical PA Form
Dolasetron	Antiemetics	Antiemetics PA Form
Doxazosin Extended-Release	BPH Medications	BPH Medications PA Form
Doxepin	Insomnia Agents	Insomnia Agents PA Form
Doxycycline Delayed Release	Acne and Rosacea (Oral)	Acne and Rosacea (Oral) PA Form
Dronabinol	Antiemetics	Antiemetics PA Form
Duac CS	Polypills-Convenience Packaging Medications	Polypills-Convenience Packaging Medications PA Form
Dulera	ICS-LABAs	ICS-LABAs PA Form
Duloxetine	Antidepressants	Antidepressants PA Form
Durezol	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Dutasteride	BPH Medications	BPH Medications PA Form
Dysport	Botulinum Toxin	Botulinum Toxin PA Form

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Ecallantide	Hereditary Angioedema	Hereditary Angioedema PA Form
Edarbi	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Edluar	Insomnia Agents	Insomnia Agents PA Form
Efalizumab	Biologic DMARDs	Biologic DMARDs PA Form
Effexor XR	Antidepressants	Antidepressants PA Form
Egrifta	Egrifta	Antidepressants PA Form
Elestat	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Eletriptan	Migraine-Specific Medications (Triptans)	Migraine-Specific Medications (Triptans) PA Form
Elidel	Atopic Dermatitis	Atopic Dermatitis PA Form
Eligard	GnRH Agents	GnRH Agents PA Form
Elite	Blood Glucose Test Strips	Blood Glucose Test Strips PA Form
Eltrombopag	Promacta	Promacta PA Form
Emadine	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Embeda	Opioids	Opioids PA Form
Emedastine Ophthalmic	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Emend	Antiemetics	Antiemetics PA Form
Emsam	Antidepressants	Antidepressants PA Form
Enbrel	Biologic DMARDs	Biologic DMARDs PA Form
Epiduo	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Epinastine	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Epogen	Erythropoiesis Stimulating Agents	Erythropoiesis Stimulating Agents PA Form
Epoprostenol	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Eprosartan	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Ery-Pads	Brand Name Topical Medications	Brand Name Topical PA Form
Erythromycin	Brand Name Topical Medications	Brand Name Topical PA Form
Erythropoietin	Erythropoiesis Stimulating Agents	Erythropoiesis Stimulating Agents PA Form
Esomeprazole	Proton Pump Inhibitors	Proton Pump Inhibitors PA Form
Eszopiclone	Insomnia Agents	Insomnia Agents PA Form
Etanercept	Biologic DMARDs	Biologic DMARDs PA Form
Euflexxa	Viscosupplements	Viscosupplements PA Form
Evoclin	Brand Name Topical Medications	Brand Name Topical PA Form
Exalgo	Opioids	Opioids PA Form
Exjade	Exjade	Exjade PA Form
Extina	Brand Name Topical Medications	Brand Name Topical PA Form

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Factor IX Complex	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Fanapt	Antipsychotics	Antipsychotics PA Form
Fazaclo	Antipsychotics	Antipsychotics PA Form
Febuxostat	Anti-Gout Medications	Anti-Gout Medications PA Form
Feiba VH, NF	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Fenofibrate (Acid, Micronized)	Fibric Acid Derivatives	Fibric Acid Derivatives PA Form
Fenoglide	Fibric Acid Derivatives	Fibric Acid Derivatives PA Form
Fentanyal OT Lozenge	Opioids	Opioids PA Form
Fentanyl Buccal	Opioids	Opioids PA Form
Fentanyl Buccal Soluble Film	Opioids	Opioids PA Form
Fentora	Opioids	Opioids PA Form
Fexmid	Skeletal Muscle Relaxants	Skeletal Muscle Relaxants PA Form
Fexofenadine/pseudoephedrine 12 Hr	Antihistamines	Antihistamines PA Form
Fexofenadine w/wo Pseudoephedrine	Antihistamines	Antihistamines PA Form
Fibricor	Fibric Acid Derivatives	Fibric Acid Derivatives PA Form
Finacea	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Fingolimod	Multiple Sclerosis	Multiple Sclerosis PA Form
Firmagon	GnRH Agents	GnRH Agents PA Form
FLBgamma DIF	IVIG, IgG	Medical Benefit PA Form
Flebogamma	IVIG, IgG	Medical Benefit PA Form
Flector Patch	NSAIDs-COX2	NSAID-Cox2 PA Form
Flolan	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Flunisolide Nasal	Nasal Corticosteroids	Nasal Corticosteroids PA Form
Fluocinolone	Brand Name Topical Medications	Brand Name Topical PA Form
Fluticasone	Brand Name Topical Medications	Brand Name Topical PA Form
Fluticasone Nasal	Nasal Corticosteroids	Nasal Corticosteroids PA Form
Fluticasone-Salmeterol	ICS-LABAs	ICS-LABAs PA Form
Fluvastatin	HMG CoA Reductase Inhibitors	HMG CoA Reductase Inhibitors PA Form
Fluvoxamine Extended-Release Capsules	Antidepressants	Antidepressants PA Form
Formoterol and Mometasone	ICS-LABAs	ICS-LABAs PA Form
FortaMet	Antidiabetic Agents - Miscellaneous	Antidiabetic Agents - Miscellaneous PA Form
Forteo	Forteo-Prolia-Xgeva	Forteo-Prolia-Xgeva PA Form
Fosamax, Plus D, Solution	Bisphosphonates	Bisphosphonates PA Form

