Utilization Management Master Drug List

This list highlights how your medications are managed under the 1199SEIU prescription program.

Drug list subject to change. Prior authorization requirements may also apply to new drugs approved to the market that do not appear on the list and/or are in the process of being added.
The administration of vaccines in the pharmacy setting is subject to state laws and regulations.
Narcotic analgesics are subject to prior authorizations and state regulations.

Updated December 1, 2022.

For more information, please call Express Scripts at (800) 753-2851.

Drug Name	Brand Name/Generic	Therapeutic Class	Coverage Notes
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET WITH SENSOR AND STRIP 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ABILIFY MYCITE STARTER KIT ORAL TABLET WITH SENSOR, STRIP, POD 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
abiraterone oral tablet 250 mg, 500 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage. Split Fill The specialty drugs on the Accredo Split-Fill list will be dispensed as a 14- or 15-day supply for six (6) consecutive fills during the initial three (3) months of drug therapy. The specialty drugs are dispensed as a 14- or 15-day supply to allow drug dosage adjustments and/or changes in drug therapy, to promote clinical drug therapy management. If a member remains on the specialty drug for longer than three (3) months, Accredo will fill a 30-day supply on the fourth (4th) month of drug therapy.
ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
acetaminophen-caff-dihydrocod oral capsule 320.5-30-16 mg	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
acetaminophen-caff-dihydrocod oral tablet 325-30-16 mg	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
acetaminophen-codeine oral solution 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ACIPHEX ORAL TABLET,DELAYED RELEASE (DR/EC) 20 MG	Brand Name	ULCER THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG/0.9 ML	Brand Name	OTHER RHEUMATOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. Step Therapy Step Therapy ensures that our members are trying a clinically effective, lower-cost medication prior to using a higher cost drug in the same class. Of course, if the medication is not effective in treatment, you can request authorization for the higher-cost medication. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML)	Brand Name	OTHER RHEUMATOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Step Therapy Step Therapy ensures that our members are trying a clinically effective, lower-cost medication prior to using a higher cost drug in the same class. Of course, if the medication is not effective in treatment, you can request authorization for the higher-cost medication. Prescribers, call Express Scripts at (800) 753-2851.
ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML	Brand Name	OTHER RHEUMATOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. Step Therapy Step Therapy ensures that our members are trying a clinically effective, lower-cost medication prior to using a higher cost drug in the same class. Of course, if the medication is not effective in treatment, you can request authorization for the higher-cost medication. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ACTHAR INJECTION GEL 80 UNIT/ML	Brand Name	ADRENAL HORMONES	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML	Brand Name	INTERFERONS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ACTIQ BUCCAL LOZENGE ON A HANDLE 1,200 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG	Brand Name	NARCOTIC ANALGESICS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ACTONEL ORAL TABLET 150 MG, 35 MG	Brand Name	OSTEOPOROSIS THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ACTOPLUS MET ORAL TABLET 15-850 MG	Brand Name	NON-INSULIN HYPOGLYCEMIC AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ACTOS ORAL TABLET 15 MG, 30 MG, 45 MG	Brand Name	NON-INSULIN HYPOGLYCEMIC AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
acyclovir topical cream 5 %	Generic	TOPICAL ANTIVIRALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
acyclovir topical ointment 5 %	Generic	TOPICAL ANTIVIRALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ADAKVEO INTRAVENOUS SOLUTION 10 MG/ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ADBRY SUBCUTANEOUS SYRINGE 150 MG/ML	Brand Name	MISCELLANEOUS DERMATOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ADCETRIS INTRAVENOUS RECON SOLN 50 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ADCIRCA ORAL TABLET 20 MG	Brand Name	PULMONARY AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG	Brand Name	PULMONARY AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ADIPEX-P ORAL CAPSULE 37.5 MG	Brand Name	ANOREXIANTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ADIPEX-P ORAL TABLET 37.5 MG	Brand Name	ANOREXIANTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ADLYXIN SUBCUTANEOUS PEN INJECTOR 10 MCG/0.2 ML- 20 MCG/0.2 ML, 20 MCG/0.2 ML	Brand Name	NON-INSULIN HYPOGLYCEMIC AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
adrenalin injection solution 1 mg/ml, 1 mg/ml (1 ml)	Generic	ANTIHISTAMINE AND ANTIALLERGENIC AGENTS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ADRIAMYCIN INTRAVENOUS RECON SOLN 50 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
adrucil intravenous solution 2.5 gram/50 ml	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ADVATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 4,000 (+/-) UNIT, 500 (+/-) UNIT	Brand Name	COAGULATION THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Client PA This medication is subject to the Client Prior Authorization Program. Prescribers, call the Benefit Fund at (646) 473-7446.
ADYNOVATE INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT, 750 (+/-) UNIT	Brand Name	COAGULATION THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Client PA This medication is subject to the Client Prior Authorization Program. Prescribers, call the Benefit Fund at (646) 473-7446.
ADZENYS XR-ODT ORAL TABLET,DISINTEG ER BIPHASE 24H 12.5 MG, 15.7 MG, 18.8 MG, 3.1 MG, 6.3 MG, 9.4 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
AEMCOLO ORAL TABLET,DELAYED RELEASE (DR/EC) 194 MG	Brand Name	MISCELLANEOUS ANTIINFECTIVES	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
AFSTYLA INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT RANGE, 1,500 (+/-) UNIT RANGE, 2,000 (+/-) UNIT RANGE, 2,500 (+/-) UNIT RANGE, 250 (+/-) UNIT RANGE, 3,000 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE	Brand Name	COAGULATION THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Client PA This medication is subject to the Client Prior Authorization Program. Prescribers, call the Benefit Fund at (646) 473-7446.
AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MG/ML, 70 MG/ML	Brand Name	MIGRAINE AND CLUSTER HEADACHE THERAPY	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
AIRDUO DIGIHALER INHALATION AERO POWDR BREATH ACT W/SENSOR 113 MCG-14 MCG/ACTUATION, 232-14 MCG/ACTUATION, 55-14 MCG/ACTUATION	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
AIRDUO RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 113-14 MCG/ACTUATION, 232-14 MCG/ACTUATION, 55-14 MCG/ACTUATION	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
AJOVY AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 225 MG/1.5 ML	Brand Name	MIGRAINE AND CLUSTER HEADACHE THERAPY	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
AJOVY SYRINGE SUBCUTANEOUS SYRINGE 225 MG/1.5 ML	Brand Name	MIGRAINE AND CLUSTER HEADACHE THERAPY	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
AKLIEF TOPICAL CREAM 0.005 %	Brand Name	THERAPY FOR ACNE	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
AKYNZEO (FOSNETUPITANT) INTRAVENOUS RECON SOLN 235-0.25 MG	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
AKYNZEO (FOSNETUPITANT) INTRAVENOUS SOLUTION 235 MG-0.25 MG /20 ML	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
AKYNZEO (NETUPITANT) ORAL CAPSULE 300-0.5 MG	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
albendazole oral tablet 200 mg	Generic	MISCELLANEOUS ANTIINFECTIVES	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation	Generic	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML	Brand Name	MISCELLANEOUS HORMONES	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Client PA This medication is subject to the Client Prior Authorization Program. Prescribers, call the Benefit Fund at (646) 473-7446.
ALECENSA ORAL CAPSULE 150 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage. Split Fill The specialty drugs on the Accredo Split-Fill list will be dispensed as a 14- or 15-day supply for six (6) consecutive fills during the initial three (3) months of drug therapy. The specialty drugs are dispensed as a 14- or 15-day supply to allow drug dosage adjustments and/or changes in drug therapy, to promote clinical drug therapy management. If a member remains on the specialty drug for longer than three (3) months, Accredo will fill a 30-day supply on the fourth (4th) month of drug therapy.
alendronate oral solution 70 mg/75 ml	Generic	OSTEOPOROSIS THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg	Generic	OSTEOPOROSIS THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ALFERON N INJECTION SOLUTION 5 MILLION UNIT/ML	Brand Name	INTERFERONS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML	Brand Name	MISCELLANEOUS ANTIINFECTIVES	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ALINIA ORAL TABLET 500 MG	Brand Name	MISCELLANEOUS ANTIINFECTIVES	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ALKERAN (AS HCL) INTRAVENOUS RECON SOLN 50 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
ALKERAN ORAL TABLET 2 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
almotriptan malate oral tablet 12.5 mg, 6.25 mg	Generic	MIGRAINE AND CLUSTER HEADACHE THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ALOGLIPTIN ORAL TABLET 12.5 MG, 25 MG, 6.25 MG	Brand Name	NON-INSULIN HYPOGLYCEMIC AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ALOGLIPTIN-METFORMIN ORAL TABLET 12.5-1,000 MG, 12.5-500 MG	Brand Name	NON-INSULIN HYPOGLYCEMIC AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 12.5-30 MG, 25-15 MG, 25-30 MG, 25-45 MG	Brand Name	NON-INSULIN HYPOGLYCEMIC AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ALPHANATE INTRAVENOUS RECON SOLN 1,000 (400 VWF) UNIT/10 ML, 1,500 (600 VWF) UNIT/10 ML, 2,000 (800 VWF) UNIT/10 ML, 250 (100 VWF) UNIT/5 ML, 500 (200 VWF) UNIT/5 ML	Brand Name	COAGULATION THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Client PA This medication is subject to the Client Prior Authorization Program. Prescribers, call the Benefit Fund at (646) 473-7446.
ALPHANINE SD INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT	Brand Name	COAGULATION THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Client PA This medication is subject to the Client Prior Authorization Program. Prescribers, call the Benefit Fund at (646) 473-7446.
alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg, 3 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
alprazolam oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ALPROLIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 500 UNIT	Brand Name	COAGULATION THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Client PA This medication is subject to the Client Prior Authorization Program. Prescribers, call the Benefit Fund at (646) 473-7446.
