abc and choices 3-tier rx drug list - messa
TRANSCRIPT
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Abilify * aripiprazole 1 1 NoAbiraterone acetate 1 1 QL NoAbstral 3 3 PA, QL NoAcanya * clindamycin phos/benzoyl perox 1 1 NoAccolate * zafirlukast 1 1 QL NoAccrufer 3 3 PA, QL No
Accupril * quinapril hcl 1Free as
preventiveNo
Accuretic * quinapril/hydrochlorothiazide 1Free as
preventiveNo
Accutane capsule 1 1 No
Aceon * perindopril erbumine 1Free as
preventiveNo
Acetasol HC; Vosol HC * hydrocortisone/acetic acid 1 1 NoAcetic Acid * acetic acid 1 1 NoAciphex tablet * rabeprazole sodium 1 1 QL NoAclovate * alclometasone dipropionate 1 1 NoActemra Actpen, syringe 2 2 PA, QL YesActhar H.P. 3 3 PA, QL YesActigall * ursodiol 1 1 NoActimmune 2 2 YesActiq * fentanyl citrate 1 1 PA, QL NoActivella * estradiol/norethindrone acet 1 1 NoActonel * risedronate sodium 1 1 QL NoActoplus Met * pioglitazone hcl/metformin hcl 1 1 NoActoplus Met XR 3 3 NoActos * pioglitazone hcl 1 1 NoAcular, LS * ketorolac tromethamine 1 1 NoAcuvail 3 3 NoAcyclovir * acyclovir 1 1 NoAczone 5% * dapsone 1 1 QL No
Adacel Free as
preventiveFree as
preventiveQL No
Adalat CC; Procardia, XL * nifedipine 1Free as
preventiveNo
Adapin; Sinequan * doxepin hcl 1 1 No
Medications covered by MESSA Choices with 3-Tier Rx and MESSA ABC with 3-Tier Rx with and without mandatory mail
This list is current as of 9/23/2021. It is subject to change without notice. If you have a question about any drug, call MESSA Member Services at 800.336.0013.
Use this list to find information about drug coverage and therapeutic options. This list is ordered alphabetically and includes generic and brand name drugs. Drugs are identified according to their tier placement; prior authorization (PA), step therapy (ST) or quantity limit (QL) requirements are noted where applicable. We encourage you to talk to your doctor to find the right drug therapies that your health plan covers. This chart contains tier information for Choices plans and ABC plans. Please refer to the appropriate column for medication details. If your 3-Tier Rx plan includes mandatory mail, please refer to the list of long-term maintenance medications requiring home delivery to see if your drug requires home delivery.
Up to 34-day supply 90-day supplySpecific preventive medications are covered 100 percent with no deductible required. Age and gender limits apply. ***ABC plans have a list of specific preventive medications in addition to those mandated by federal law.
No cost to you No cost to you
Tier 1Generics
Tier 2Most brand drugs with no generic equivalent
Tier 3Most brand drugs with a generic equivalent or therapeutic alternative
Note: The amount you pay for brand name medications varies because coinsurance is based on the price of the drug when it is filled. If you obtain a brand name drug when a Tier 1 drug is available, you will pay the Tier 3 coinsurance plus the difference in cost between the Tier 1 drug and the brand name drug. These drugs are identified with an asterisk (*) in the list below. A drug may switch from one tier to another. Up to a 90-day supply of insulin may be obtained for the same amount as a 34-day supply from any in-network provider. All over the counter (OTC) medications are excluded from coverage except the Affordable Care Act (ACA) mandated OTC medications.