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GamaSTAN	IVIG, IgG	Medical Benefit PA Form
Gammagard	IVIG, IgG	Medical Benefit PA Form
Gammar-P	IVIG, IgG	Medical Benefit PA Form
Gamunex	IVIG, IgG	Medical Benefit PA Form
Gardasil	HPV Vaccines	Medical Benefit PA Form
Gatifloxacin	Ophthalmic Antibiotics	Ophthalmic Antibiotics PA Form
Gelnique	Urinary Antispasmodic Medications	Urinary Antispasmodic Medication PA Form
Genotropin	Growth Hormones and IGF-1	Growth Hormones and IGF1 PA Form
Gilenya	Multiple Sclerosis	Multiple Sclerosis PA Form
Glumetza	Antidiabetic Agents - Miscellaneous	Antidiabetic Agents - Miscellaneous PA Form
Golimumab	Biologic DMARDs	Biologic DMARDs PA Form
Golytely	Brand Name PEG Products	Brand Name PEG Products PA Form
Goserelin	GnRH Agents	GnRH Agents PA Form
Gralise	Anticonvulsants	Anticonvulsants-PA-Form
Granisetron	Antiemetics	Antiemetics PA Form
Granisetron Transdermal Patch	Antiemetics	Antiemetics PA Form
Guanfacine	ADHD Medications	ADHD Medications PA Form

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Halobetasol	Brand Name Topical Medications	Brand Name Topical PA Form
Halog (E)	Brand Name Topical Medications	Brand Name Topical PA Form
Helidac	Polypills-Convenience Packaging Medications	Polypills-Convenience Packaging Medications PA Form
Helixate FS	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Hemofil-M	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Histrelin	GnRH Agents	GnRH Agents PA Form
Hizentra	IVIG, IgG	Medical Benefit PA Form
Horizant	Anticonvulsants	Anticonvulsants-PA-Form
Human Papillomavirus	HPV Vaccines	Medical Benefit PA Form
Humate-P	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Humatrope	Growth Hormones and IGF-1	Growth Hormones and IGF1 PA Form
Humira	Biologic DMARDs	Biologic DMARDs PA Form
Hyalgan	Viscosupplements	Viscosupplements PA Form
Hyaluronan	Viscosupplements	Viscosupplements PA Form
Hyaluronate Sodium Injection	Viscosupplements	Viscosupplements PA Form
Hyate:C	Antihemophilic Medications	Antihemophilic Medications PA Form
Hydrochlorothiazide and Irbesartan	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Hydrochlorothiazide and Losartan	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Hydrocortisone	Brand Name Topical Medications	Brand Name Topical PA Form
Hydromorphone Hydrochloride	Opioids	Opioids PA Form
Hydroxyprogesterone Caproate	Makena	Makena PA Form
Hylan G-F 20	Viscosupplements	Viscosupplements PA Form
Hyzaar	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form