ALTABAX TOPICAL OINTMENT 1 %	Brand Name	TOPICAL ANTIBACTERIALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HR 20 MG, 40 MG, 60 MG	Brand Name	LIPID/CHOLESTEROL LOWERING AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ALTRENO TOPICAL LOTION 0.05 %	Brand Name	THERAPY FOR ACNE	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG (23)	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ALVESCO INHALATION HFA AEROSOL INHALER 160 MCG/ACTUATION, 80 MCG/ACTUATION	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ALYMSYS INTRAVENOUS SOLUTION 25 MG/ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
alyq oral tablet 20 mg	Generic	PULMONARY AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
AMBIEN CR ORAL TABLET,EXT RELEASE MULTIPHASE 12.5 MG, 6.25 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
AMBIEN ORAL TABLET 10 MG, 5 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ambrisentan oral tablet 10 mg, 5 mg	Generic	PULMONARY AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
AMELUZ TOPICAL GEL 10 %	Brand Name	MISCELLANEOUS DERMATOLOGICALS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml	Generic	MISCELLANEOUS ANTIINFECTIVES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg	Generic	LIPID/CHOLESTEROL LOWERING AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
amphetamine sulfate oral tablet 10 mg, 5 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg, 2 gram, 250 mg, 500 mg	Generic	PENICILLINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, 3 gram	Generic	PENICILLINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG	Brand Name	MISCELLANEOUS NEUROLOGICAL THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
AMVUTTRA SUBCUTANEOUS SYRINGE 25 MG/0.5 ML	Brand Name	MISCELLANEOUS NEUROLOGICAL THERAPY	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
anastrozole oral tablet 1 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR	Brand Name	MISCELLANEOUS HORMONES	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)	Brand Name	MISCELLANEOUS HORMONES	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM), 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)	Brand Name	MISCELLANEOUS HORMONES	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ANZEMET ORAL TABLET 50 MG	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
APADAZ ORAL TABLET 4.08-325 MG, 6.12-325 MG, 8.16-325 MG	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG, 348 MG, 522 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML	Brand Name	ANTIPARKINSONISM AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
apomorphine subcutaneous cartridge 10 mg/ml	Generic	ANTIPARKINSONISM AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
aprepitant oral capsule 125 mg, 40 mg, 80 mg	Generic	MISCELLANEOUS GASTROINTESTINAL AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2)	Generic	MISCELLANEOUS GASTROINTESTINAL AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
APTENSIO XR ORAL CAP,ER SPRINKLE,BIPHASIC 40-60 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ARAKODA ORAL TABLET 100 MG	Brand Name	MISCELLANEOUS ANTIINFECTIVES	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG, 500 MG	Brand Name	MISCELLANEOUS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 40 MCG/ML, 60 MCG/ML	Brand Name	BIOTECHNOLOGY DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML	Brand Name	BIOTECHNOLOGY DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ARAVA ORAL TABLET 10 MG, 20 MG	Brand Name	OTHER RHEUMATOLOGICALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ARAZLO TOPICAL LOTION 0.045 %	Brand Name	THERAPY FOR ACNE	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ARCALYST SUBCUTANEOUS RECON SOLN 220 MG	Brand Name	BIOTECHNOLOGY DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
arformoterol inhalation solution for nebulization 15 mcg/2 ml	Generic	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ARIKAYCE INHALATION SUSPENSION FOR NEBULIZATION 590 MG/8.4 ML	Brand Name	MISCELLANEOUS ANTIINFECTIVES	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ARIMIDEX ORAL TABLET 1 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
aripiprazole oral tablet,disintegrating 10 mg, 15 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ARISTADA INITIO INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 675 MG/2.4 ML	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML, 441 MG/1.6 ML, 662 MG/2.4 ML, 882 MG/3.2 ML	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ARIXTRA SUBCUTANEOUS SYRINGE 10 MG/0.8 ML, 2.5 MG/0.5 ML, 5 MG/0.4 ML, 7.5 MG/0.6 ML	Brand Name	COAGULATION THERAPY	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ARMONAIR DIGIHALER INHALATION AERO POWDR BREATH ACT W/SENSOR 113 MCG/ACTUATION, 232 MCG/ACTUATION, 55 MCG/ACTUATION	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
AROMASIN ORAL TABLET 25 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ARRANON INTRAVENOUS SOLUTION 250 MG/50 ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
arsenic trioxide intravenous solution 1 mg/ml, 2 mg/ml	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
ARZERRA INTRAVENOUS SOLUTION 1,000 MG/50 ML, 100 MG/5 ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
ASCENIV INTRAVENOUS SOLUTION 10 %	Brand Name	VACCINES AND MISCELLANEOUS IMMUNOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ascomp with codeine oral capsule 30-50-325-40 mg	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ascorbic acid (vitamin c) injection solution 500 mg/ml	Generic	VITAMINS AND HEMATINICS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
asenapine maleate sublingual tablet 10 mg, 2.5 mg, 5 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (120), 220 MCG/ ACTUATION (14), 220 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (60)	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ATELVIA ORAL TABLET,DELAYED RELEASE (DR/EC) 35 MG	Brand Name	OSTEOPOROSIS THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ATGAM INTRAVENOUS SOLUTION 50 MG/ML	Brand Name	VACCINES AND MISCELLANEOUS IMMUNOLOGICALS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ATIVAN INJECTION SOLUTION 2 MG/ML, 4 MG/ML	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ATIVAN ORAL TABLET 0.5 MG, 1 MG, 2 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg	Generic	LIPID/CHOLESTEROL LOWERING AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
atovaquone-proguanil oral tablet 250-100 mg, 62.5-25 mg	Generic	MISCELLANEOUS ANTIINFECTIVES	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ATRALIN TOPICAL GEL 0.05 %	Brand Name	THERAPY FOR ACNE	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ATROPEN INTRAMUSCULAR PEN INJECTOR 0.5 MG/0.7 ML, 1 MG/0.7 ML	Brand Name	ANTIDOTES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
atropine injection solution 0.4 mg/ml, 1 mg/ml	Generic	ANTIDIARRHEALS AND ANTISPASMODICS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
atropine injection syringe 0.05 mg/ml, 0.1 mg/ml	Generic	ANTIDIARRHEALS AND ANTISPASMODICS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
AUBAGIO ORAL TABLET 14 MG, 7 MG	Brand Name	MULTIPLE SCLEROSIS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG	Brand Name	MISCELLANEOUS NEUROLOGICAL THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
AVASTIN INTRAVENOUS SOLUTION 25 MG/ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
AVEED INTRAMUSCULAR SOLUTION 750 MG/3 ML (250 MG/ML)	Brand Name	MISCELLANEOUS HORMONES	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
avita topical cream 0.025 %	Generic	THERAPY FOR ACNE	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
AVITA TOPICAL GEL 0.025 %	Brand Name	THERAPY FOR ACNE	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML	Brand Name	MULTIPLE SCLEROSIS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML	Brand Name	MULTIPLE SCLEROSIS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
AVSOLA INTRAVENOUS RECON SOLN 100 MG	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
AYVAKIT ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 50 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
azacitidine injection recon soln 100 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
AZACTAM INJECTION RECON SOLN 1 GRAM, 2 GRAM	Brand Name	MISCELLANEOUS ANTIINFECTIVES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
AZSTARYS ORAL CAPSULE 26.1 MG- 5.2 MG, 39.2 MG- 7.8 MG, 52.3 MG- 10.4 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
aztreonam injection recon soln 1 gram, 2 gram	Generic	MISCELLANEOUS ANTIINFECTIVES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
b complex 100 injection solution 100-2-100-2-2 mg/ml	Generic	VITAMINS AND HEMATINICS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
bacitracin intramuscular recon soln 50,000 unit	Generic	MISCELLANEOUS ANTIINFECTIVES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
BAFIERTAM ORAL CAPSULE,DELAYED RELEASE(DR/EC) 95 MG	Brand Name	MULTIPLE SCLEROSIS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
BAQSIMI NASAL SPRAY,NON-AEROSOL 3 MG/ACTUATION	Brand Name	GLUCOSE ELEVATING AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BAVENCIO INTRAVENOUS SOLUTION 20 MG/ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
BAXDELA ORAL TABLET 450 MG	Brand Name	QUINOLONES	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG	Brand Name	NARCOTIC ANALGESICS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BELEODAQ INTRAVENOUS RECON SOLN 500 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
belladonna alkaloids-opium rectal suppository 16.2-30 mg, 16.2-60 mg	Generic	ANTIDIARRHEALS AND ANTISPASMODICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BELRAPZO INTRAVENOUS SOLUTION 25 MG/ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BENDAMUSTINE INTRAVENOUS SOLUTION 25 MG/ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
BENDEKA INTRAVENOUS SOLUTION 25 MG/ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
BENEFIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT	Brand Name	COAGULATION THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Client PA This medication is subject to the Client Prior Authorization Program. Prescribers, call the Benefit Fund at (646) 473-7446.
BENLYSTA INTRAVENOUS RECON SOLN 120 MG, 400 MG	Brand Name	OTHER RHEUMATOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MG/ML	Brand Name	OTHER RHEUMATOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
BENLYSTA SUBCUTANEOUS SYRINGE 200 MG/ML	Brand Name	OTHER RHEUMATOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
BENTYL INTRAMUSCULAR SOLUTION 10 MG/ML	Brand Name	ANTIDIARRHEALS AND ANTISPASMODICS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
BENZHYDROCODONE-ACETAMINOPHEN ORAL TABLET 4.08-325 MG, 6.12-325 MG, 8.16-325 MG	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BENZNIDAZOLE ORAL TABLET 100 MG, 12.5 MG	Brand Name	MISCELLANEOUS ANTIINFECTIVES	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
benzphetamine oral tablet 50 mg	Generic	ANOREXIANTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
benztropine injection solution 1 mg/ml	Generic	ANTIPARKINSONISM AGENTS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
BEOVU INTRAVITREAL SYRINGE 6 MG/0.05 ML	Brand Name	MISCELLANEOUS OPHTHALMOLOGICS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
BERINERT INTRAVENOUS KIT 500 UNIT (10 ML)	Brand Name	PULMONARY AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
BESPONSA INTRAVENOUS RECON SOLN 0.9 MG (0.25 MG/ML INITIAL)	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
BESREMI SUBCUTANEOUS SYRINGE 500 MCG/ML	Brand Name	INTERFERONS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
betamethasone acet,sod phos injection suspension 6 mg/ml	Generic	ADRENAL HORMONES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
BETAMETHASONE SOD PHOSPH-WATER INJECTION SOLUTION 6 MG/ML	Brand Name	ADRENAL HORMONES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
BETASERON SUBCUTANEOUS KIT 0.3 MG	Brand Name	MULTIPLE SCLEROSIS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML	Brand Name	MISCELLANEOUS ANTIINFECTIVES	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-4.8 MCG	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
bexarotene oral capsule 75 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
bexarotene topical gel 1 %	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
bicalutamide oral tablet 50 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K)	Brand Name	PENICILLINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML	Brand Name	PENICILLINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
BICNU INTRAVENOUS RECON SOLN 100 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
BINOSTO ORAL TABLET, EFFERVESCENT 70 MG	Brand Name	OSTEOPOROSIS THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BIVIGAM INTRAVENOUS SOLUTION 10 %	Brand Name	VACCINES AND MISCELLANEOUS IMMUNOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
BLENREP INTRAVENOUS RECON SOLN 100 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
bleomycin injection recon soln 15 unit, 30 unit	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
BLINCYTO INTRAVENOUS KIT 35 MCG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
BONIVA ORAL TABLET 150 MG	Brand Name	OSTEOPOROSIS THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BORTEZOMIB INJECTION RECON SOLN 1 MG, 2.5 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
bortezomib injection recon soln 3.5 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
BORTEZOMIB INTRAVENOUS RECON SOLN 3.5 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
BORTEZOMIB INTRAVENOUS SOLUTION 2.5 MG/ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
bosentan oral tablet 125 mg, 62.5 mg	Generic	PULMONARY AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage. Split Fill The specialty drugs on the Accredo Split-Fill list will be dispensed as a 14- or 15-day supply for six (6) consecutive fills during the initial three (3) months of drug therapy. The specialty drugs are dispensed as a 14- or 15-day supply to allow drug dosage adjustments and/or changes in drug therapy, to promote clinical drug therapy management. If a member remains on the specialty drug for longer than three (3) months, Accredo will fill a 30-day supply on the fourth (4th) month of drug therapy.