$10 copayment $25 copayment
20 percent coinsurance $40 minimum - $80 maximum
20 percent coinsurance $100 minimum - $200 maximum
20 percent coinsurance $60 minimum - $100 maximum
20 percent coinsurance $150 minimum - $250 maximum
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Adcirca * tadalafil, Alyq 1 1 PA, QL YesAdderall * dextroamphetamine/amphetamin e 1 1 QL NoAdderall XR * dextroamphetamine/amphetamin e 1 1 QL NoAddyi 3 3 PA, QL NoAdempas 2 2 PA, QL Yes
Adipex-P * phentermine hcl 1Free as
preventiveNo
Adoxa capsule * doxycycline monohydrate 1 1 PA NoAdoxa tablet * doxycycline monohydrate 1 1 PA NoAdvair Diskus 1 1 QL NoAdvair HFA fluticasone-salmeterol, Wixela Inhub 1 1 QL NoAdzenys ER 3 3 PA, QL NoAdzenys XR-ODT 3 3 PA, QL NoAfinitor *, Disperz Everolimus 1 1 PA, QL Yes
Afluria Free as
preventiveFree as
preventiveQL No
Afluria Quad Free as
preventiveFree as
preventiveQL No
Afrezza 3 3 ST NoAggrenox * aspirin/dipyridamole 1 1 NoAgrylin * anagrelide hcl 1 1 NoAimovig 2 2 PA, QL NoAjovy 2 2 PA, QL NoAktipak 3 3 NoAkynzeo 3 3 PA, QL NoAla-Cort * hydrocortisone 1 1 NoAla-scalp HP * hydrocortisone 1 1 NoAlbenza * albendazole 1 1 QL NoAlbuterol nebulizer solution * albuterol sulfate 1 1 No
Aldactazide * spironolact/hydrochlorothiazid 1Free as
preventiveNo
Aldactazide 50/50mg 3 3 No
Aldactone * spironolactone 1Free as
preventiveNo
Aldara * imiquimod 1 1 No
Aldomet * methyldopa 1Free as
preventiveNo
Aldoril * methyldopa/hydrochlorothiazide 1Free as
preventiveNo
Alecensa 2 2 PA, QL Yes
Alesse; Levlite * levonorgestrel-ethin estradiol, afirmelleFree as
preventiveFree as
preventiveNo
Alferon N 2 2 NoAlinia * Nitazoxanide 1 1 NoAlkeran tablet * melphalan 1 1 NoAlocril 3 3 NoAlomide 3 3 NoAlora 2 2 NoAlphagan 0.2%, P 0.15% * brimonidine tartrate 1 1 NoAlphagan P 0.1% 2 2 NoAlrex 3 3 NoAlsuma * sumatriptan succinate 1 1 QL No
Altace * ramipril 1Free as
preventiveNo
Altreno 3 3 QL NoAlunbrig 2 2 PA, QL YesAlupent * metaproterenol sulfate 1 1 NoAmaryl * glimepiride 1 1 NoAmbien * zolpidem tartrate 1 1 QL NoAmbien CR * zolpidem tartrate 1 1 QL NoAmerge * naratriptan hcl 1 1 QL NoAmicar * aminocaproic acid 1 1 NoAmicar solution 2 2 NoAmitiza 2 2 QL NoAmnesteem; Claravis; Myorisan; Zenatane * isotretinoin 1 1 QL NoAmoxapine * amoxapine 1 1 NoAmoxil * amoxicillin 1 1 NoAmphetamine suspension 3 3 PA, QL No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Ampicillin * ampicillin trihydrate 1 1 NoAmpyra * dalfampridine 1 1 PA, QL YesAnadrol-50 3 3 NoAnafranil * clomipramine hcl 1 1 NoAnalpram-HC 1-1% cream 2 2 NoAnalpram-HC cream 2.5-1%, 1-1% * hydrocortisone/pramoxine 1 1 NoAnamantle HC * lidocaine/hydrocortisone ac 1 1 NoAnamantle HC Forte * lidocaine/hydrocortisone ac 1 1 NoAnamantle HC Kit * lidocaine/hydrocortisone ac 1 1 NoAnaprox, DS * naproxen sodium 1 1 NoAncobon * flucytosine 1 1 NoAndroderm 2 2 PA, QL NoAndrogel * testosterone 1 1 PA, QL NoAndroid, Testred * methyltestosterone 1 1 NoAngeliq 3 3 NoAnoro Ellipta 2 2 QL NoAnsaid * flurbiprofen 1 1 No
Antabuse * disulfiram 1Free as
preventiveNo
Antara * fenofibrate,micronized 1Free as
preventiveNo
Antara 30, 90mg 3 3 NoAntivert * meclizine hcl 1 1 NoApexicon E * diflorasone diacetate/emoll 1 1 NoApokyn 2 2 QL Yes
Apresoline * hydralazine hcl 1Free as
preventiveNo
