A

PA = Prior Authorization is required; QL = Quantity limits apply; ST = Step Therapy applies; 
RD  = Specialty Formulary, please refer to Specialty Pharmacy Program section for additional information;
OTC = Over-the-counter Product, may be covered if a prescription is written, and it is filled at a retail or mailorder pharmacy

Medications written in all CAPITAL letters are Brand names.
Medications written in all lower case letters are available generically. The brand name is listed in parenthesis for reference only.


A
ABILIFY
acarbose (Precose)
ACCU-CHEK ACTIVE
ACCU-CHEK ADVANTAGE
ACCU-CHEK AVIVA
ACCU-CHEK COMFORT CURVE
ACCU-CHEK COMPACT 
acebutolol (Sectral)
acetaminophen/butalbital (Phrenilin)
acetaminophen/caffeine/ butalbital (Esgic Plus, Fioricet)
acetaminophen/caffeine/ butalbital/codeine (Fioricet w/Codeine)
acetaminophen/phenyltoloxamine  (Flextra-650, Vistra 650)
acetazolamide (Diamox, Diamox Sequels)
acetic acid (Volsol)
acetic acid/aluminum acetate (Otic Domeboro)
acetic acid/hydrocortisone (Volsol HC)
acetic acid/oxyquinoline/ricinoleic acid/glycerin (Aci-Jel)
acetylcysteine (Mucomyst)
ACTIMMUNE, RD 
ACTOPLUS MET, ST 
ACTOS, ST
ACULAR
ACULAR LS
ACULAR PF
acyclovir (Zovirax) caps/tabs
ADVAIR
ADVICOR
AFINITOR, RD, PA
AGENERASE
ALAMAST
albuterol neb soln (AccuNeb)
albuterol extended-release (Vospire ER)
albuterol/ipratropium soln for nebulization (Duoneb)
alclometasone (Aclovate)
ALDARA
alendronate (Fosamax), QL
ALFERON N, RD
ALKERAN
allopurinol (Zyloprim)
alprazolam (Xanax)
alprazolam ext-rel (Xanax XR)
alprazolam rapid-dissolve (Niravam)
aluminum chloride 20% (Drysol)
amantadine (Symmetrel)
AMBIEN CR, QL, ST
amcinonide cream/oint/lotion, 0.1% (Cyclocort)
AMEVIVE, PA, RD
amiloride (Midamor)
amiloride/hydrochlorothiazide (Moduretic)
aminocaproic Acid (Amicar)
AMINOPHYLLINE
amiodarone (Pacerone)
amitriptyline (Elavil)
amitriptyline/chlordiazepoxide (Limbitrol)
amitriptyline/perphenazine (Triavil)
amlodipine (Norvasc)
amlodipine/benazepril (Lotrel)
ammonium lactate 12% (Lac-Hydrin)
amoxapine (Asendin)
amoxicillin (Amoxil)
amoxicillin/clavulanate (Augmentin)
amphetamine salts, mixed (Adderall)
ampicillin (Principen)
anagrelide (Agrylin)
ANALPRAM-HC
ANDRODERM
ANDROGEL
anthralin (Psoriatec)
antipyrine/benzocaine (Auralgan original formula)
antipyrine/benzocaine/acetic acid/polycosanol (Auralgan)
APOKYN, PA, RD  
apraclonidine (Iopidine)
apri (Desogen, Ortho-Cept)
APTIVUS
aranelle (Tri-Norinyl)
ARANESP, PA, RD 
ARCALYST, RD, PA
ARICEPT
ARICEPT ODT
ARIMIDEX
AROMASIN
ASACOL
ASMANEX
aspirin/caffeine/butalbital (Fiorinal)
aspirin/caffeine/butalbital/codeine (Fiorinal w/codeine)
ASTELIN
ASTEPRO
atenolol (Tenormin)
atenolol/chlorthalidone (Tenoretic)
ATRIPLA
atropine sulfate (Isopto Atropine)
ATROVENT inhaler
augmented betamethasone dipropionate cream/oint/gel/lotion, 0.05% (Diprolene, Diprolene AF)
AUGMENTIN XR
AVANDAMET, ST
AVANDIA , ST
aviane (Alesse, Levlite)
AVODART male over 46 yrs
AVONEX, RD 
azathioprine (Imuran)
AZILECT
azithromycin (Zithromax) 
AZOPT


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