BOTOX INJECTION RECON SOLN 100 UNIT, 200 UNIT	Brand Name	VACCINES AND MISCELLANEOUS IMMUNOLOGICALS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
BRAFTOVI ORAL CAPSULE 50 MG, 75 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage. Split Fill The specialty drugs on the Accredo Split-Fill list will be dispensed as a 14- or 15-day supply for six (6) consecutive fills during the initial three (3) months of drug therapy. The specialty drugs are dispensed as a 14- or 15-day supply to allow drug dosage adjustments and/or changes in drug therapy, to promote clinical drug therapy management. If a member remains on the specialty drug for longer than three (3) months, Accredo will fill a 30-day supply on the fourth (4th) month of drug therapy.
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BREXAFEMME ORAL TABLET 150 MG	Brand Name	ANTIFUNGAL AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BREZTRI AEROSPHERE INHALATION HFA AEROSOL INHALER 160-9-4.8 MCG/ACTUATION	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BRONCHITOL INHALATION CAPSULE, W/INHALATION DEVICE 40 MG	Brand Name	PULMONARY AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG/2 ML	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BRUKINSA ORAL CAPSULE 80 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml	Generic	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BUDESONIDE-FORMOTEROL INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
bumetanide injection solution 0.25 mg/ml	Generic	ANTIHYPERTENSIVE THERAPY	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
BUPRENEX INJECTION SOLUTION 0.3 MG/ML	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
buprenorphine hcl injection solution 0.3 mg/ml	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
buprenorphine hcl injection syringe 0.3 mg/ml	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour	Generic	NARCOTIC ANALGESICS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
buprenorphine-naloxone sublingual film 2-0.5 mg, 4-1 mg, 8-2 mg	Generic	NON-NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
buprenorphine-naloxone sublingual tablet 2-0.5 mg	Generic	NON-NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg	Generic	SMOKING DETERRENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BUPROPION HCL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
bupropion hcl oral tablet sustained-release 12 hr 100 mg, 150 mg, 200 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
butalbital compound w/codeine oral capsule 30-50-325-40 mg	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 mg, 50-325-40-30 mg	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
butorphanol injection solution 1 mg/ml, 2 mg/ml	Generic	NON-NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
butorphanol nasal spray,non-aerosol 10 mg/ml	Generic	NON-NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR	Brand Name	NARCOTIC ANALGESICS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85 ML	Brand Name	NON-INSULIN HYPOGLYCEMIC AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML	Brand Name	NON-INSULIN HYPOGLYCEMIC AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BYLVAY ORAL CAPSULE 1,200 MCG, 400 MCG	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BYLVAY ORAL PELLET 200 MCG, 600 MCG	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
BYOOVIZ INTRAVITREAL SOLUTION 0.5 MG/0.05 ML	Brand Name	MISCELLANEOUS OPHTHALMOLOGICS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
CABENUVA INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE 400 MG/2 ML- 600 MG/2 ML, 600 MG/3 ML- 900 MG/3 ML	Brand Name	ANTIVIRALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
cabergoline oral tablet 0.5 mg	Generic	MISCELLANEOUS HORMONES	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CABLIVI INJECTION KIT 11 MG	Brand Name	COAGULATION THERAPY	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage. Split Fill The specialty drugs on the Accredo Split-Fill list will be dispensed as a 14- or 15-day supply for six (6) consecutive fills during the initial three (3) months of drug therapy. The specialty drugs are dispensed as a 14- or 15-day supply to allow drug dosage adjustments and/or changes in drug therapy, to promote clinical drug therapy management. If a member remains on the specialty drug for longer than three (3) months, Accredo will fill a 30-day supply on the fourth (4th) month of drug therapy.
CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG	Brand Name	LIPID/CHOLESTEROL LOWERING AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
calcipotriene scalp solution 0.005 %	Generic	ANTIPSORIATIC / ANTISEBORRHEIC	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
calcipotriene topical cream 0.005 %	Generic	ANTIPSORIATIC / ANTISEBORRHEIC	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CALCIPOTRIENE TOPICAL FOAM 0.005 %	Brand Name	ANTIPSORIATIC / ANTISEBORRHEIC	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
calcipotriene topical ointment 0.005 %	Generic	ANTIPSORIATIC / ANTISEBORRHEIC	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
calcipotriene-betamethasone topical ointment 0.005-0.064 %	Generic	ANTIPSORIATIC / ANTISEBORRHEIC	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
calcipotriene-betamethasone topical suspension 0.005-0.064 %	Generic	ANTIPSORIATIC / ANTISEBORRHEIC	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
calcitonin (salmon) injection solution 200 unit/ml	Generic	MISCELLANEOUS HORMONES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CALQUENCE (ACALABRUTINIB MAL) ORAL TABLET 100 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CALQUENCE ORAL CAPSULE 100 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CAMBIA ORAL POWDER IN PACKET 50 MG	Brand Name	NON-NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CAMCEVI (6 MONTH) SUBCUTANEOUS SYRINGE 42 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CAMPTOSAR INTRAVENOUS SOLUTION 100 MG/5 ML, 300 MG/15 ML, 40 MG/2 ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
CAMZYOS ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 5 MG	Brand Name	MISCELLANEOUS CARDIOVASCULAR AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
capecitabine oral tablet 150 mg, 500 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CAPLYTA ORAL CAPSULE 10.5 MG, 21 MG, 42 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CAPRELSA ORAL TABLET 100 MG, 300 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CARAC TOPICAL CREAM 0.5 %	Brand Name	MISCELLANEOUS DERMATOLOGICALS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG	Brand Name	MISCELLANEOUS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523.
carboplatin intravenous solution 10 mg/ml	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG	Brand Name	ANTIHYPERTENSIVE THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR 4 MG, 8 MG	Brand Name	ANTIHYPERTENSIVE THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
carisoprodol oral tablet 250 mg, 350 mg	Generic	MUSCLE RELAXANTS AND ANTISPASMODIC THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
carisoprodol-aspirin oral tablet 200-325 mg	Generic	MUSCLE RELAXANTS AND ANTISPASMODIC THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
carisoprodol-aspirin-codeine oral tablet 200-325-16 mg	Generic	MUSCLE RELAXANTS AND ANTISPASMODIC THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
carmustine intravenous recon soln 100 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
CARMUSTINE INTRAVENOUS RECON SOLN 300 MG, 50 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
CASODEX ORAL TABLET 50 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY 0.1 MG/24 HR	Brand Name	ANTIHYPERTENSIVE THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CATAPRES-TTS-2 TRANSDERMAL PATCH WEEKLY 0.2 MG/24 HR	Brand Name	ANTIHYPERTENSIVE THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CATAPRES-TTS-3 TRANSDERMAL PATCH WEEKLY 0.3 MG/24 HR	Brand Name	ANTIHYPERTENSIVE THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CAVERJECT IMPULSE INTRACAVERNOSAL KIT 10 MCG, 20 MCG	Brand Name	MISCELLANEOUS UROLOGICALS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CAVERJECT INTRACAVERNOSAL RECON SOLN 20 MCG, 40 MCG	Brand Name	MISCELLANEOUS UROLOGICALS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CAVERJECT INTRACAVERNOSAL SYRINGE 10 MCG, 20 MCG	Brand Name	MISCELLANEOUS UROLOGICALS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML	Brand Name	MISCELLANEOUS ANTIINFECTIVES	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
cefazolin injection recon soln 1 gram, 10 gram, 100 gram, 20 gram, 300 g, 500 mg	Generic	CEPHALOSPORINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CEFAZOLIN INJECTION RECON SOLN 2 GRAM	Brand Name	CEPHALOSPORINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
cefepime injection recon soln 1 gram, 2 gram	Generic	CEPHALOSPORINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CEFOTAN INJECTION RECON SOLN 1 GRAM, 2 GRAM	Brand Name	CEPHALOSPORINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
cefotaxime injection recon soln 1 gram, 2 gram	Generic	CEPHALOSPORINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
cefotetan injection recon soln 1 gram, 2 gram	Generic	CEPHALOSPORINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ceftazidime injection recon soln 1 gram, 2 gram, 6 gram	Generic	CEPHALOSPORINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg	Generic	CEPHALOSPORINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
cefuroxime sodium injection recon soln 750 mg	Generic	CEPHALOSPORINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CELESTONE SOLUSPAN INJECTION SUSPENSION 6 MG/ML	Brand Name	ADRENAL HORMONES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CELEXA ORAL TABLET 10 MG, 20 MG, 40 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CENTANY AT TOPICAL OINTMENT KIT 2 %	Brand Name	TOPICAL ANTIBACTERIALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CENTANY TOPICAL OINTMENT 2 %	Brand Name	TOPICAL ANTIBACTERIALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN 500 UNIT	Brand Name	COAGULATION THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523.
CEPROTIN (GREEN BAR) INTRAVENOUS RECON SOLN 1,000 UNIT	Brand Name	COAGULATION THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523.
CEQUA OPHTHALMIC (EYE) DROPPERETTE 0.09 %	Brand Name	MISCELLANEOUS OPHTHALMOLOGICS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
CERDELGA ORAL CAPSULE 84 MG	Brand Name	MISCELLANEOUS HORMONES	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
CEREBYX INJECTION SOLUTION 100 MG PE/2 ML, 500 MG PE/10 ML	Brand Name	ANTICONVULSANTS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CEREZYME INTRAVENOUS RECON SOLN 400 UNIT	Brand Name	MISCELLANEOUS HORMONES	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Client PA This medication is subject to the Client Prior Authorization Program. Prescribers, call the Benefit Fund at (646) 473-7446.