Apriso * Mesalamine Er 1 1 NoAptensio XR * Methylphenidate ER 1 1 QL NoAptiom 3 3 ST, QL NoAptivus 2 2 NoArakoda 3 3 QL NoAralen * chloroquine phosphate 1 1 NoAranesp 3 3 PA YesArava * leflunomide 1 1 NoArcalyst 2 2 PA YesArcapta Neohaler 3 3 QL NoAricept 23mg * donepezil hcl 1 1 QL NoAricept 5, 10mg; ODT * donepezil hcl 1 1 NoArikayce 2 2 PA, QL Yes
Arimidex * anastrozoleFree as
preventiveFree as
preventivePA No
Aristocort; Kenalog 0.5% * triamcinolone acetonide 1 1 NoArixtra * fondaparinux sodium 1 1 NoArmonair Respiclick 3 3 QL NoArmour Thyroid * thyroid,pork 1 1 NoArmour Thyroid 15mg, 30mg, 60mg, 3 3 NoArnuity Ellipta 2 2 QL No
Aromasin * exemestaneFree as
preventiveFree as
preventivePA No
Artane * trihexyphenidyl hcl 1 1 NoArthrotec * diclofenac sodium/misoprostol 1 1 NoAsacol HD * mesalamine 1 1 NoAsmanex, HFA 2 2 QL No
Aspirin; Ecotrin 81mg, 325mg (OTC) aspirinFree as
preventiveFree as
preventiveNo
Astagraf XL 3 3 YesAstelin nasal spray * azelastine hcl 1 1 QL NoAstepro nasal spray * azelastine hcl 1 1 QL No
Atacand * candesartan cilexetil 1Free as
preventiveNo
Atacand HCT * candesartan/hydrochlorothiazid 1Free as
preventiveNo
Atarax * hydroxyzine hcl 1 1 NoAtelvia * risedronate sodium 1 1 ST, QL NoAtivan * lorazepam 1 1 NoAtralin * tretinoin 1 1 NoAtripla * Efavirenz-Emtric-Tenof Disop 1 1 No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Atrovent HFA 2 2 QL NoAtrovent nasal spray * ipratropium bromide 1 1 QL NoAtrovent solution * ipratropium bromide 1 1 QL NoAubagio 3 3 QL YesAugmentin 125mg-31.25mg/ml suspension 2 2 NoAugmentin, ES, XR * amoxicillin/potassium clav 1 1 NoAuralgan * aa/antipyrin/bcaine/polico1/al 1 1 No
Aurovela 24 FeFree as
preventiveFree as
preventiveNo
Auryxia 3 3 NoAustedo 3 3 PA, QL Yes
Avalide * irbesartan/hydrochlorothiazide 1Free as
preventiveNo
Avandia 3 3 No
Avapro * irbesartan 1Free as
preventiveNo
AVC 3 3 NoAvelox * moxifloxacin hcl 1 1 NoAventyl; Pamelor * nortriptyline hcl 1 1 NoAvidoxy 100mg * doxycycline monohydrate 1 1 NoAvinza * morphine sulfate 1 1 QL NoAvita gel 3 3 NoAvodart * dutasteride 1 1 NoAvonex 2 2 QL YesAxert * almotriptan malate 1 1 ST, QL NoAxid (Rx only) * nizatidine 1 1 NoAxiron * testosterone 1 1 ST, QL NoAygestin * norethindrone acetate 1 1 NoAyvakit tablet 2 2 YesAzasan 3 3 NoAzasite 3 3 NoAzelex 3 3 NoAzilect * rasagiline mesylate 1 1 NoAzopt* brinzolamide drops 1 1 No
Azor * amlodipine bes/olmesartan med 1Free as
preventiveNo
Azstarys 3 $3 PA, QL NoAzulfidine, EN-tab * sulfasalazine 1 1 NoBacitracin * bacitracin 1 1 NoBaciguent ointment 3 3 NoBaclofen * baclofen 1 1 NoBaclofen 5mg 3 3 NoBactroban ointment * mupirocin 1 1 NoBafiertam capsule 3 3 YesBalcoltra 3 3 NoBalversa tablet 3 3 YesBanzel* Rufinamide suspension 1 1 PA, QL NoBaraclude * entecavir 1 1 YesBaraclude solution 2 2 YesBasaglar Kwikpen U-100 3 3 NoBaxdela tablet 3 3 NoBeconase AQ 3 3 ST, QL NoBelbuca* buprenorphine hcl 1 1 PA, QL NoBelsomra 3 3 ST, QL NoBenadryl (Rx Only) * diphenhydramine hcl 1 1 No
Benicar * olmesartan medoxomil 1Free as
preventiveNo
Benicar HCT * olmesartan/hydrochlorothiazide 1Free as
preventiveNo
Benlysta 2 2 PA, QL YesBentyl * dicyclomine hcl 1 1 NoBenzaclin * clindamycin phos/benzoyl perox 1 1 NoBenzamycin * erythromycin/benzoyl peroxide 1 1 NoBenznidazole 2 2 QL NoBepreve* bepotastine besilate drops 1 1 NoBesivance 3 3 NoBetagan * levobunolol hcl 1 1 No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?