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Ibandronate	Bisphosphonates	Bisphosphonates PA Form
Ilaris	IL-1 Antagonists	IL-1 Antagonists PA Form
Iloperidone	Antipsychotics	Antipsychotics PA Form
Iloprost	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Imipramine	Antidepressants	Antidepressants PA Form
Imiquimod	Topical Immunomodulators	Topical Immunomodulators PA Form
Imitrex Stardose	Migraine-Specific Medications (Triptans)	Migraine-Specific Medications (Triptans) PA Form
Immune Globulin IV/IM	IVIG, IgG	Medical Benefit PA Form
Immunoglobulin G (IgG)	IVIG, IgG	Medical Benefit PA Form
Incivek	Hepatitis C	Hepatitis C PA Form
IncobotulinumtoxinA	Botulinum Toxin	Botulinum Toxin PA Form
Increlex	Growth Hormones and IGF-1	Growth Hormones and IGF1 PA Form
Infergen	Hepatitis C	Hepatitis C PA Form
Infliximab	Biologic DMARDs	Biologic DMARDs PA Form
Interferon Alfa-2a	Hepatitis C	Hepatitis C PA Form
Interferon Alfa-2b	Hepatitis C	Hepatitis C PA Form
Interferon-Alfacon-1	Hepatitis C	Hepatitis C PA Form
Intuniv	ADHD Medications	ADHD Medications PA Form
Invega	Antipsychotics	Antipsychotics PA Form
Iprivask	Iprivask	Iprivask PA Form
Iquix	Ophthalmic Antibiotics	Ophthalmic Antibiotics PA Form
Irbesartan	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Isocarboxazid	Antidepressants	Antidepressants PA Form
Isotretinoin	Acne and Rosacea (Oral)	Acne and Rosacea (Oral) PA Form
Itraconazole	Antifungal Agents	Antifungal Agents PA Form
Iveegam En	IVIG, IgG	Medical Benefit PA Form

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Jalyn	BPH Medications	BPH Medications PA Form
Janumet	DPP-4 Inhibitors	DPP4 Inhibitors PA Form
Januvia	DPP-4 Inhibitors	DPP4 Inhibitors PA Form

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Kadian	Opioids	Opioids PA Form
Kalbitor	Hereditary Angioedema	Hereditary Angioedema PA Form
Kapvay	ADHD Medications	ADHD Medications PA Form
Kenalog	Brand Name Topical Medications	Brand Name Topical PA Form
Keppra XR	Anticonvulsants	Anticonvulsants-PA-Form
Ketoconazole	Brand Name Topical Medications	Brand Name Topical PA Form
Ketorolac	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Ketotifen OTC	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Kineret	Biologic DMARDs	Biologic DMARDs PA Form
Koate-DVI	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Kogenate FS	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Kombiglyze XR	DPP-4 Inhibitors	DPP4 Inhibitors PA Form
Kytril	Antiemetics	Antiemetics PA Form

L

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Lacosamide	Anticonvulsants	Anticonvulsants-PA-Form
Lamictal ODT	Anticonvulsants	Anticonvulsants-PA-Form
Lamisil	Antifungal Agents	Antifungal Agents PA Form
Lansoprazole	Proton Pump Inhibitors	Proton Pump Inhibitors PA Form
Lastacraft	Lastacraft	Antipsychotics PA Form
Latuda	Antipsychotics	Antipsychotics PA Form
Lazanda	Opioids	Opioids PA Form
Lescol, Lescol XL	HMG CoA Reductase Inhibitors	HMG CoA Reductase Inhibitors PA Form
Letairis	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Leuprolide	GnRH Agents	GnRH Agents PA Form
Levalbuterol Tartrate Inhalation Aerosol	Xopenex-Xopenex HFA	Xopenex-Xopenex HFA PA Form
Levetiracetam	Anticonvulsants	Anticonvulsants-PA-Form
Levocetirizine Dihydrochloride	Antihistamines	Antihistamines PA Form
Levofloxacin	Ophthalmic Antibiotics	Ophthalmic Antibiotics PA Form
Lexapro	Antidepressants	Antidepressants PA Form
Linezolid	Antibiotics (systemic)	Zyvox PA Form
Lipitor	HMG CoA Reductase Inhibitors	HMG CoA Reductase Inhibitors PA Form
Lipofen	Fibric Acid Derivatives	Fibric Acid Derivatives PA Form
Liraglutide	Victoza	Victoza PA Form
Lisdexamfetamine	ADHD Medications	ADHD Medications PA Form
Livalo	HMG CoA Reductase Inhibitors	HMG CoA Reductase Inhibitors PA Form
Losartan	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Loteprednol Ophthalmic	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Loteprednol/Tobramycin	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Lovastatin-Niacin	HMG CoA Reductase Inhibitors	HMG CoA Reductase Inhibitors PA Form
Lovaza	Lovaza	Lovaza PA Form
Lubiprostone	Amitiza	Amitiza PA Form
Lunesta	Insomnia Agents	Insomnia Agents PA Form
Lupron, Lupron Depot, Lupron Depot Ped	GnRH Agents	GnRH Agents PA Form
Luvox CR	Antidepressants	Antidepressants PA Form
Luxiq	Brand Name Topical Medications	Brand Name Topical PA Form
Lyrica	Anticonvulsants	Anticonvulsants-PA-Form