CHEMET ORAL CAPSULE 100 MG	Brand Name	MISCELLANEOUS AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
CHENODAL ORAL TABLET 250 MG	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
chlorpromazine injection solution 25 mg/ml	Generic	PSYCHOTHERAPEUTIC DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CHOLBAM ORAL CAPSULE 250 MG	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
CHOLBAM ORAL CAPSULE 50 MG	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CIBINQO ORAL TABLET 100 MG, 200 MG, 50 MG	Brand Name	MISCELLANEOUS DERMATOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ciclodan topical cream 0.77 %	Generic	TOPICAL ANTIFUNGALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ciclopirox topical cream 0.77 %	Generic	TOPICAL ANTIFUNGALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ciclopirox topical gel 0.77 %	Generic	TOPICAL ANTIFUNGALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ciclopirox topical shampoo 1 %	Generic	TOPICAL ANTIFUNGALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ciclopirox topical suspension 0.77 %	Generic	TOPICAL ANTIFUNGALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CIMERLI INTRAVITREAL SOLUTION 0.3 MG/0.05 ML, 0.5 MG/0.05 ML	Brand Name	MISCELLANEOUS OPHTHALMOLOGICS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. Step Therapy Step Therapy ensures that our members are trying a clinically effective, lower-cost medication prior to using a higher cost drug in the same class. Of course, if the medication is not effective in treatment, you can request authorization for the higher-cost medication. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2)	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. Step Therapy Step Therapy ensures that our members are trying a clinically effective, lower-cost medication prior to using a higher cost drug in the same class. Of course, if the medication is not effective in treatment, you can request authorization for the higher-cost medication. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
cinacalcet oral tablet 30 mg, 60 mg, 90 mg	Generic	MISCELLANEOUS HORMONES	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
CINQAIR INTRAVENOUS SOLUTION 10 MG/ML	Brand Name	PULMONARY AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML)	Brand Name	PULMONARY AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CISPLATIN INTRAVENOUS RECON SOLN 50 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
cisplatin intravenous solution 1 mg/ml	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
CITALOPRAM ORAL CAPSULE 30 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
citalopram oral tablet 10 mg, 20 mg, 40 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
cladribine intravenous solution 10 mg/10 ml	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
CLAFORAN INJECTION RECON SOLN 2 GRAM	Brand Name	CEPHALOSPORINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CLEOCIN INJECTION SOLUTION 150 MG/ML	Brand Name	MISCELLANEOUS ANTIINFECTIVES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CLEOCIN T TOPICAL LOTION 1 %	Brand Name	THERAPY FOR ACNE	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CLINDAGEL TOPICAL GEL, ONCE DAILY 1 %	Brand Name	THERAPY FOR ACNE	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clindamycin phosphate injection solution 150 mg/ml	Generic	MISCELLANEOUS ANTIINFECTIVES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
clindamycin phosphate topical foam 1 %	Generic	THERAPY FOR ACNE	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clindamycin phosphate topical gel 1 %	Generic	THERAPY FOR ACNE	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clindamycin phosphate topical gel, once daily 1 %	Generic	THERAPY FOR ACNE	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clindamycin phosphate topical lotion 1 %	Generic	THERAPY FOR ACNE	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clindamycin phosphate topical solution 1 %	Generic	THERAPY FOR ACNE	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clindamycin-tretinoin topical gel 1.2-0.025 %	Generic	THERAPY FOR ACNE	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
clobetasol scalp solution 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clobetasol topical cream 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clobetasol topical foam 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clobetasol topical gel 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clobetasol topical lotion 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clobetasol topical ointment 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clobetasol topical shampoo 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clobetasol topical spray,non-aerosol 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clobetasol-emollient topical cream 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clobetasol-emollient topical foam 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CLOBEX TOPICAL SHAMPOO 0.05 %	Brand Name	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CLOBEX TOPICAL SPRAY,NON-AEROSOL 0.05 %	Brand Name	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CLODAN KIT TOPICAL KIT,SHAMPOO AND CLEANSER 0.05 %	Brand Name	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clodan topical shampoo 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clofarabine intravenous solution 1 mg/ml	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
CLOLAR INTRAVENOUS SOLUTION 1 MG/ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
clonazepam oral tablet 0.5 mg, 1 mg, 2 mg	Generic	ANTICONVULSANTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg	Generic	ANTICONVULSANTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clonidine hcl oral tablet extended release 12 hr 0.1 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr	Generic	ANTIHYPERTENSIVE THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clotrimazole topical cream 1 %	Generic	TOPICAL ANTIFUNGALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clotrimazole topical solution 1 %	Generic	TOPICAL ANTIFUNGALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clotrimazole-betamethasone topical cream 1-0.05 %	Generic	TOPICAL ANTIFUNGALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
clotrimazole-betamethasone topical lotion 1-0.05 %	Generic	TOPICAL ANTIFUNGALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
COARTEM ORAL TABLET 20-120 MG	Brand Name	MISCELLANEOUS ANTIINFECTIVES	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
codeine sulfate oral tablet 15 mg, 30 mg, 60 mg	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
codeine-butalbital-asa-caff oral capsule 30-50-325-40 mg	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
colistin (colistimethate na) injection recon soln 150 mg	Generic	MISCELLANEOUS ANTIINFECTIVES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
COLY-MYCIN M PARENTERAL INJECTION RECON SOLN 150 MG	Brand Name	MISCELLANEOUS ANTIINFECTIVES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY)	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage. Split Fill The specialty drugs on the Accredo Split-Fill list will be dispensed as a 14- or 15-day supply for six (6) consecutive fills during the initial three (3) months of drug therapy. The specialty drugs are dispensed as a 14- or 15-day supply to allow drug dosage adjustments and/or changes in drug therapy, to promote clinical drug therapy management. If a member remains on the specialty drug for longer than three (3) months, Accredo will fill a 30-day supply on the fourth (4th) month of drug therapy.
COMPAZINE ORAL TABLET 10 MG, 5 MG	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
COMPAZINE RECTAL SUPPOSITORY 25 MG	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
compro rectal suppository 25 mg	Generic	MISCELLANEOUS GASTROINTESTINAL AGENTS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CONCERTA ORAL TABLET EXTENDED RELEASE 24HR 18 MG, 27 MG, 36 MG, 54 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
CONDYLOX TOPICAL GEL 0.5 %	Brand Name	MISCELLANEOUS DERMATOLOGICALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CONTRAVE ORAL TABLET EXTENDED RELEASE 8-90 MG	Brand Name	ANOREXIANTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
CONZIP ORAL CAPSULE,ER BIPHASE 24 HR 17-83 300 MG	Brand Name	NON-NARCOTIC ANALGESICS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CONZIP ORAL CAPSULE,ER BIPHASE 24 HR 25-75 100 MG, 200 MG	Brand Name	NON-NARCOTIC ANALGESICS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML, 40 MG/ML	Brand Name	MULTIPLE SCLEROSIS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
COPIKTRA ORAL CAPSULE 15 MG, 25 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CORDRAN TOPICAL CREAM 0.025 %, 0.05 %	Brand Name	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CORDRAN TOPICAL LOTION 0.05 %	Brand Name	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CORDRAN TOPICAL OINTMENT 0.05 %	Brand Name	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CORIFACT INTRAVENOUS RECON SOLN 1,000-1,600 UNIT	Brand Name	COAGULATION THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Client PA This medication is subject to the Client Prior Authorization Program. Prescribers, call the Benefit Fund at (646) 473-7446.
CORLANOR ORAL SOLUTION 5 MG/5 ML	Brand Name	MISCELLANEOUS CARDIOVASCULAR AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
CORLANOR ORAL TABLET 5 MG, 7.5 MG	Brand Name	MISCELLANEOUS CARDIOVASCULAR AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
CORTROPHIN GEL INJECTION GEL 80 UNIT/ML	Brand Name	ADRENAL HORMONES	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CORTROSYN INJECTION RECON SOLN 0.25 MG	Brand Name	ADRENAL HORMONES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
COSELA INTRAVENOUS RECON SOLN 300 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MG/ML	Brand Name	ANTIPSORIATIC / ANTISEBORRHEIC	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. Step Therapy Step Therapy ensures that our members are trying a clinically effective, lower-cost medication prior to using a higher cost drug in the same class. Of course, if the medication is not effective in treatment, you can request authorization for the higher-cost medication. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MG/ML	Brand Name	ANTIPSORIATIC / ANTISEBORRHEIC	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. Step Therapy Step Therapy ensures that our members are trying a clinically effective, lower-cost medication prior to using a higher cost drug in the same class. Of course, if the medication is not effective in treatment, you can request authorization for the higher-cost medication. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML	Brand Name	ANTIPSORIATIC / ANTISEBORRHEIC	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. Step Therapy Step Therapy ensures that our members are trying a clinically effective, lower-cost medication prior to using a higher cost drug in the same class. Of course, if the medication is not effective in treatment, you can request authorization for the higher-cost medication. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
COSENTYX SUBCUTANEOUS SYRINGE 150 MG/ML	Brand Name	ANTIPSORIATIC / ANTISEBORRHEIC	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. Step Therapy Step Therapy ensures that our members are trying a clinically effective, lower-cost medication prior to using a higher cost drug in the same class. Of course, if the medication is not effective in treatment, you can request authorization for the higher-cost medication. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
COSENTYX SUBCUTANEOUS SYRINGE 75 MG/0.5 ML	Brand Name	ANTIPSORIATIC / ANTISEBORRHEIC	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
COSMEGEN INTRAVENOUS RECON SOLN 0.5 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
cosyntropin injection recon soln 0.25 mg	Generic	ADRENAL HORMONES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
COTELLIC ORAL TABLET 20 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
COTEMPLA XR-ODT ORAL TABLET,DISINTEG ER BIPHASE 24H 17.3 MG, 25.9 MG, 8.6 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
CRESEMBA INTRAVENOUS RECON SOLN 372 MG	Brand Name	ANTIFUNGAL AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
CRESEMBA ORAL CAPSULE 186 MG	Brand Name	ANTIFUNGAL AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG	Brand Name	LIPID/CHOLESTEROL LOWERING AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CRYSVITA SUBCUTANEOUS SOLUTION 10 MG/ML, 20 MG/ML, 30 MG/ML	Brand Name	MISCELLANEOUS HORMONES	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CUTAQUIG SUBCUTANEOUS SOLUTION 16.5 %	Brand Name	VACCINES AND MISCELLANEOUS IMMUNOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
CUVITRU SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %), 8 GRAM/40 ML (20 %)	Brand Name	VACCINES AND MISCELLANEOUS IMMUNOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
cyanocobalamin (vitamin b-12) injection solution 1,000 mcg/ml	Generic	VITAMINS AND HEMATINICS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
cyclophosphamide oral capsule 25 mg, 50 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
CYCLOPHOSPHAMIDE ORAL TABLET 25 MG, 50 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
cyclosporine ophthalmic (eye) dropperette 0.05 %	Generic	MISCELLANEOUS OPHTHALMOLOGICS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG, 30 MG, 60 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml), 20 mg/ml	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
cytarabine injection solution 20 mg/ml	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
dacarbazine intravenous recon soln 100 mg, 200 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
dactinomycin intravenous recon soln 0.5 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
dalfampridine oral tablet extended release 12 hr 10 mg	Generic	MISCELLANEOUS NEUROLOGICAL THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
DALIRESP ORAL TABLET 250 MCG	Brand Name	PULMONARY AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
DALIRESP ORAL TABLET 500 MCG	Brand Name	PULMONARY AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
DANYELZA INTRAVENOUS SOLUTION 4 MG/ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
DARAPRIM ORAL TABLET 25 MG	Brand Name	MISCELLANEOUS ANTIINFECTIVES	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
DARZALEX FASPRO SUBCUTANEOUS SOLUTION 1,800 MG-30,000 UNIT/15 ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
DARZALEX INTRAVENOUS SOLUTION 20 MG/ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
daunorubicin intravenous solution 5 mg/ml	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
DAURISMO ORAL TABLET 100 MG, 25 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
DAYTRANA TRANSDERMAL PATCH 24 HOUR 10 MG/9 HR, 15 MG/9 HR, 20 MG/9 HR, 30 MG/9 HR	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
decitabine intravenous recon soln 50 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
deferasirox oral granules in packet 180 mg, 360 mg, 90 mg	Generic	MISCELLANEOUS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Split Fill The specialty drugs on the Accredo Split-Fill list will be dispensed as a 14- or 15-day supply for six (6) consecutive fills during the initial three (3) months of drug therapy. The specialty drugs are dispensed as a 14- or 15-day supply to allow drug dosage adjustments and/or changes in drug therapy, to promote clinical drug therapy management. If a member remains on the specialty drug for longer than three (3) months, Accredo will fill a 30-day supply on the fourth (4th) month of drug therapy.