Betapace, AF * sotalol hcl 1Free as
preventiveNo
Betaseron 3 3 QL YesBethkis * Tobramycin Ampul-Neb 1 1 PA, QL YesBetimol 2 2 NoBetoptic S 2 2 No
Betoptic solution * betaxolol hcl 1Free as
preventiveNo
Bevespi Aerosphere 3 3 QL NoBevyxxa tablet 3 3 QL No
Beyaz * drospir/eth estra/levomefol caFree as
preventiveFree as
preventiveNo
Biaxin, XL * clarithromycin 1 1 NoBidil 2 2 NoBiktarvy 2 2 QL NoBiltricide * praziquantel 1 1 NoBinosto 3 3 ST, QL No
Bisacodyl OTC * bisacodylFree as
preventiveFree as
preventiveQL No
Bleph-10 ointment * sulfacetamide sodium 1 1 NoBleph-10, Sodium Sulamyde drops * sulfacetamide sodium 1 1 NoBlephamide 2 2 No
Blocadren * timolol maleate 1Free as
preventiveNo
Boniva * ibandronate sodium 1 1 QL NoBonjesta 3 3 PA, QL No
Bontril * phendimetrazine tartrate 1Free as
preventiveNo
Boostrix Free as
preventiveFree as
preventiveQL No
Bosulif 2 2 PA, QL YesBraftovi 2 2 PA, QL YesBravelle 2 2 YesBreo Ellipta 2 2 QL NoBrethine * terbutaline sulfate 1 1 NoBrilinta 2 2 NoBrisdelle * paroxetine mesylate 1 1 QL NoBriviact 3 3 PA, QL NoBromday; Xibrom * bromfenac sodium 1 1 NoBromfed-DM * brompheniramine/pseudoephed/ dm 1 1 NoBronchitol capsule with device 3 3 PA, QL NoBrovana* arformoterol tartrate vial-neb 3 3 NoBryhali 3 3 QL No
Bumex * bumetanide 1Free as
preventiveNo
Bunavail 3 3 QL NoBuphenyl powder * sodium phenylbutyrate 1 1 NoBuphenyl tablet * sodium phenylbutyrate 1 1 QL NoBuprenorphine 7.5 mcg/hr patch 2 2 QL NoBupropion Hcl XL 450mg 3 3 ST, QL NoBuspar * buspirone hcl 1 1 NoButisol sodium 3 3 NoButrans * buprenorphine 2 2 QL NoButrans 7.5mcg/hr 2 2 QL NoBynfezia pen injector 3 3 PA, QL YesBystolic 2.5, 5, 10mg 3 3 ST NoBystolic 20mg 3 3 ST NoByvalson 3 3 QL NoCabometyx 2 2 PA, QL Yes
Caduet * amlodipine/atorvastatin 1Free as
preventiveQL No
Cafcit * caffeine citrate 1 1 NoCafergot * ergotamine tartrate/caffeine 1 1 QL No
Calan SR; Isoptin SR * verapamil hcl 1Free as
preventiveNo
Calciferol (Rx Only) * ergocalciferol (vitamin d2) 1 1 NoCalquence 2 2 PA, QL Yes
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?