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Makena	Makena	Makena PA Form
Marinol	Antiemetics	Antiemetics PA Form
Mariviroc	Selzentry	Selzentry PA Form
Marplan	Antidepressants	Antidepressants PA Form
Maxalt	Migraine-Specific Medications (Triptans)	Migraine-Specific Medications (Triptans) PA Form
Mecasermin	Growth Hormones and IGF-1	Growth Hormones and IGF1 PA Form
Mefenamic Acid	NSAIDs-COX2	NSAID-Cox2 PA Form
Metaxolone	Skeletal Muscle Relaxants	Skeletal Muscle Relaxants PA Form
Metformin and Saxagliptin	DPP-4 Inhibitors	DPP4 Inhibitors PA Form
Metformin-Sitagliptin	DPP-4 Inhibitors	DPP4 Inhibitors PA Form
Methylnaltrexone	Relistor	Relistor PA Form
Methylphenidate (Transdermal)	ADHD Medications	ADHD Medications PA Form
Metoclopramide	Metozolv ODT	Metozolv ODT PA Form
Metozolv ODT	Metozolv ODT	Metozolv ODT PA Form
Metrogel 1%	Brand Name Topical Medications	Brand Name Topical PA Form
Metronidazole	Brand Name Topical Medications	Brand Name Topical PA Form
Micardis, Micardis HCT	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Miconazole	Antifungal Agents	Antifungal Agents PA Form
Milnacipran	Savella	Savella PA Form
Minocycline HCL Extended Release	Acne and Rosacea (Oral)	Acne and Rosacea (Oral) PA Form
Mirapex ER	Antiparkinson Agents	Antiparkinson Agents PA Form
Modafinil	Provigil-Nuvigil	Provigi-lNuvigil PA Form
Mometasone Nasal	Nasal Corticosteroids	Nasal Corticosteroids PA Form
Monarc-M	Antihemophilic Medications	Antihemophilic Medications PA Form
Monoclate-P	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Mononine	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Montelukast	Leukotriene Modifiers	Leukotriene Modifiers PA Form
Morphine and Naltrexone	Opioids	Opioids PA Form
Morphine Controlled-Release	Opioids	Opioids PA Form
Moxeza	Moxeza	Moxeza
Moxifloxacin Ophthalmic	Ophthalmic Antibiotics	Ophthalmic Antibiotics PA Form
Mozobil	Mozobil	Mozobil PA Form
Mupirocin	Brand Name Topical Medications	Brand Name Topical PA Form
Myobloc	Botulinum Toxin	Botulinum Toxin PA Form

N

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Nabilone	Antiemetics	Antiemetics PA Form
Naltrexone	Vivitrol	Vivitrol PA Form
Naproxen and Esomeprazole Magnesium	Proton Pump Inhibitors	Proton Pump Inhibitors PA Form
Nardil	Antidepressants	Antidepressants PA Form
Nasacort, Nasacort AQ	Nasal Corticosteroids	Nasal Corticosteroids PA Form
Nasonex	Nasal Corticosteroids	Nasal Corticosteroids PA Form
Nebivolol	Bystolic-Coreg CR-Nexiclon XR	Bystolic-Coreg CRNexiclon XR PA Form
Nedocromil	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Nepafenac Ophthalmic	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Nevanac	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Nexiclon XR	Bystolic-Coreg CR-Nexiclon XR	Bystolic-Coreg CRNexiclon XR PA Form
Nexium	Proton Pump Inhibitors	Proton Pump Inhibitors PA Form
Nizoral AD	Brand Name Topical Medications	Brand Name Topical PA Form
Norditropin	Growth Hormones and IGF-1	Growth Hormones and IGF1 PA Form
Noritate 1%	Brand Name Topical Medications	Brand Name Topical PA Form
NovoSeven, NovoSeven RT	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Nplate	Nplate	Nplate PA Form
Nucynta	Opioids	Opioids PA Form
Nulytely	Brand Name PEG Products	Brand Name PEG Products PA Form
Nutropin	Growth Hormones and IGF-1	Growth Hormones and IGF1 PA Form
Nuvigil	Provigil-Nuvigil	Provigi-lNuvigil PA Form

