Drug List - P

P
Drug Name Tier Restrictions
PAMELOR 3 Prior authorization, Step therapy
PANCREAZE 2
PANCRELIPASE CAP 5000UNIT 1
PANDEL 3 Quantity limit
PANTOPRAZOLE SODIUM NC
PARAGARD INTRAUTERINE COPPE IUD $0
PARI TREK COMBO PAK NC
PARI TREK S COMPACT COMPRESS NC Prior authorization
PARI TREK S PORTABLE POWER KIT POWER NC Prior authorization
PARICALCITOL CAP 1
PARLODEL 3 Prior authorization
PAROMOMYCIN SULFATE 1
PAROXETINE ER 1
PAROXETINE HCL 1
PATADAY SOL 3 Prior authorization
PATANESE 3 Prior authorization, Quantity limit
PATANOL 3 Prior authorization
PAXIL 3 Prior authorization
PAZEO DRO 0.7% 3
PEG 3350 SOL ELECTROL 1
PEG-INTRON KIT 2
PEG-INTRON REDIPEN PAK 4 KIT 80MCG RP UD 2
PEGASYS INJ 180MCG/M UD 2
PEGASYS KIT 2
PENICILLIN V POTASSIUM 1
PENTASA 2
PENTAZOCINE/ACETAMINOPHEN 1
PENTOXIFYLLINE ER 1
PEPCID TAB 40MG NC
PERCOCET 3 Prior authorizaton
PERIDEX RINSE 3 Quantity limit
PERINDOPRIL TAB
PERMAX 2
PERMETHRIN 1 Quantity limit
PERPHENAZINE 1
PHENAZOPYRIDINE 1
PHENELZINE TAB 15MG 1
PHENOBARBITAL 1
PHENTERMINE HCL 1
PHENYLERPHRINE 1
PHENYTEK 1
PHENYTOIN 1
PHOS FLUR 1 Quantity limit
PHOS-NAK 1
PHOSLO 2
PILOCARPINE HCL 1
PILOPINE HS 3 Prior authorization
PINDOLOL 1
PIOGLITAZONE 1
PIOGLITAZONE/GLIMEPIRIDE 1
PIROXICAM 1
PLAVIX 3 Prior authorization
PLEGRIDY 2
PLENDIL 3 Prior authorizaton
PLEXION 3 Quantity limit
PODOFILOX SOL 0.5% 1
POLY-VITAMIN/FLUORIDE 1*
POLY-VITAMIN/IRON/FLUORIDE DRO 1*
POLYETHYLENE GLYCOL NC
POLYMYXIN B/ SOL TRIMETHP 1
POMALYST 3 Prior authorizaton
PONSTEL 3 Prior authorizaton
PORTIA-28 1*
POT CITRATE TAB 1080MG 1
POTASSIUM CHLORIDE 1
POTASSIUM CHLORIDE ER 1
PRADAXA 3
PRALUENT 3 Prior authorization
PRAMIPEXOLE TAB 1
PRAMOSONE 1 Quantity limit
PRANDIN 3
PRASCION EMU 1 Quantity limit
PRAVACHOL 3 Prior authorization
PRAVASTATIN SODIUM 1 Quantity limit
PRAZOSIN HCL 1
PRECARE CHW 3
PRECARE PREMIER 3
PRED FORTE 3 Prior authorization
PRED MILD 3
PRED SOD PHO SOL 1% OP 1
PRED-G 3
PRED-G-S.O.P. 3
PREDNICARBATE 1 Quantity limit
PREDNISOLONE 1
PREDNISOLONE ACETATE 1
PREDNISOLONE SODIUM PHOSPHA 1
PREDNISONE 1
PREFEST TAB 3
PREMARIN 3
PREMARIN W/APP CREAM 2
PREMPHASE 3
PREMPRO 3
PRENATAL 19 1
PRENATAL DHA 3
PRENATAL ELITE 3 Prior authorization
PRENATAL PLUS 1*
PRENATE CAP ENHANCE 3
PREVACID NC
PREVACID SOLUTAB (AGE RESTRICTION 4-12 YEARS OLD) 2
PREVALITE 1
PREVIDENT 3 Prior authorization, Quantity limit
PREVIFEM 1
PREVPAC NC Prior authorization, Step therapy
PREZCOBIX TAB 800-150 3 Prior authorization
PREZISTA 2
PRILOSEC NC
PRIMACARE ONE 3
PRIMAQUINE PHOSPHATE 3
PRIMIDONE 1
PRINIVIL 3
PRINZIDE 3
PRISTIQ 3
PROAIR MDI 3 Prior authorization, Step therapy
PROAMATINE 3
PROBENECID 1
PROCAINAMIDE HCL 1
PROCARDIA 3
PROCARDIA XL 3 Prior authorizaton
PROCHLORPERAZINE 1
PROCRIT INJ 2000U/ML UD 2 Prior authorization, Quantity limit
PROCTOFOAM-HC AER 3 Quantity limit
PROCTOFOAM-NS AER 3 Quantity limit
PROCTOZONE-HC 1 Quantity limit
PROGESTERONE IN OIL 3
PROGRAF $0
PROGUANIL 1 Travel
PROLENSA SOL 0.07% 3
PROMETHAZINE 1
PROMETHAZINE/CODEINE 1
PROMETRIUM 2
PRONEB ULTRA II ADULT $0
PRONEB ULTRA II PEDI $0
PROPAFENONE HCL 1
PROPANTHELINE 1
PROPARACAINE HCL 1
PROPECIA NC Quantity limit
PROPIMEX-2 2
PROPRANOLOL 1
PROSCAR 3 Prior authorization
PROSED EC 3
PROTONIX NC
PROTOPIC 3 Prior authorization, Quantity limit
PROTRIPTYLINE
PROVENT 3
PROVENTIL AER HFA 3 Prior authorization, Quantity limit
PROVIGIL 3 Prior authorization
PROZAC 3 Prior authorization
PROZAC WEEKLY 3 Prior authorization, Step therapy
PRUDOXIN 2 Prior authorization, Quantity limit, Step therapy
PSORCON E 3 Prior authorization, Quantity limit, Step therapy
PULMICORT FLEXHALER 2 Quantity limit
PULMICORT RESPULES 2
PULMOZYME 2
PURALUBE TEARS 1
PYLERA CAP 3 Prior Authorization
PYRAZINAMIDE $0
PYRIDOSTIGMINE 1
PYRIDOXINE $0