Campral * acamprosate calcium 1Free as
preventiveNo
Canasa * mesalamine 1 1 NoCapex shampoo 2 2 No
Capoten * captopril 1Free as
preventiveNo
Capozide * captopril/hydrochlorothiazide 1Free as
preventiveNo
Caprelsa 2 2 PA, QL YesCarafate suspension 2 2 NoCarafate tablet, suspension * sucralfate 1 1 NoCarbaglu 2 2 PA YesCarbatrol * carbamazepine 1 1 No
Cardene * nicardipine hcl 1Free as
preventiveNo
Cardizem LA 120mg 3 3 No
Cardizem, CD, LA, SR * diltiazem hcl, diltiazem 24hr ER 1Free as
preventiveNo
Cardura * doxazosin mesylate 1Free as
preventiveNo
Cardura XL 3 3 NoCarnitor * levocarnitine 1 1 NoCarnitor SF* levocarnitine SF 1 1 NoCarnitor solution * levocarnitine (with sugar) 1 1 NoCarospir 3 3 NoCasodex * bicalutamide 1 1 NoCataflam * diclofenac potassium, Cataflam 1 1 No
Catapres * clonidine hcl 1Free as
preventiveNo
Catapres-TTS * clonidine 1Free as
preventiveNo
Caverject 2 2 PA, QL NoCayston 3 3 PA, QL YesCeclor, ER * cefaclor 1 1 NoCeftin * cefuroxime axetil 1 1 NoCefzil * cefprozil 1 1 NoCelebrex * celecoxib 1 1 NoCelexa * citalopram hydrobromide 1 1 NoCellcept * mycophenolate mofetil 1 1 YesCelontin 3 3 NoCequa 3 3 PA, QL NoCerdelga 3 3 PA, QL YesCesamet 3 3 NoCetraxal * ciprofloxacin hcl 1 1 NoCetrotide 2 2 YesCetylev 3 3 NoChantix 2 2 QL No
Chantix Free as
preventiveFree as
preventiveST, QL No
Chemet 2 2 NoChenodal 3 3 PA YesCheratussin AC 3 3 NoChlorzoxazone 1 1 NoCholbam 2 2 PA, QL YesChorionic Gonadotropin 3 3 PA YesCialis * tadalafil 1 1 PA, QL NoCialis 2.5mg, 5mg * tadalafil 1 1 PA, QL NoCiloxan drops * ciprofloxacin hcl 1 1 NoCiloxan ointment 2 2 NoCimduo 2 2 QL NoCimzia syringe 3 3 PA, QL YesCipro HC 3 3 NoCipro suspension * ciprofloxacin 1 1 NoCipro tablet * ciprofloxacin hcl 1 1 NoCipro XR * ciprofloxacin/ciprofloxa hcl 1 1 NoCiprodex 2 2 NoCiprofloxacin HCL- Fluocinolone 2 2 No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?
Citrate of Magnesia OTC * magnesium citrateFree as
preventiveFree as
preventiveQL No
Clarinex * desloratadine 1 1 QL NoClarinex syrup 3 3 NoClarinex-D 3 3 QL NoClenpiq 3 3 NoCleocin capsule * clindamycin hcl 1 1 NoCleocin solution * clindamycin palmitate hcl 1 1 NoCleocin vaginal cream * clindamycin phosphate 1 1 NoCleocin vaginal ovules 3 3 NoCleocin-T, swabs * clindamycin phosphate 1 1 NoClimara * estradiol 1 1 NoClimara Pro 3 3 NoClindesse 3 3 NoClinoril * sulindac 1 1 NoClobevate; Temovate * clobetasol propionate 1 1 NoClobex, spray * clobetasol propionate 1 1 NoClocortolone pivalate 2 2 NoCloderm 2 2 NoClomid * clomiphene citrate 1 1 NoClozapine 200mg * clozapine 1 1 NoClozapine ODT * clozapine ODT 1 1 NoClozaril * clozapine 1 1 NoCoartem 2 2 NoCodeine sulfate tablet * codeine sulfate 1 1 QL NoCoditussin AC 3 3 NoCogentin * benztropine mesylate 1 1 NoColazal * balsalazide disodium 1 1 NoColbenemid * probenecid/colchicine 1 1 NoColchicine capsule 3 3 NoColchicine tablet 2 2 NoColcrys 2 2 No