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Octagam	IVIG, IgG	Medical Benefit PA Form
Olanzapine ODT	Antipsychotics	Antipsychotics PA Form
Oleptro	Antidepressants	Antidepressants PA Form
Olmesartan	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Olopatadine Nasal	Nasal Antihistamines	Nasal Antihistamines PA Form
Olopatadine Opthalmic	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Omalizumab	Xolair	Xolair PA Form
Omega-3-Acid Ethyl Esters	Lovaza	Lovaza PA Form
Omeprazole	Proton Pump Inhibitors	Proton Pump Inhibitors PA Form
Omnaris	Nasal Corticosteroids	Nasal Corticosteroids PA Form
Omnitrope	Growth Hormones and IGF-1	Growth Hormones and IGF1 PA Form
Ondansetron	Antiemetics	Antiemetics PA Form
One Touch	Blood Glucose Test Strips	Blood Glucose Test Strips PA Form
Onglyza	DPP-4 Inhibitors	DPP4 Inhibitors PA Form
Onsolis	Opioids	Opioids PA Form
Opana, Opana ER	Opioids	Opioids PA Form
Optivar	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Oracea	Acne and Rosacea (Oral)	Acne and Rosacea (Oral) PA Form
Oravig	Antifungal Agents	Antifungal Agents PA Form
Orencia	Biologic DMARDs	Biologic DMARDs PA Form
Orphen CDP	Skeletal Muscle Relaxants	Skeletal Muscle Relaxants PA Form
Orphenadrine/Aspirin/Caffeine	Skeletal Muscle Relaxants	Skeletal Muscle Relaxants PA Form
Orthovisc	Viscosupplements	Viscosupplements PA Form
Oxandrolone	Anabolic Steroids	Anabolic Steroids PA Form
Oxybutynin	Urinary Antispasmodic Medications	Iprivask PA Form
Oxycontin	Opioids	Opioids PA Form
Oxandrolone	Anabolic Steroids	Anabolic Steroids PA Form
Oxymorphone Extended Release Tablet	Opioids	Opioids PA Form
Oxymorphone Immediate Release Tablet	Opioids	Opioids PA Form
Oxymorphone Tablet	Opioids	Opioids PA Form
Oxytrol	Urinary Antispasmodic Medications	Urinary Antispasmodics PA Form

P

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Paliperidone	Antipsychotics	Antipsychotics PA Form
Palivizumab	Synagis	Synagis PA Form
Palonosetron Injection	Antiemetics	Antiemetics PA Form
Pandel	Brand Name Topical Medications	Brand Name Topical PA Form
Panglobulin NF	IVIG, IgG	Medical Benefit PA Form
Pantoprazole	Proton Pump Inhibitors	Proton Pump Inhibitors PA Form
Paroxetine Extended Release	Antidepressants	Antidepressants PA Form
Pataday	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Patanase	Nasal Antihistamines	Nasal Antihistamines PA Form
Patonol	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Paxil CR	Antidepressants	Antidepressants PA Form
PEG Interferon Alfa-2a	Hepatitis C	Hepatitis C PA Form
PEG Interferon Alfa-2b	Hepatitis C	Hepatitis C PA Form
Pegasys	Hepatitis C	Hepatitis C PA Form
PEG-Intron	Hepatitis C	Hepatitis C PA Form
Pemirolast	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Pennsaid	NSAIDs-COX2	NSAID-Cox2 PA Form
Pexeva	Antidepressants	Antidepressants PA Form
Phenelzine	Antidepressants	Antidepressants PA Form
Pimecrolimus Topical	Atopic Dermatitis	Atopic Dermatitis PA Form
Pitavastatin	HMG CoA Reductase Inhibitors	HMG CoA Reductase Inhibitors PA Form
Plerixafor	Mozobil	Mozobil PA Form
Polygam S/D	IVIG, IgG	Medical Benefit PA Form
Ponstel	NSAIDs-COX2	NSAID-Cox2 PA Form
Pradaxa	Anticoagulants (Oral)	Anticoagulants (Oral) PA Form
Pramipexole	Antiparkinson Agents	Antiparkinson Agents PA Form
Pravigard Pac	HMG CoA Reductase Inhibitors	HMG CoA Reductase Inhibitors PA Form
Prednicarbate	Brand Name Topical Medications	Brand Name Topical PA Form
Pregabalin	Anticonvulsants	Anticonvulsants-PA-Form
Prenatal	Brand Name Prescription Vitamins	Brand Name Vitamins PA Form
Prevacid	Proton Pump Inhibitors	Proton Pump Inhibitors PA Form
Prevacid NapraPac	Polypills-Convenience Packaging Medications	Polypills-Convenience Packaging Medications PA Form
Prevpac	Polypills-Convenience Packaging Medications	Polypills-Convenience Packaging Medications PA Form
Pristiq	Antidepressants	Antidepressants PA Form
Procrit	Erythropoiesis Stimulating Agents	Erythropoiesis Stimulating Agents PA Form
Profilnine SD	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Prolia	Forteo-Prolia-Xgeva	Forteo-Prolia-Xgeva PA Form
Promacta	Promacta	Promacta PA Form
Proplex T	Antihemophilic Medications	Antihemophilic Medications PA Form
Protopic	Atopic Dermatitis	Atopic Dermatitis PA Form
Protriptyline	Antidepressants	Antidepressants PA Form
Protropin	Growth Hormones and IGF-1	Growth Hormones and IGF1 PA Form
Provigil	Provigil-Nuvigil	Provigi-lNuvigil PA Form
Prozac Weekly	Antidepressants	Antidepressants PA Form
Pylera	Polypills-Convenience Packaging Medications	Polypills-Convenience Packaging Medications PA Form