deferasirox oral tablet 180 mg, 360 mg, 90 mg	Generic	MISCELLANEOUS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Split Fill The specialty drugs on the Accredo Split-Fill list will be dispensed as a 14- or 15-day supply for six (6) consecutive fills during the initial three (3) months of drug therapy. The specialty drugs are dispensed as a 14- or 15-day supply to allow drug dosage adjustments and/or changes in drug therapy, to promote clinical drug therapy management. If a member remains on the specialty drug for longer than three (3) months, Accredo will fill a 30-day supply on the fourth (4th) month of drug therapy.
deferasirox oral tablet, dispersible 125 mg, 250 mg, 500 mg	Generic	MISCELLANEOUS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Split Fill The specialty drugs on the Accredo Split-Fill list will be dispensed as a 14- or 15-day supply for six (6) consecutive fills during the initial three (3) months of drug therapy. The specialty drugs are dispensed as a 14- or 15-day supply to allow drug dosage adjustments and/or changes in drug therapy, to promote clinical drug therapy management. If a member remains on the specialty drug for longer than three (3) months, Accredo will fill a 30-day supply on the fourth (4th) month of drug therapy.
deferiprone oral tablet 1,000 mg	Generic	MISCELLANEOUS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
deferiprone oral tablet 500 mg	Generic	MISCELLANEOUS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML, 20 MG/ML, 40 MG/ML	Brand Name	ESTROGENS AND PROGESTINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
DEMEROL (PF) INJECTION SOLUTION 100 MG/2 ML	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
DEMEROL (PF) INJECTION SYRINGE 100 MG/ML, 25 MG/ML, 50 MG/ML, 75 MG/ML	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
DEMEROL INJECTION SOLUTION 50 MG/ML	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML	Brand Name	ESTROGENS AND PROGESTINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML, 40 MG/ML, 80 MG/ML	Brand Name	ADRENAL HORMONES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML	Brand Name	ESTROGENS AND PROGESTINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
DEPO-PROVERA INTRAMUSCULAR SYRINGE 150 MG/ML	Brand Name	ESTROGENS AND PROGESTINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 104 MG/0.65 ML	Brand Name	ESTROGENS AND PROGESTINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
DEPO-TESTOSTERONE INTRAMUSCULAR OIL 100 MG/ML, 200 MG/ML	Brand Name	MISCELLANEOUS HORMONES	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
DESOXYN ORAL TABLET 5 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 50 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
dexamethasone sodium phos (pf) injection solution 10 mg/ml	Generic	ADRENAL HORMONES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
dexamethasone sodium phosphate injection solution 10 mg/ml, 4 mg/ml	Generic	ADRENAL HORMONES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
dexamethasone sodium phosphate injection syringe 4 mg/ml	Generic	ADRENAL HORMONES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
DEXEDRINE SPANSULE ORAL CAPSULE, EXTENDED RELEASE 10 MG, 15 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS 30 MG, 60 MG	Brand Name	ULCER THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
DEXLANSOPRAZOLE ORAL CAPSULE,BIPHASE DELAYED RELEAS 30 MG, 60 MG	Brand Name	ULCER THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
dexmethylphenidate oral capsule,er biphasic 50-50 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
dextroamphetamine sulfate oral capsule, extended release 10 mg, 15 mg, 5 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
dextroamphetamine sulfate oral solution 5 mg/5 ml	Generic	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
dextroamphetamine sulfate oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
DIACOMIT ORAL CAPSULE 250 MG, 500 MG	Brand Name	ANTICONVULSANTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
DIACOMIT ORAL POWDER IN PACKET 250 MG, 500 MG	Brand Name	ANTICONVULSANTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
diazepam injection solution 5 mg/ml	Generic	PSYCHOTHERAPEUTIC DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
diazepam injection syringe 5 mg/ml	Generic	PSYCHOTHERAPEUTIC DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
diazepam intensol oral concentrate 5 mg/ml	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
diazepam oral solution 5 mg/5 ml (1 mg/ml)	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
diazepam oral tablet 10 mg, 2 mg, 5 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
DICLOFENAC EPOLAMINE TRANSDERMAL PATCH 12 HOUR 1.3 %	Brand Name	NON-NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
diclofenac sodium topical drops 1.5 %	Generic	NON-NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
diclofenac sodium topical gel 1 %	Generic	NON-NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
diclofenac sodium topical gel 3 %	Generic	MISCELLANEOUS DERMATOLOGICALS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
dicyclomine intramuscular solution 10 mg/ml	Generic	ANTIDIARRHEALS AND ANTISPASMODICS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
diethylpropion oral tablet 25 mg	Generic	ANOREXIANTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
diethylpropion oral tablet extended release 75 mg	Generic	ANOREXIANTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
DIFICID ORAL SUSPENSION FOR RECONSTITUTION 40 MG/ML	Brand Name	ERYTHROMYCINS AND OTHER MACROLIDES	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
DIFICID ORAL TABLET 200 MG	Brand Name	ERYTHROMYCINS AND OTHER MACROLIDES	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
diflorasone topical cream 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
diflorasone topical ointment 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION 10 MG/ML, 40 MG/ML	Brand Name	ANTIFUNGAL AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
DIFLUCAN ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG	Brand Name	ANTIFUNGAL AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
dihydroergotamine injection solution 1 mg/ml	Generic	MIGRAINE AND CLUSTER HEADACHE THERAPY	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
dihydroergotamine nasal spray,non-aerosol 0.5 mg/pump act. (4 mg/ml)	Generic	MIGRAINE AND CLUSTER HEADACHE THERAPY	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
DILAUDID (PF) INJECTION SYRINGE 0.2 MG/ML, 0.5 MG/0.5 ML, 1 MG/ML, 2 MG/ML, 4 MG/ML	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
DILAUDID ORAL LIQUID 1 MG/ML	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
DILAUDID ORAL TABLET 2 MG, 4 MG, 8 MG	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
dimethyl fumarate oral capsule,delayed release(dr/ec) 120 mg, 120 mg (14)- 240 mg (46), 240 mg	Generic	MULTIPLE SCLEROSIS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
diphenhydramine hcl injection solution 50 mg/ml	Generic	ANTIHISTAMINE AND ANTIALLERGENIC AGENTS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
diphenhydramine hcl injection syringe 50 mg/ml	Generic	ANTIHISTAMINE AND ANTIALLERGENIC AGENTS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
diskets oral tablet,soluble 40 mg	Generic	NARCOTIC ANALGESICS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
DOCEFREZ INTRAVENOUS RECON SOLN 20 MG, 80 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
dodex injection solution 1,000 mcg/ml	Generic	VITAMINS AND HEMATINICS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
DOJOLVI ORAL LIQUID 8.3 KCAL/ML	Brand Name	MISCELLANEOUS VITAMINS, HEMATINICS, AND ELECTROLYTES	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523.
DOPTELET (15 TAB PACK) ORAL TABLET 20 MG	Brand Name	COAGULATION THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
DOVONEX TOPICAL CREAM 0.005 %	Brand Name	ANTIPSORIATIC / ANTISEBORRHEIC	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg	Generic	ANTIHYPERTENSIVE THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
doxepin oral tablet 3 mg, 6 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
doxepin topical cream 5 %	Generic	MISCELLANEOUS DERMATOLOGICALS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
DOXIL INTRAVENOUS SUSPENSION 2 MG/ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
doxorubicin intravenous recon soln 10 mg, 50 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
doxorubicin intravenous solution 10 mg/5 ml, 2 mg/ml, 20 mg/10 ml, 50 mg/25 ml	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
doxorubicin, peg-liposomal intravenous suspension 2 mg/ml	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG, 30 MG, 40 MG, 60 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
dronabinol oral capsule 10 mg, 2.5 mg, 5 mg	Generic	MISCELLANEOUS GASTROINTESTINAL AGENTS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
droperidol injection solution 2.5 mg/ml	Generic	MISCELLANEOUS GASTROINTESTINAL AGENTS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
droxidopa oral capsule 100 mg, 200 mg, 300 mg	Generic	MISCELLANEOUS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Split Fill The specialty drugs on the Accredo Split-Fill list will be dispensed as a 14- or 15-day supply for six (6) consecutive fills during the initial three (3) months of drug therapy. The specialty drugs are dispensed as a 14- or 15-day supply to allow drug dosage adjustments and/or changes in drug therapy, to promote clinical drug therapy management. If a member remains on the specialty drug for longer than three (3) months, Accredo will fill a 30-day supply on the fourth (4th) month of drug therapy.
DUAKLIR PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400-12 MCG/ACTUATION	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
DUETACT ORAL TABLET 30-2 MG, 30-4 MG	Brand Name	NON-INSULIN HYPOGLYCEMIC AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION, 50-5 MCG/ACTUATION	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 40 mg, 60 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
DUOBRII TOPICAL LOTION 0.01-0.045 %	Brand Name	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
DUOPA J-TUBE INTESTINAL PUMP SUSPENSION 4.63-20 MG/ML	Brand Name	ANTIPARKINSONISM AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523.
DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 200 MG/1.14 ML, 300 MG/2 ML	Brand Name	MISCELLANEOUS DERMATOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 100 MG/0.67 ML, 200 MG/1.14 ML, 300 MG/2 ML	Brand Name	MISCELLANEOUS DERMATOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
duramorph (pf) injection solution 0.5 mg/ml, 1 mg/ml	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
DURYSTA INTRACAMERAL IMPLANT 10 MCG	Brand Name	OTHER GLAUCOMA DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523.
DYANAVEL XR ORAL SUSPEN, IR - ER, BIPHASIC 24HR 2.5 MG/ML	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
DYANAVEL XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10 MG, 15 MG, 20 MG, 5 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT, 500 UNIT	Brand Name	VACCINES AND MISCELLANEOUS IMMUNOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
econazole topical cream 1 %	Generic	TOPICAL ANTIFUNGALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ECOZA TOPICAL FOAM 1 %	Brand Name	TOPICAL ANTIFUNGALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
EDEX INTRACAVERNOSAL KIT 10 MCG, 20 MCG, 40 MCG	Brand Name	MISCELLANEOUS UROLOGICALS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
EDLUAR SUBLINGUAL TABLET 10 MG, 5 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR 150 MG, 37.5 MG, 75 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
EFUDEX TOPICAL CREAM 5 %	Brand Name	MISCELLANEOUS DERMATOLOGICALS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
EGRIFTA SV SUBCUTANEOUS RECON SOLN 2 MG	Brand Name	GROWTH HORMONES	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML	Brand Name	MISCELLANEOUS HORMONES	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Client PA This medication is subject to the Client Prior Authorization Program. Prescribers, call the Benefit Fund at (646) 473-7446.
ELELYSO INTRAVENOUS RECON SOLN 200 UNIT	Brand Name	MISCELLANEOUS HORMONES	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Client PA This medication is subject to the Client Prior Authorization Program. Prescribers, call the Benefit Fund at (646) 473-7446.
eletriptan oral tablet 20 mg, 40 mg	Generic	MIGRAINE AND CLUSTER HEADACHE THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ELIDEL TOPICAL CREAM 1 %	Brand Name	MISCELLANEOUS DERMATOLOGICALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH)	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ELLENCE INTRAVENOUS SOLUTION 200 MG/100 ML, 50 MG/25 ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
ELOCTATE INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 5,000 UNIT, 500 UNIT, 6,000 UNIT, 750 UNIT	Brand Name	COAGULATION THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Client PA This medication is subject to the Client Prior Authorization Program. Prescribers, call the Benefit Fund at (646) 473-7446.
ELYXYB ORAL SOLUTION 120 MG/4.8 ML (25 MG/ML)	Brand Name	MIGRAINE AND CLUSTER HEADACHE THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ELZONRIS INTRAVENOUS SOLUTION 1,000 MCG/ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
EMCYT ORAL CAPSULE 140 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
EMEND ORAL CAPSULE 80 MG	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
EMEND ORAL CAPSULE,DOSE PACK 125 MG (1)- 80 MG (2)	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.)	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
EMFLAZA ORAL SUSPENSION 22.75 MG/ML	Brand Name	ADRENAL HORMONES	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG	Brand Name	ADRENAL HORMONES	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MG/ML	Brand Name	MIGRAINE AND CLUSTER HEADACHE THERAPY	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MG/ML, 300 MG/3 ML (100 MG/ML X 3)	Brand Name	MIGRAINE AND CLUSTER HEADACHE THERAPY	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
EMPAVELI SUBCUTANEOUS SOLUTION 1,080 MG/20 ML	Brand Name	MISCELLANEOUS AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
EMVERM ORAL TABLET,CHEWABLE 100 MG	Brand Name	MISCELLANEOUS ANTIINFECTIVES	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (1 ML)	Brand Name	OTHER RHEUMATOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)	Brand Name	OTHER RHEUMATOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5 ML	Brand Name	OTHER RHEUMATOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5), 50 MG/ML (1 ML)	Brand Name	OTHER RHEUMATOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (1 ML)	Brand Name	OTHER RHEUMATOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ENDARI ORAL POWDER IN PACKET 5 GRAM	Brand Name	MISCELLANEOUS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ENHERTU INTRAVENOUS RECON SOLN 100 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
ENJAYMO INTRAVENOUS SOLUTION 50 MG/ML	Brand Name	MISCELLANEOUS AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
enoxaparin subcutaneous solution 300 mg/3 ml	Generic	COAGULATION THERAPY	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml	Generic	COAGULATION THERAPY	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ENSPRYNG SUBCUTANEOUS SYRINGE 120 MG/ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG	Brand Name	MISCELLANEOUS CARDIOVASCULAR AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ENTYVIO INTRAVENOUS RECON SOLN 300 MG	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
EPCLUSA ORAL PELLETS IN PACKET 150-37.5 MG, 200-50 MG	Brand Name	ANTIVIRALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. Split Fill The specialty drugs on the Accredo Split-Fill list will be dispensed as a 14- or 15-day supply for six (6) consecutive fills during the initial three (3) months of drug therapy. The specialty drugs are dispensed as a 14- or 15-day supply to allow drug dosage adjustments and/or changes in drug therapy, to promote clinical drug therapy management. If a member remains on the specialty drug for longer than three (3) months, Accredo will fill a 30-day supply on the fourth (4th) month of drug therapy.
EPCLUSA ORAL TABLET 200-50 MG, 400-100 MG	Brand Name	ANTIVIRALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. Split Fill The specialty drugs on the Accredo Split-Fill list will be dispensed as a 14- or 15-day supply for six (6) consecutive fills during the initial three (3) months of drug therapy. The specialty drugs are dispensed as a 14- or 15-day supply to allow drug dosage adjustments and/or changes in drug therapy, to promote clinical drug therapy management. If a member remains on the specialty drug for longer than three (3) months, Accredo will fill a 30-day supply on the fourth (4th) month of drug therapy.
EPIDIOLEX ORAL SOLUTION 100 MG/ML	Brand Name	ANTICONVULSANTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
EPINEPHRINE HCL (PF) INJECTION SOLUTION 1 MG/ML (1 ML)	Brand Name	ANTIHISTAMINE AND ANTIALLERGENIC AGENTS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
EPINEPHRINE INJECTION AUTO-INJECTOR 0.15 MG/0.15 ML	Brand Name	ANTIHISTAMINE AND ANTIALLERGENIC AGENTS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
epinephrine injection auto-injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml	Generic	ANTIHISTAMINE AND ANTIALLERGENIC AGENTS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
epinephrine injection solution 1 mg/ml	Generic	ANTIHISTAMINE AND ANTIALLERGENIC AGENTS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
epinephrine injection syringe 0.1 mg/ml	Generic	ANTIHISTAMINE AND ANTIALLERGENIC AGENTS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
epirubicin intravenous recon soln 200 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
epirubicin intravenous solution 200 mg/100 ml	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML	Brand Name	BIOTECHNOLOGY DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
epoprostenol (glycine) intravenous recon soln 0.5 mg, 1.5 mg	Generic	ANTIHYPERTENSIVE THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
epoprostenol intravenous recon soln 0.5 mg, 1.5 mg	Generic	ANTIHYPERTENSIVE THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML, 200 MG/100 ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ERIVEDGE ORAL CAPSULE 150 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage. Split Fill The specialty drugs on the Accredo Split-Fill list will be dispensed as a 14- or 15-day supply for six (6) consecutive fills during the initial three (3) months of drug therapy. The specialty drugs are dispensed as a 14- or 15-day supply to allow drug dosage adjustments and/or changes in drug therapy, to promote clinical drug therapy management. If a member remains on the specialty drug for longer than three (3) months, Accredo will fill a 30-day supply on the fourth (4th) month of drug therapy.
ERLEADA ORAL TABLET 60 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
erlotinib oral tablet 100 mg, 150 mg, 25 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage. Split Fill The specialty drugs on the Accredo Split-Fill list will be dispensed as a 14- or 15-day supply for six (6) consecutive fills during the initial three (3) months of drug therapy. The specialty drugs are dispensed as a 14- or 15-day supply to allow drug dosage adjustments and/or changes in drug therapy, to promote clinical drug therapy management. If a member remains on the specialty drug for longer than three (3) months, Accredo will fill a 30-day supply on the fourth (4th) month of drug therapy.
ERTACZO TOPICAL CREAM 2 %	Brand Name	TOPICAL ANTIFUNGALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ertapenem injection recon soln 1 gram	Generic	MISCELLANEOUS ANTIINFECTIVES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ERWINASE INJECTION RECON SOLN 10,000 UNIT	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
ESBRIET ORAL CAPSULE 267 MG	Brand Name	PULMONARY AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ESBRIET ORAL TABLET 267 MG, 801 MG	Brand Name	PULMONARY AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg, 40 mg	Generic	ULCER THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
esomeprazole magnesium oral granules dr for susp in packet 10 mg, 20 mg, 40 mg	Generic	ULCER THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ESPEROCT INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT	Brand Name	COAGULATION THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Client PA This medication is subject to the Client Prior Authorization Program. Prescribers, call the Benefit Fund at (646) 473-7446.
estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml	Generic	ESTROGENS AND PROGESTINS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
eszopiclone oral tablet 1 mg, 2 mg, 3 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
etoposide intravenous solution 20 mg/ml	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
etoposide oral capsule 50 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
EUCRISA TOPICAL OINTMENT 2 %	Brand Name	MISCELLANEOUS DERMATOLOGICALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
EUFLEXXA INTRA-ARTICULAR SYRINGE 10 MG/ML(MW 2.4 -3.6 MILLION)	Brand Name	NON-NARCOTIC ANALGESICS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
EULEXIN ORAL CAPSULE 125 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
EVEKEO ODT ORAL TABLET,DISINTEGRATING 10 MG, 15 MG, 20 MG, 5 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
EVEKEO ORAL TABLET 10 MG, 5 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
EVENITY SUBCUTANEOUS SYRINGE 105 MG/1.17 ML, 210MG/2.34ML ( 105MG/1.17MLX2)	Brand Name	OSTEOPOROSIS THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
everolimus (antineoplastic) oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
everolimus (antineoplastic) oral tablet for suspension 2 mg, 3 mg, 5 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
EVOCLIN TOPICAL FOAM 1 %	Brand Name	THERAPY FOR ACNE	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
EVOMELA INTRAVENOUS RECON SOLN 50 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
EVRYSDI ORAL RECON SOLN 0.75 MG/ML	Brand Name	MISCELLANEOUS NEUROLOGICAL THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
EVUSHELD (EUA) INTRAMUSCULAR SOLUTION 150 MG/1.5 ML- 150 MG/1.5 ML	Brand Name	ANTIVIRALS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
EXELDERM TOPICAL CREAM 1 %	Brand Name	TOPICAL ANTIFUNGALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
EXELDERM TOPICAL SOLUTION 1 %	Brand Name	TOPICAL ANTIFUNGALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
exemestane oral tablet 25 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250 MG, 500 MG	Brand Name	MISCELLANEOUS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Split Fill The specialty drugs on the Accredo Split-Fill list will be dispensed as a 14- or 15-day supply for six (6) consecutive fills during the initial three (3) months of drug therapy. The specialty drugs are dispensed as a 14- or 15-day supply to allow drug dosage adjustments and/or changes in drug therapy, to promote clinical drug therapy management. If a member remains on the specialty drug for longer than three (3) months, Accredo will fill a 30-day supply on the fourth (4th) month of drug therapy.
