PRESCRIPTION DRUG - Public Employees' Benefits Program (PEBP)

$ levobunolol hcl (M) X$ metipranolol (M) X$ pilocarpine hcl (M) X$ timolol maleate (M) X$$$$$ ALPHAGAN P X$$$$ AZOPT X$$$ BETAGAN* X levobunolol hcl$$$ BETIMOL X levobunolol, timolol$$$ BETOPTIC S X$$$$$ COSOPT X timolol + AZOPT$$$$$ COMBIGAN X timolol + brimonidine$$$$$ IOPIDINE X$$ ISOPTO CARBACHOL X$$ ISOPTO-CARPINE X$$$$$ LUMIGAN X TRAVATAN, XALATAN$$$ OPTIPRANOLOL* X metipranolol$$ PHOSPHOLINE IODIDE X$$ PILOPINE HS X$$ PROPINE* X dipivefrin$$$$ RESCULA X TRAVATAN, XALATAN$$$ TIMOPTIC* X timolol maleate$$$$$ TRAVATAN X$$$$$ TRAVATAN Z X$$$ TRUSOPT X AZOPT$$$$ XALATAN X14.6 OTHER OPHTHALMIC DRUGS$ atropine sulfate (M) X$ azelastine x$ bromefenac x$ cromolyn sodium (M) X$ flucaine (M) X$ flurbiprofen sodium (M) X$ tropicamide (M) X$$$$$ ACULAR X$$$$ ACULAR LS X$$$$$ ACULAR PF X$$$$ ACUVAIL 0.45% X$$$$ ALAMAST X cromolyn sodium, PATANOL$$$$$ ALOCRIL X cromolyn sodium, PATANOL$$$$$ ALOMIDE X ACULAR/PF, LIVOSTIN(ST) history of bromefenac,diclofenac or flurbiprofen X bromefenac, diclofenac, flurbiprofen$$$$$ BROMDAY$$$ CROLOM* X cromolyn sodium$$$$$ ELESTAT X$$$$ EMADINE X PATANOL$$ ISOPTO HOMATROPINE X$$$$$ LACRISERT(PAR) Ophthalmologist Prescribedonly and trial of OTC artificial tears X OTC artificial tears$$$$$ LASTACAFT (ST) history of azelastine X$$$$$ LATISSE Not Covered$$$$ LIVOSTIN X$$$ NEVANAC X VOLTAREN$$$ OCUFEN* X flurbiprofen sodium$$$$ OPTIVAR X PATANOL$$$$$ PATADAY X PATANOL$$$$$ PATANOL X$$$$$ RESTASIS(PAR) Ophthalmologist Prescribedonly X OTC products for dry eyes$$$ VOLTAREN X$$$$ ZADITOR Not Covered OTC ALAWAY15.1.1 BETA-2 ADRENERGIC DRUGS$ albuterol (M) QLL=2 inhalers/Month X$ albuterol sulfate (M) X$ metaproterenol (M) X$ terbutaline sulfate (M) X$$$ ACCUNEB X albuterol sulfate$$$ ALUPENT QLL= 3 inhalers/Rx X PROVENTIL HFA$$$ BRETHINE* X terbutaline sulfate$$$$$ BROVANA (PAR) QLL= 60 vials/Rx X$$$$$ FORADIL QLL=120 caps/Rx X$$$$$ MAXAIR AUTOHALER QLL=2 inhalers/Rx X albuterol, PROVENTIL HFA$$$$$ PERFOROMIST (PAR) QLL=60 vials/Rx XBROVANA, FORADIL, SEREVENTDISKUS$$$ PROAIR HFA QLL=2 inhalers/Month X$$$ PROVENTIL HFA QLL=2 inhalers/Month X!!!!! SEREVENT DISKUS QLL=120 disks/Rx X$$$ VENTOLIN HFA QLL=2 inhalers/Month X PROVENTIL HFA$$$ VOSPIRE* X albuterol sulfate!!!!! XOPENEX X albuterol$$$$ XOPENEX HFA X PROVENTIL HFA15.1.2 METHYL XANTHINE DRUGS$ aminophylline (M) X$ theophylline (M) X$ theophylline anhydrous (M) X$$ LUFYLLIN X$$ THEO-24 X theophylline, theophylline anhydrous$$$ UNIPHYL* X theophylline15.1.3 OTHER DRUGS FOR ASTHMA$ cromolyn sodium (M) X$ ipratropium bromide (M) X!!!!! ADVAIR DISKUSQLL=60 disks/Rx (ST) history ofFLOVENT (HFA) and albuterol(PAR) required 500/50 age edit >50X!!!!! ADVAIR HFAQLL= 1 inhalers/Rx (ST) history ofFLOVENT (HFA) and albuterolX$$$ AEROBID QLL=3 inhalers/Rx X ASMANEX, FLOVENT HFA$$$ AEROBID-M QLL=3 inhalers/Rx X ASMANEX, FLOVENT HFA$$$ ALVESCOQLL=2 inhalers/Rx (ST) history ofFLOVENT (HFA) Age edit of 12and older X ASMANEX, FLOVENT HFA(ST) History of treatment with$$$$$ ARCAPTA NEOHALERalbuterolX$$$ ASMANEX QLL=2 inhalers/Rx X$$$$$ ATROVENT HFA QLL=3 inhalers/Rx X$$$$$ COMBIVENT QLL=3 inhalers/Rx X21