Q

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Quixin	Ophthalmic Antibiotics	Ophthalmic Antibiotics PA Form
Qutenza	Qutenza	Qutenza PA Form

R

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Rabeprazole	Proton Pump Inhibitors	Proton Pump Inhibitors PA Form
Ramelteon	Insomnia Agents	Insomnia Agents PA Form
Ranexa	Ranexa	Ranexa PA Form
Ranolazine Extended Release	Ranexa	Ranexa PA Form
Rapaflo	BPH Medications	BPH Medications PA Form
Raptiva	Biologic DMARDs	Biologic DMARDs PA Form
Rebetol	Hepatitis C	Hepatitis C PA Form
Rebetron	Hepatitis C	Hepatitis C PA Form
Reclast	Bisphosphonates	Bisphosphonates PA Form
Recombinate	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Refacto	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form
Relistor	Relistor	Relistor PA Form
Relpax	Migraine-Specific Medications (Triptans)	Migraine-Specific Medications (Triptans) PA Form
Remicade	Biologic DMARDs	Biologic DMARDs PA Form
Remodulin	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Requip XL	Antiparkinson Agents	Antiparkinson Agents PA Form
Restasis	Restasis	Restasis PA Form
Retapamulin Ointment	Altabax	Altabax PA Form
Retin-A Micro	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Revatio	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Rhinocort Aqua	Nasal Corticosteroids	Nasal Corticosteroids PA Form
Ribapak	Hepatitis C	Hepatitis C PA Form
Ribatab	Hepatitis C	Hepatitis C PA Form
Ribavirin	Hepatitis C	Hepatitis C PA Form
Ribavirin and Interferon Alfa-2b	Hepatitis C	Hepatitis C PA Form
Rilonacept	IL-1 Antagonists	IL-1 Antagonists PA Form
Risedronate	Bisphosphonates	Bisphosphonates PA Form
Risperdal M	Antipsychotics	Antipsychotics PA Form
Risperidone ODT	Antipsychotics	Antipsychotics PA Form
Rituxan	Biologic DMARDs	Biologic DMARDs PA Form
Rituximab	Biologic DMARDs	Biologic DMARDs PA Form
Rizatriptan	Migraine-Specific Medications (Triptans)	Migraine-Specific Medications (Triptans) PA Form
Roferon-A	Hepatitis C	Hepatitis C PA Form
Romiplostim	Nplate	Nplate PA Form
Ropinirole Extended-Release	Antiparkinson Agents	Antiparkinson Agents PA Form
Rosuvastatin	HMG CoA Reductase Inhibitors	HMG CoA Reductase Inhibitors PA Form
Rozerem	Insomnia Agents	Insomnia Agents PA Form
Rybix-ODT	Tramadol ER-Ryzolt	Tramadol ERRyzolt PA Form
Ryzolt	Tramadol ER-Ryzolt	Tramadol ERRyzolt PA Form