Colestid * colestipol hcl 1Free as
preventiveNo
Colestid granules, packet 3 3 NoColy-Mycin S 3 3 No
Colyte * peg3350/sod sulf,bicarb,cl/kclFree as
preventiveFree as
preventiveQL No
Colyte * peg3350/sod sulf,bicarb,cl/kcl 1 1 NoCombigan 3 3 NoCombipatch 3 3 NoCombivent Respimat 2 2 NoCombivir * lamivudine/zidovudine 1 1 NoCombunox * ibuprofen/oxycodone hcl 1 1 QL NoCometriq 2 2 PA, QL Yes
Commit Lozenge OTC * nicotine polacrilexFree as
preventiveFree as
preventiveQL No
Compazine suppository * prochlorperazine 1 1 NoCompazine tablet * prochlorperazine maleate 1 1 NoComplera 2 2 QL NoComplete Natal DHA combo package 2 2Comtan * entacapone 1 1 No
Conceptrol Free as
preventiveFree as
preventiveQL No
Concerta * methylphenidate hcl 1 1 NoCondylox gel 2 2 NoCondylox solution * podofilox 1 1 NoContrave 3 3 PA, QL NoCopaxone * glatiramer acetate 1 1 QL YesCopegus * ribavirin 1 1 YesCopiktra 2 2 PA, QL YesCordarone; Pacerone * amiodarone hcl 1 1 NoCordran cream, ointment * flurandrenolide 1 1 NoCordran tape 2 2 No
Coreg CR * carvedilol phosphate 1Free as
preventiveQL No
Coreg immediate-release * carvedilol 1Free as
preventiveNo
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?
Corgard * nadolol 1Free as
preventiveNo
Corlanor 2 2 PA, QL NoCortef; Hydrocortisone * hydrocortisone 1 1 NoCortenema * hydrocortisone 1 1 NoCortifoam 3 3 NoCortisone acetate * cortisone acetate 1 1 NoCortisporin * neomycin/polymyxin b/hydrocort 1 1 NoCortisporin cream 0.5% 3 3 NoCortisporin eye drops * neomycin/polymyxin b/hydrocort 1 1 NoCortisporin eye ointment * neomycin/bacit/p-myx/hydrocort 1 1 NoCortisporin ointment 1% 3 3 No
Corzide * nadolol/bendroflumethiazide 1Free as
preventiveNo
Cosopt * dorzolamide hcl/timolol maleat 1 1 NoCosopt PF * dorzolamide/timolol/pf 1 1 NoCotellic 2 2 PA, QL YesCoumadin * warfarin sodium 1 1 NoCovaryx, H.S. * estrogen,ester/me-testosterone 1 1 NoCoverject syringe 2 2 No
Cozaar * losartan potassium 1Free as
preventiveNo
CPB WC * bromphenira/pseudoephed/codei n 1 1 NoCreon 2 2 NoCresemba capsule 2 2 QL No
Crestor * rosuvastatin calcium 1Free as
preventiveQL No
Crestor* 5mg, 10mg * rosuvastatin calciumFree as
preventiveFree as
preventiveQL No
Crinone 4% 2 2 NoCrinone 8% 2 2 NoCrotan * crotamiton 1 1 NoCutaquig vial 3 3 PA YesCutivate * fluticasone propionate, Beser 1 1 NoCuvitru 3 3 PA YesCuvposa 3 3 NoCyanocobalamin injection * cyanocobalamin (vitamin b-12) 1 1 No
Cyclessa * desogestrel-ethinyl estradiolFree as
preventiveFree as
preventiveNo