EXKIVITY ORAL CAPSULE 40 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
EXSERVAN ORAL FILM 50 MG	Brand Name	MISCELLANEOUS AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
EXTAVIA SUBCUTANEOUS KIT 0.3 MG	Brand Name	MULTIPLE SCLEROSIS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
EXTAVIA SUBCUTANEOUS RECON SOLN 0.3 MG	Brand Name	MULTIPLE SCLEROSIS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
EXTINA TOPICAL FOAM 2 %	Brand Name	TOPICAL ANTIFUNGALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
EYLEA INTRAVITREAL SOLUTION 2 MG/0.05 ML	Brand Name	MISCELLANEOUS OPHTHALMOLOGICS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
EYLEA INTRAVITREAL SYRINGE 2 MG/0.05 ML	Brand Name	MISCELLANEOUS OPHTHALMOLOGICS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
EYSUVIS OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 %	Brand Name	STEROIDS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
EZALLOR SPRINKLE ORAL CAPSULE, SPRINKLE 10 MG, 20 MG, 40 MG, 5 MG	Brand Name	LIPID/CHOLESTEROL LOWERING AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
EZETIMIBE-ROSUVASTATIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-5 MG	Brand Name	LIPID/CHOLESTEROL LOWERING AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg	Generic	LIPID/CHOLESTEROL LOWERING AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FABIOR TOPICAL FOAM 0.1 %	Brand Name	THERAPY FOR ACNE	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
FABRAZYME INTRAVENOUS RECON SOLN 35 MG, 5 MG	Brand Name	MISCELLANEOUS HORMONES	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Client PA This medication is subject to the Client Prior Authorization Program. Prescribers, call the Benefit Fund at (646) 473-7446.
famciclovir oral tablet 125 mg, 250 mg, 500 mg	Generic	ANTIVIRALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2)	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FARESTON ORAL TABLET 60 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
FARXIGA ORAL TABLET 10 MG, 5 MG	Brand Name	NON-INSULIN HYPOGLYCEMIC AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MG/ML	Brand Name	PULMONARY AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FASENRA SUBCUTANEOUS SYRINGE 30 MG/ML	Brand Name	PULMONARY AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
febuxostat oral tablet 40 mg, 80 mg	Generic	GOUT THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FEIBA NF INTRAVENOUS RECON SOLN 1,750-3,250 UNIT, 350-650 UNIT, 700-1,300 UNIT	Brand Name	COAGULATION THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. Client PA This medication is subject to the Client Prior Authorization Program. Prescribers, call the Benefit Fund at (646) 473-7446.
FEMARA ORAL TABLET 2.5 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
FENSOLVI SUBCUTANEOUS SYRINGE 45 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
FENTANYL (PF)-BUPIVACAINE-NACL INJECTION SOLUTION 2 MCG/ML- 0.0625 %, 2 MCG/ML- 0.1 %, 2 MCG/ML- 0.125 %, 4 MCG/ML- 0.125 %	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FENTANYL CITRATE (PF) INTRAVENOUS PATIENT CONTROL.ANALGESIA SOLN 1,500 MCG/30 ML (50 MCG/ML)	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FENTANYL CITRATE (PF) INTRAVENOUS PREFILLED PUMP RESERVOIR 2,500 MCG/50 ML (50 MCG/ML)	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fentanyl citrate (pf) intravenous pt controlled analgesia syring 1,000 mcg/20 ml (50 mcg/ml)	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FENTANYL CITRATE (PF) INTRAVENOUS PT CONTROLLED ANALGESIA SYRING 1,500 MCG/30 ML (50 MCG/ML), 2,500 MCG/50 ML (50 MCG/ML), 2,750 MCG/55 ML (50 MCG/ML)	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fentanyl citrate (pf) intravenous syringe 100 mcg/2 ml (50 mcg/ml)	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FENTANYL CITRATE (PF) INTRAVENOUS SYRINGE 250 MCG/5 ML (50 MCG/ML)	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FENTANYL CITRATE (PF)-0.9%NACL INJECTION PREFILLED PUMP RESERVOIR 10 MCG/ML	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fentanyl citrate (pf)-0.9%nacl injection pt controlled analgesia syring 1,250 mcg/25 ml	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FENTANYL CITRATE (PF)-0.9%NACL INJECTION PT CONTROLLED ANALGESIA SYRING 550 MCG/55 ML	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FENTANYL CITRATE (PF)-0.9%NACL INTRAVENOUS PT CONTROLLED ANALGESIA SYRING 1,000 MCG/20 ML (50 MCG/ML), 500 MCG/50 ML (10 MCG/ML)	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fentanyl citrate (pf)-0.9%nacl intravenous pt controlled analgesia syring 2,500 mcg/50 ml (50 mcg/ml)	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FENTANYL CITRATE (PF)-0.9%NACL INTRAVENOUS SOLUTION 10 MCG/ML, 20 MCG/ML	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fentanyl citrate (pf)-0.9%nacl intravenous solution 5 mcg/ml	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fentanyl citrate (pf)-0.9%nacl intravenous syringe 10 mcg/ml	Generic	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FENTANYL CITRATE (PF)-0.9%NACL INTRAVENOUS SYRINGE 100 MCG/10 ML (10 MCG/ML), 20 MCG/2 ML (10 MCG/ML), 250 MCG/5 ML (50 MCG/ML), 50 MCG/5 ML (10 MCG/ML)	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg	Generic	NARCOTIC ANALGESICS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FENTANYL CITRATE BUCCAL TABLET, EFFERVESCENT 100 MCG	Brand Name	NARCOTIC ANALGESICS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour	Generic	NARCOTIC ANALGESICS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FENTANYL-ROPIVACAINE-NACL (PF) INJECTION PREFILLED PUMP RESERVOIR 2 MCG/ML-0.1 %	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FENTANYL-ROPIVACAINE-NACL (PF) INJECTION SOLUTION 2-0.2 MCG/ML-%	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FENTORA BUCCAL TABLET, EFFERVESCENT 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG	Brand Name	NARCOTIC ANALGESICS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FERAHEME INTRAVENOUS SOLUTION 510 MG/17 ML (30 MG/ML)	Brand Name	VITAMINS AND HEMATINICS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
FERRIPROX (2 TIMES A DAY) ORAL TABLET 1,000 MG	Brand Name	MISCELLANEOUS AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
FERRIPROX ORAL SOLUTION 100 MG/ML	Brand Name	MISCELLANEOUS AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
FERRIPROX ORAL TABLET 1,000 MG, 500 MG	Brand Name	MISCELLANEOUS AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
FERRLECIT INTRAVENOUS SOLUTION 62.5 MG/5 ML	Brand Name	MISCELLANEOUS AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
ferumoxytol intravenous solution 510 mg/17 ml (30 mg/ml)	Generic	VITAMINS AND HEMATINICS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26)	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fingolimod oral capsule 0.5 mg	Generic	MULTIPLE SCLEROSIS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
FINTEPLA ORAL SOLUTION 2.2 MG/ML	Brand Name	ANTICONVULSANTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FIORICET WITH CODEINE ORAL CAPSULE 50-300-40-30 MG	Brand Name	NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML	Brand Name	PULMONARY AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
FIRDAPSE ORAL TABLET 10 MG	Brand Name	MISCELLANEOUS NEUROLOGICAL THERAPY	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG, 80 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
FIRVANQ ORAL RECON SOLN 25 MG/ML, 50 MG/ML	Brand Name	VANCOMYCIN	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 %, 5 %	Brand Name	VACCINES AND MISCELLANEOUS IMMUNOLOGICALS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
FLECTOR TRANSDERMAL PATCH 12 HOUR 1.3 %	Brand Name	NON-NARCOTIC ANALGESICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FLOLAN INTRAVENOUS RECON SOLN 0.5 MG, 1.5 MG	Brand Name	ANTIHYPERTENSIVE THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
FLOLIPID ORAL SUSPENSION 20 MG/5 ML (4 MG/ML), 40 MG/5 ML (8 MG/ML)	Brand Name	LIPID/CHOLESTEROL LOWERING AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
floxuridine injection recon soln 0.5 gram	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 200 mg/100 ml, 400 mg/200 ml	Generic	ANTIFUNGAL AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml	Generic	ANTIFUNGAL AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg	Generic	ANTIFUNGAL AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fludarabine intravenous recon soln 50 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
fludarabine intravenous solution 50 mg/2 ml	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
fluocinonide topical cream 0.05 %, 0.1 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fluocinonide topical gel 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fluocinonide topical ointment 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fluocinonide topical solution 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fluocinonide-e topical cream 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FLUOROPLEX TOPICAL CREAM 1 %	Brand Name	MISCELLANEOUS DERMATOLOGICALS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
fluorouracil intravenous solution 1 gram/20 ml, 2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
FLUOROURACIL TOPICAL CREAM 0.5 %	Brand Name	MISCELLANEOUS DERMATOLOGICALS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
fluorouracil topical cream 5 %	Generic	MISCELLANEOUS DERMATOLOGICALS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
fluorouracil topical solution 2 %, 5 %	Generic	MISCELLANEOUS DERMATOLOGICALS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
fluoxetine oral capsule 10 mg, 40 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fluoxetine oral capsule,delayed release(dr/ec) 90 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fluoxetine oral tablet 10 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fluphenazine decanoate injection solution 25 mg/ml	Generic	PSYCHOTHERAPEUTIC DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
fluphenazine hcl injection solution 2.5 mg/ml	Generic	PSYCHOTHERAPEUTIC DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
flurandrenolide topical cream 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
flurandrenolide topical lotion 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
flurandrenolide topical ointment 0.05 %	Generic	TOPICAL CORTICOSTEROIDS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
flutamide oral capsule 125 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
FLUTICASONE FUROATE-VILANTEROL INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FLUTICASONE PROPIONATE INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FLUTICASONE PROPION-SALMETEROL INHALATION AEROSOL POWDR BREATH ACTIVATED 113-14 MCG/ACTUATION, 232-14 MCG/ACTUATION, 55-14 MCG/ACTUATION	Brand Name	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fluticasone propion-salmeterol inhalation blister with device 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose	Generic	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fluvastatin oral capsule 20 mg, 40 mg	Generic	LIPID/CHOLESTEROL LOWERING AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fluvastatin oral tablet extended release 24 hr 80 mg	Generic	LIPID/CHOLESTEROL LOWERING AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fluvoxamine oral capsule,extended release 24hr 100 mg, 150 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fluvoxamine oral tablet 100 mg, 25 mg, 50 mg	Generic	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