S

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Sabril	Anticonvulsants	Anticonvulsants-PA-Form
Saizen	Growth Hormones and IGF-1	Growth Hormones and IGF1 PA Form
Samsca	Samsca	Samsca PA Form
Sancuso	Antiemetics	Antiemetics PA Form
Saphris	Antipsychotics	Antipsychotics PA Form
Sarafem	Antidepressants	Antidepressants PA Form
Savella	Savella	Savella PA Form
Saxagliptin	DPP-4 Inhibitors	DPP4 Inhibitors PA Form
Selegiline Transdermal	Antidepressants	Antidepressants PA Form
Selzentry	Selzentry	Selzentry PA Form
Seroquel XR	Antipsychotics	Antipsychotics PA Form
Sildenafil Citrate	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Silenor	Insomnia Agents	Insomnia Agents PA Form
Silodosin	BPH Medications	BPH Medications PA Form
Simponi	Biologic DMARDs	Biologic DMARDs PA Form
Singulair	Leukotriene Modifiers	Leukotriene Modifiers PA Form
Sitagliptin	DPP-4 Inhibitors	DPP4 Inhibitors PA Form
Skelaxin	Skeletal Muscle Relaxants	Skeletal Muscle Relaxants PA Form
Solodyn	Acne and Rosacea (Oral)	Acne and Rosacea (Oral) PA Form
Soma	Skeletal Muscle Relaxants	Skeletal Muscle Relaxants PA Form
Somatropin	Growth Hormones and IGF-1	Growth Hormones and IGF1 PA Form
Sonata	Insomnia Agents	Insomnia Agents PA Form
Sporanox	Antifungal Agents	Antifungal Agents PA Form
Sprix	NSAIDs-COX2	NSAID-Cox2 PA Form
Stavzor	Anticonvulsants	Anticonvulsants-PA-Form
Stelara	Biologic DMARDs	Biologic DMARDs PA Form
Strattera	ADHD Medications	ADHD Medications PA Form
Suboxone Film	Suboxone-Buprenorphine HCL	Suboxone-Buprenorphine HCL PA Form
Subutex	Suboxone-Buprenorphine HCL	Suboxone-Buprenorphine HCL PA Form
Sumatriptan Nasal Spray	Migraine-Specific Medications (Triptans)	Migraine-Specific Medications (Triptans) PA Form
Sumavel DosePro	Migraine-Specific Medications (Triptans)	Migraine-Specific Medications (Triptans) PA Form
Supartz	Viscosupplements	Viscosupplements PA Form
Supprelin LA	GnRH Agents	GnRH Agents PA Form
Surmontil	Antidepressants	Antidepressants PA Form
Symbicort	ICS-LABAs	ICS-LABAs PA Form
Synagis	Synagis	Synagis PA Form
Synvisc	Viscosupplements	Viscosupplements PA Form
Synvisc-One	Viscosupplements	Viscosupplements PA Form

T

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Tacrolimus Topical	Atopic Dermatitis	Atopic Dermatitis PA Form
Tapentadol	Opioids	Opioids PA Form
Tazarotene	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Tazorac	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Tekamlo	Direct Renin Inhibitors	Direct Renin Inhibitors PA Form
Tekturna	Direct Renin Inhibitors	Direct Renin Inhibitors PA Form
Tekturna HCT	Direct Renin Inhibitors	Direct Renin Inhibitors PA Form
Telaprevir	Hepatitis C	Hepatitis C PA Form
Telmisartan	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Terbinafine Oral	Antifungal Agents	Antifungal Agents PA Form
Teriparatide	Forteo-Prolia-Xgeva	Forteo-Prolia-Xgeva PA Form
Teveten, Teveten HCT	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Tev-Tropin	Growth Hormones and IGF-1	Growth Hormones and IGF1 PA Form
Tizanadine	Skeletal Muscle Relaxants	Skeletal Muscle Relaxants PA Form
Tobradex ST	Tobradex ST	Tobradex ST
Tocilizumab	Biologic DMARDs	Biologic DMARDs PA Form
Tofranil-PM	Antidepressants	Antidepressants PA Form
Tolvaptan	Samsca	Samsca PA Form
Tracleer	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Tramadol Extended-release	Tramadol ER-Ryzolt	Tramadol ERRyzolt PA Form
Trazodone Hydrochloride	Antidepressants	Antidepressants PA Form
Trelstar Depot	GnRH Agents	GnRH Agents PA Form
Trelstar Depot	GnRH Agents	GnRH Agents PA Form
Treprostinil	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Tretin X Gel Kit	Polypills-Convenience Packaging Medications	Polypills-Convenience Packaging Medications PA Form
Tretinoin	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Tretinoin Topical (TRET In Oin)	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Tazorac	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Treximet	Migraine-Specific Medications (Triptans)	Migraine-Specific Medications (Triptans) PA Form
Triamcinolone	Brand Name Topical Medications	Brand Name Topical PA Form
Triamcinolone Nasal	Nasal Corticosteroids	Nasal Corticosteroids PA Form
Tribenzor	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Tricor	Fibric Acid Derivatives	Fibric Acid Derivatives PA Form
Triglide	Fibric Acid Derivatives	Fibric Acid Derivatives PA Form
Trilipix	Fibric Acid Derivatives	Fibric Acid Derivatives PA Form
Trimipramine	Antidepressants	Antidepressants PA Form
Trelstar Depot	GnRH Agents	GnRH Agents PA Form
Tyvaso	Pulmonary Hypertension	Pulmonary Hypertension PA Form

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Uloric	Anti-Gout Medications	Anti-Gout Medications PA Form
Ultram ER	Tramadol ER-Ryzolt	Tramadol ERRyzolt PA Form
Uroxatral	BPH Medications	BPH Medications PA Form
Ustekinumab	Biologic DMARDs	Biologic DMARDs PA Form