Cyclocort * amcinonide 1 1 NoCyclogyl * cyclopentolate hcl 1 1 NoCyclogyl 5ml 3 3 NoCyclomydril 3 3 NoCyclophosphamide capsule * cyclophosphamide 1 1 NoCyclophosphamide tablet 3 3 NoCycloserine 2 2 NoCycloset 3 3 PA, QL NoCymbalta * duloxetine hcl 1 1 NoCystadane 3 3 YesCystagon 2 2 YesCystaran 2 2 PA, QL YesCytomel * liothyronine sodium 1 1 NoCytotec * misoprostol 1 1 NoD.H.E.45 * dihydroergotamine mesylate 1 1 QL NoDaliresp 3 3 PA, QL NoDalmane * flurazepam hcl 1 1 QL NoDanocrine * danazol 1 1 NoDantrium * dantrolene sodium 1 1 NoDapsone * dapsone 1 1 NoDaraprim 2 2 PA YesDaurismo 3 3 PA, QL YesDaypro * oxaprozin 1 1 NoDaytrana 3 3 NoDayvigo 3 3 NoDDAVP * desmopressin acetate 1 1 NoDDAVP solution 3 3 NoDecadron ophthalmic * dexamethasone sodium phosphate 1 1 NoDeclomycin * demeclocycline hcl 1 1 No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Delatestryl * testosterone enanthate 1 1 NoDelestrogen * estradiol valerate 1 1 NoDelestrogen 10mg/ml 3 3 NoDelstrigo 2 2 QL NoDeltasone * prednisone 1 1 NoDelzicol* Mesalamine Dr 1 1 No
Demadex * torsemide 1Free as
preventiveNo
Demerol * meperidine hcl 1 1 QL NoDemser * metyrosine 1 1 No
Demulen * ethynodiol d-ethinyl estradiolFree as
preventiveFree as
preventiveNo
Depakene * valproic acid 1 1 NoDepakote, ER, Sprinkles * divalproex sodium 1 1 NoDepen * Penicillamine 1 1 NoDepo-estradiol 3 3 No
Depo-Provera 150mg * medroxyprogesterone acetateFree as
preventiveFree as
preventiveNo
Depo-Provera 400mg 2 2 NoDepo-subq Provera 104 2 2 NoDepo-Testosterone * testosterone cypionate 1 1 NoDepot, LA 2 2 YesDermacort, Hytone 2.5% * hydrocortisone 1 1 NoDermacort; Hytone 1% (Rx Only) * hydrocortisone 1 1 NoDerma-smoothe-FS * fluocinolone acetonide 1 1 NoDermatop * prednicarbate 1 1 NoDermotic * fluocinolone acetonide oil 1 1 NoDescovy 2 2 PA, QL NoDesferal * deferoxamine mesylate 1 1 No
Desogen; Ortho-cept * desogestrel-ethinyl estradiol, kalligaFree as
preventiveFree as
preventiveNo
Desonate * desonide, desrx gel 1 1 NoDesowen * desonide 1 1 NoDesoxyn * methamphetamine hcl 1 1 NoDesvenlafaxine ER 3 3 ST, QL NoDesyrel * trazodone hcl 1 1 NoDetrol, LA * tolterodine tartrate 1 1 NoDexedrine * dextroamphetamine sulfate 1 1 NoDexilant 3 3 ST NoDexpak * dexamethasone 1 1 NoDiabeta; Micronase * glyburide 1 1 NoDiabinese * chlorpropamide 1 1 NoDiacomit capsule and powder pack 3 3 YesDiamox, Sequels * acetazolamide 1 1 NoDiastat 2.5mg 2 2 NoDiastat 2.5mg * diazepam 1 1 NoDiastat Acudial * diazepam 1 1 No
Dibenzyline * phenoxybenzamine hcl 1Free as
preventivePA, QL No
Diclegis * doxylamine succ-pyridoxine 1 1 PA, QL NoDiclofenac Epolamine patch 3 3 PA, QL NoDicofenac capsule 3 3 PA, QL NoDicloxacillin * dicloxacillin sodium 1 1 No
Didrex * benzphetamine hcl 1Free as
preventiveNo
Didronel * etidronate disodium 1 1 QL NoDifferin 0.1% lotion 3 3 NoDifferin cream, gel * adapalene 1 1 NoDificid 3 3 QL NoDiflucan * fluconazole 1 1 NoDilantin * phenytoin 1 1 NoDilantin 30mg capsule 2 2 NoDilantin; Phenytek capsule * phenytoin sodium extended 1 1 NoDilatrate-SR 2 2 NoDilaudid * hydromorphone hcl 1 1 QL No
Diovan * valsartan 1Free as
preventiveNo
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?