FOCALIN XR ORAL CAPSULE,ER BIPHASIC 50-50 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
folic acid injection solution 5 mg/ml	Generic	VITAMINS AND HEMATINICS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
FOLOTYN INTRAVENOUS SOLUTION 20 MG/ML (1 ML), 40 MG/2 ML (20 MG/ML)	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
fondaparinux subcutaneous syringe 10 mg/0.8 ml, 2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml	Generic	COAGULATION THERAPY	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
formoterol fumarate inhalation solution for nebulization 20 mcg/2 ml	Generic	PULMONARY AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE (600MCG/2.4ML)	Brand Name	OSTEOPOROSIS THERAPY	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
FORTESTA TRANSDERMAL GEL IN METERED-DOSE PUMP 10 MG/0.5 GRAM /ACTUATION	Brand Name	MISCELLANEOUS HORMONES	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
FOSAMAX ORAL TABLET 70 MG	Brand Name	OSTEOPOROSIS THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FOSAMAX PLUS D ORAL TABLET 70 MG- 2,800 UNIT, 70 MG- 5,600 UNIT	Brand Name	OSTEOPOROSIS THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
fosphenytoin injection solution 100 mg pe/2 ml, 500 mg pe/10 ml	Generic	ANTICONVULSANTS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
FOTIVDA ORAL CAPSULE 0.89 MG, 1.34 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
FRAGMIN SUBCUTANEOUS SOLUTION 2,500 ANTI-XA UNIT/ML, 25,000 ANTI-XA UNIT/ML	Brand Name	COAGULATION THERAPY	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5 ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML, 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML, 7,500 ANTI-XA UNIT/0.3 ML	Brand Name	COAGULATION THERAPY	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
FROVA ORAL TABLET 2.5 MG	Brand Name	MIGRAINE AND CLUSTER HEADACHE THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
frovatriptan oral tablet 2.5 mg	Generic	MIGRAINE AND CLUSTER HEADACHE THERAPY	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
FULPHILA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML	Brand Name	BIOTECHNOLOGY DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
fulvestrant intramuscular syringe 250 mg/5 ml	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
FUROSCIX SUBCUTANEOUS KIT 80 MG/10 ML	Brand Name	ANTIHYPERTENSIVE THERAPY
furosemide injection solution 10 mg/ml	Generic	ANTIHYPERTENSIVE THERAPY	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
furosemide injection syringe 10 mg/ml	Generic	ANTIHYPERTENSIVE THERAPY	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
FUZEON SUBCUTANEOUS RECON SOLN 90 MG	Brand Name	ANTIVIRALS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
FYARRO INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
FYLNETRA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML	Brand Name	BIOTECHNOLOGY DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
gabapentin oral capsule 100 mg, 300 mg, 400 mg	Generic	ANTICONVULSANTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
gabapentin oral solution 250 mg/5 ml	Generic	ANTICONVULSANTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
gabapentin oral tablet 600 mg, 800 mg	Generic	ANTICONVULSANTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
GALAFOLD ORAL CAPSULE 123 MG	Brand Name	MISCELLANEOUS HORMONES	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
GAMIFANT INTRAVENOUS SOLUTION 5 MG/ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
GAMMAGARD LIQUID INJECTION SOLUTION 10 %	Brand Name	VACCINES AND MISCELLANEOUS IMMUNOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN 10 GRAM, 5 GRAM	Brand Name	VACCINES AND MISCELLANEOUS IMMUNOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
GAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 20 GRAM/200 ML (10 %), 5 GRAM/50 ML (10 %)	Brand Name	VACCINES AND MISCELLANEOUS IMMUNOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5 %	Brand Name	VACCINES AND MISCELLANEOUS IMMUNOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
GAMMAPLEX INTRAVENOUS SOLUTION 10 %	Brand Name	VACCINES AND MISCELLANEOUS IMMUNOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 40 GRAM/400 ML (10 %), 5 GRAM/50 ML (10 %)	Brand Name	VACCINES AND MISCELLANEOUS IMMUNOLOGICALS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
GATTEX 30-VIAL SUBCUTANEOUS KIT 5 MG	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523.
GAVRETO ORAL CAPSULE 100 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage. Split Fill The specialty drugs on the Accredo Split-Fill list will be dispensed as a 14- or 15-day supply for six (6) consecutive fills during the initial three (3) months of drug therapy. The specialty drugs are dispensed as a 14- or 15-day supply to allow drug dosage adjustments and/or changes in drug therapy, to promote clinical drug therapy management. If a member remains on the specialty drug for longer than three (3) months, Accredo will fill a 30-day supply on the fourth (4th) month of drug therapy.
GAZYVA INTRAVENOUS SOLUTION 1,000 MG/40 ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
gemcitabine intravenous recon soln 1 gram, 2 gram, 200 mg	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml)	Generic	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization.
GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML	Brand Name	GROWTH HORMONES	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML)	Brand Name	GROWTH HORMONES	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
gentamicin injection solution 20 mg/2 ml, 40 mg/ml	Generic	MISCELLANEOUS ANTIINFECTIVES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
gentamicin sulfate (ped) (pf) injection solution 20 mg/2 ml	Generic	MISCELLANEOUS ANTIINFECTIVES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
gentamicin topical cream 0.1 %	Generic	TOPICAL ANTIBACTERIALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
gentamicin topical ointment 0.1 %	Generic	TOPICAL ANTIBACTERIALS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
GENTAMICIN-SODIUM CITRATE INTRA-CATHETER SOLUTION 320 MCG/ML-4 %	Brand Name	MISCELLANEOUS ANTIINFECTIVES	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.)	Brand Name	PSYCHOTHERAPEUTIC DRUGS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 MG	Brand Name	PSYCHOTHERAPEUTIC DRUGS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
GILENYA ORAL CAPSULE 0.5 MG	Brand Name	MULTIPLE SCLEROSIS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
GIMOTI NASAL SPRAY WITH PUMP 15 MG/SPRAY	Brand Name	MISCELLANEOUS GASTROINTESTINAL AGENTS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
GIVLAARI SUBCUTANEOUS SOLUTION 189 MG/ML	Brand Name	MISCELLANEOUS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
GLASSIA INTRAVENOUS SOLUTION 1 GRAM/50 ML (2 %)	Brand Name	MISCELLANEOUS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
glatiramer subcutaneous syringe 20 mg/ml, 40 mg/ml	Generic	MULTIPLE SCLEROSIS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
glatopa subcutaneous syringe 20 mg/ml, 40 mg/ml	Generic	MULTIPLE SCLEROSIS AGENTS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
GLEEVEC ORAL TABLET 100 MG, 400 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage. Split Fill The specialty drugs on the Accredo Split-Fill list will be dispensed as a 14- or 15-day supply for six (6) consecutive fills during the initial three (3) months of drug therapy. The specialty drugs are dispensed as a 14- or 15-day supply to allow drug dosage adjustments and/or changes in drug therapy, to promote clinical drug therapy management. If a member remains on the specialty drug for longer than three (3) months, Accredo will fill a 30-day supply on the fourth (4th) month of drug therapy.
GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG	Brand Name	ANTINEOPLASTIC AND IMMUNOSUPPRESSANT DRUGS	eviCore PA If the indication is CANCER, and the drug is subject to management by eviCore Comprehensive Oncology Management Program, please contact (888) 910-1199 for additional assistance. Claims where there is a Prior Authorization requirement will have claims checked against the quantities and approvals obtained in the Prior Authorization. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG	Brand Name	GLUCOSE ELEVATING AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
GLUCAGON (HCL) EMERGENCY KIT INJECTION RECON SOLN 1 MG	Brand Name	GLUCOSE ELEVATING AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
glucagon emergency kit (human) injection recon soln 1 mg	Generic	GLUCOSE ELEVATING AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 1,000 MG, 500 MG	Brand Name	NON-INSULIN HYPOGLYCEMIC AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
GLYCOPYRROLATE (PF) IN WATER INJECTION SYRINGE 0.2 MG/ML	Brand Name	ANTIDIARRHEALS AND ANTISPASMODICS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
glycopyrrolate (pf) injection syringe 0.6 mg/3 ml (0.2 mg/ml)	Generic	ANTIDIARRHEALS AND ANTISPASMODICS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
glycopyrrolate injection solution 0.2 mg/ml	Generic	ANTIDIARRHEALS AND ANTISPASMODICS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
glydo mucous membrane jelly in applicator 2 %	Generic	TOPICAL ANESTHETICS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
GLYRX-PF INJECTION SOLUTION 0.2 MG/ML	Brand Name	ANTIDIARRHEALS AND ANTISPASMODICS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
GLYRX-PF INJECTION SYRINGE 0.6 MG/3 ML (0.2 MG/ML), 1 MG/5 ML (0.2 MG/ML)	Brand Name	ANTIDIARRHEALS AND ANTISPASMODICS	PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG	Brand Name	NON-INSULIN HYPOGLYCEMIC AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 24HR 137 MG	Brand Name	ANTIPARKINSONISM AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851.
GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 24HR 68.5 MG	Brand Name	ANTIPARKINSONISM AGENTS	PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 300 MG, 600 MG	Brand Name	ANTICONVULSANTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851.
granisetron hcl oral tablet 1 mg	Generic	MISCELLANEOUS GASTROINTESTINAL AGENTS	Quantity Limit Based on FDA recommended prescribing and safety information, our Quantity Management rules ensure that our members are receiving the most clinically effective dosages of medication (treatment endpoints and frequency). Physicians can call Express Scripts at (800) 753-2851. PICA This specialty drug is available through the NYC employee program called PICA. NYC municipal employees can contact Accredo customer service at (800) 467-2006 and inquire about drug coverage.
GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, 480 MCG/1.6 ML	Brand Name	BIOTECHNOLOGY DRUGS	Accredo Specialty medications must be obtained through Accredo. Please call Accredo at (800) 803-2523. PA Certain medications require prior authorization. Your pharmacist will help you arrange for these drugs. Prescribers, call Express Scripts at (800) 753-2851. PICA This specialty drug is avail