V

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Valproic Acid	Anticonvulsants	Anticonvulsants-PA-Form
Valsartan	Angiotensin Receptor Antagonists	Angiotensin Receptor Antagonists PA Form
Valturna	Direct Renin Inhibitors	Direct Renin Inhibitors PA Form
Vantas	GnRH Agents	GnRH Agents PA Form
Veletri	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Veltin	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Venoglobulin	IVIG, IgG	Medical Benefit PA Form
Ventavis	Pulmonary Hypertension	Pulmonary Hypertension PA Form
Veramyst	Nasal Corticosteroids	Nasal Corticosteroids PA Form
Verdeso	Brand Name Topical Medications	Brand Name Topical PA Form
Victoza	Victoza	Victoza PA Form
Victrelis	Hepatitis C	Hepatitis C PA Form
Vigabatrin	Anticonvulsants	Anticonvulsants-PA-Form
Vigamox	Ophthalmic Antibiotics	Ophthalmic Antibiotics PA Form
Viibryd	Antidepressants	Antidepressants PA Form
Vimovo	NSAIDs-COX2	NSAID-Cox2 PA Form
Vimpat	Anticonvulsants	Anticonvulsants-PA-Form
Vivactil	Antidepressants	Antidepressants PA Form
Vivaglobulin	IVIG, IgG	Medical Benefit PA Form
Vivitrol	Vivitrol	Vivitrol PA Form
Voltaren Gel	NSAIDs-COX2	NSAID-Cox2 PA Form
Vytorin	Cholesterol Absorption Inhibitors	Cholesterol Absorption Inhibitors PA Form
Vyvanse	ADHD Medications	ADHD Medications PA Form

W

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Wellbutrin XL	Antidepressants	Antidepressants PA Form
Wilate	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form

X

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Xeomin	Anticoagulants (Oral)	Anticoagulants (Oral) PA Form
Xeomin	Botulinum Toxin	Botulinum Toxin PA Form
Xgeva	Forteo-Prolia-Xgeva	Forteo-Prolia-Xgeva PA Form
Xiaflex	Xiaflex	Xiaflex PA Form
Xibrom	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Xifaxan	Antibiotics (systemic) policy	Antibiotics (systemic) PA Form
Xolair	Xolair	Xolair PA Form
Xolegel	Brand Name Topical Medications	Brand Name Topical PA Form
Xopenex	Xopenex-Xopenex HFA	Xopenex-Xopenex HFA PA Form
Xopenex HFA	Xopenex-Xopenex HFA	Xopenex-Xopenex HFA PA Form
Xyntha	Blood Clotting Disorder Medications	Blood Clotting Disorder Medications PA Form

Y

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Z

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Zaditor	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Zafirlukast	Leukotriene Modifiers	Leukotriene Modifiers PA Form
Zaleplon	Insomnia Agents	Insomnia Agents PA Form
Zanaflex	Skeletal Muscle Relaxants	Skeletal Muscle Relaxants PA Form
Zetia	Cholesterol Absorption Inhibitors	Cholesterol Absorption Inhibitors PA Form
Ziana	Acne and Rosacea (Topical)	Acne and Rosacea (Topical) PA Form
Zileuton	Leukotriene Modifiers	Leukotriene Modifiers PA Form
Zileuton CR	Leukotriene Modifiers	Leukotriene Modifiers PA Form
Zipsor	NSAIDs-COX2	NSAID-Cox2 PA Form
Zoladex	GnRH Agents	GnRH Agents PA Form
Zoledronic Acid	Bisphosphonates	Bisphosphonates PA Form
Zolmitriptan	Migraine-Specific Medications (Triptans)	Migraine-Specific Medications (Triptans) PA Form
Zolpidem Extended Release	Insomnia Agents	Insomnia Agents PA Form
Zolpimist	Insomnia Agents	Insomnia Agents PA Form
Zomig	Migraine-Specific Medications (Triptans)	Migraine-Specific Medications (Triptans) PA Form
Zuplenz	Antiemetics	Antiemetics PA Form
Zyclara	Topical Immunomodulators	Topical Immunomodulators PA Form
Zyflo	Leukotriene Modifiers	Leukotriene Modifiers PA Form
Zyflo CR	Leukotriene Modifiers	Leukotriene Modifiers PA Form
Zylet	Ophthalmic Anti-Allergy-Anti-Inflammatory	Opthalmic AntiallergyAntiinflammatory PA Form
Zymar	Ophthalmic Antibiotics	Ophthalmic Antibiotics PA Form
Zymaxid	Ophthalmic Antibiotics	Ophthalmic Antibiotics PA Form
Zyprexa Zydis	Antipsychotics	Antipsychotics PA Form
Zyrtec (OTC)	Antihistamines	Antihistamines PA Form
Zyvox	Antibiotics (systemic)	Antibiotics (systemic) PA Form