| Form |
Last Update |
| ADHD therapy and CNS stimulants |
12/21/11 |
| Alprazolam Alternative (Niravam, Xanax XR ) |
6/6/05 |
| Ampyra |
5/8/12 |
| Antidepressants adolescent |
10/28/05 |
| Antidepressants pediatric |
10/28/05 |
| Antiobesity drug |
10/28/05 |
| Becapelemin ( Regranex ) |
10/28/05 |
| Bone Resorption Suppression and Related Agents |
2/23/12 |
| Buprenorphine ( Suboxone, Subutex ) |
11/11/11 |
| Butorpahanol NS ( Stadol NS ) |
10/28/05 |
| Celecoxib valdecoxib (Celebrex) |
4/8/05 |
| Aricept (donepezil), Razadyne (galantamine), Exelon (rivastigmine), Namenda (memantine) |
10/28/05 |
| Cinacalcet ( Sensipar ) |
10/28/05 |
| Duplicate Therapy |
10/28/05 |
| Early Refill |
10/28/05 |
| Epidermal Growth Factor (Iressa and Tarceva ) |
10/28/05 |
| Epoetin Alpha ( Epogen, Procrit, Aranesp ) |
10/28/05 |
| Fentanyl transmucosal ( Actiq ) and Buccal ( Fentora ) |
10/28/05 |
| Growth Hormone |
10/28/05 |
| Hemophilia Factor |
10/28/05 |
| Hepatitis C Agents |
2/23/12 |
| High Dose or Long Acting Narcotic Pain Medication |
5/8/12 |
| Immunomodulators for Atopic Dermatitis |
2/23/12 |
| Incretin mimetics ( Exenatide (Byetta®) & Liraglutide (Victoza®) |
6/1/10 |
| Isotretinoin ( Accutane, Clarvavis ) |
10/28/05 |
| Leukotriene ( Singular, Accolate, Zyflo) |
9/29/08 |
| Levalbuterol ( Xopenex respules) |
4/9/08 |
| Lidocaine Topical Patch ( Lidoderm ) |
10/28/08 |
| Linezolid ( Zyvox ) |
10/28/05 |
| Long-Acting Beta Agonist Corticosterioid Inhalant Combinations Medications |
2/23/12 |
| Lubiprostone ( Amitiza ) |
5/31/07 |
| Maraviorac (Selzentry) |
11/8/10 |
| Med Claims over $500 |
10/28/05 |
| Medical Necessity |
10/28/05 |
| MedWatchForm |
10/28/05 |
| Megestrol (Megace), Oxandrolone (Oxandrin), Dronabinol (Marinol) |
7/10/06 |
| Modafinil (Provigil) and Armodafinil (Nuvigil) |
6/30/09 |
| Monthly Prescription Count Override |
11/16/09 |
| Naltrexone HCL IM ( Vivitrol ) |
4/3/07 |
| Nicotine Replacement and varenicline ( Chantix ) |
5/24/11 |
| Palivizumab Injection ( Synagis ) |
9/27/11 |
| Part D Override Request |
3/14/06 |
| PDL Override |
4/3/09 |
| Phosphorous Binders |
2/23/12 |
| Pramlintide Acetate ( Symlin ) |
3/14/06 |
| Proton Pump Inhibitors |
8/31/11 |
| Pregabalin (Lyrica), Milnacipran HCL (Savella) |
10/20/09 |
| Pulmonary Arterial Hypertension Agents |
2/23/12 |
| Quantity Override |
11/16/09 |
| Long Acting Injectable Atypical Antipsychotics (Risperdal Consta, Zyprexa Relprevv, Invega Sustenna ) |
2/16/12 |
| Sitagliptin (Januvia Janumet), Saxagliptin (Onglyza) |
11/8/10 |