Diovan HCT * valsartan/hydrochlorothiazide 1Free as
preventiveNo
Dipentum 3 3 NoDiprolene cream, lotion; AF * betamethasone/propylene glyc 1 1 NoDiprolene gel, ointment * betamethasone dipropionate/diprop A 1 1 NoDiprolene ointment* betamethasone dipropionate Augmented 1 1 NoDiprosone cream, ointment * betamethasone dipropionate 1 1 NoDiprosone lotion * betamethasone dipropionate 1 1 NoDisalcid * salsalate 1 1 NoDitropan, XL * oxybutynin chloride 1 1 No
Diuril * chlorothiazide 1Free as
preventiveNo
Diuril suspension 3 3 NoDivigel 3 3 NoDolobid * diflunisal 1 1 No
Donnatal*Phenobarbital-Hyposcyamine-Atropine-Scopolamine
1 1 No
Doptelet 3 3 PA, QL YesDoryx * doxycycline hyclate 1 1 PA NoDoryx MPC 3 3 PA NoDostinex * cabergoline 1 1 NoDovato tablet 3 3 NoDovonex * calcipotriene 1 1 NoDoxycycline IR-DR 3 3 PA NoDroxia 2 2 NoDrysol 2 2 NoDuac * clindamycin phos/benzoyl perox 1 1 NoDuavee 3 3 NoDuetact * pioglitazone hcl/glimepiride 1 1 NoDulera 2 2 QL NoDulara HFA 2 2 QL NoDuoneb * ipratropium/albuterol sulfate 1 1 QL NoDuopa 2 2 PA, QL YesDupixent 3 3 PA, QL YesDuragesic * fentanyl 1 1 QL NoDurezol 3 3 NoDuricef * cefadroxil 1 1 NoDutoprol 3 3 NoDyanavel XR 3 3 PA, QL No
Dyazide; Maxzide * triamterene/hydrochlorothiazid 1Free as
preventiveNo
Dymista * Azelastine-Fluticasone spray 3 3 PA, QL NoDynacin * minocycline hcl 1 1 No
Dynacirc * isradipine 1Free as
preventiveNo
Dyrenium * Triamterene capsule 1 1 NoE.E.S. * erythromycin ethylsuccinate 1 1 NoEC-Naproxyn * naproxen 1 1 NoEcoza 3 3 PA, QL NoEdarbi 3 3 ST, QL NoEdarbyclor 3 3 ST, QL No
Edecrin * ethacrynic acid 1Free as
preventiveNo
Edex 3 3 PA, QL NoEdluar 3 3 ST, QL NoEdurant 2 2 QL NoEffexor * venlafaxine hcl 1 1 NoEffexor XR; Venlafaxine hcl ER capsule * venlafaxine hcl 1 1 NoEffexor XR; Venlafaxine hcl ER tablet * venlafaxine hcl 1 1 NoEffient * prasugrel hcl 1 1 NoEfudex * fluorouracil 1 1 NoEgrifta 3 3 PA, QL YesElavil * amitriptyline hcl 1 1 NoEldepryl * selegiline hcl 1 1 NoElepsia XR 3 3 PA, QL NoElestat * epinastine hcl 1 1 NoElestrin 3 3 NoElidel * pimecrolimus 1 1 No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Elimite * permethrin 1 1 NoEliquis 2 2 QL NoElixophyllin 3 3 No
Ella Free as
preventiveFree as
preventiveQL No
Elmiron 2 2 NoElocon cream, lotion, solution * mometasone furoate 1 1 NoElocon ointment * mometasone furoate 1 1 NoEmadine 3 3 NoEmbeda 3 3 PA, QL NoEmcyt 2 2 NoEmend * aprepitant 1 1 QL NoEmend 40mg (1 pack, 5 pack) 2 2 QL NoEmend 40mg * aprepitant 1 1 QL NoEmend suspension 2 2 QL NoEmflaza 3 3 PA YesEmgality 2 2 PA, QL NoEmla * lidocaine/prilocaine 1 1 NoEmsam 3 3 PA, QL NoEmtriva * Emtricitabine 1 1 NoEmverm 3 3 QL NoEnablex * darifenacin hydrobromide 1 1 QL NoEnbrel 2 2 PA, QL YesEndometrin 2 2 No
Enduron * methyclothiazide 1Free as
preventiveNo
Enstilar 3 3 PA, QL NoEntocort EC * budesonide 1 1 NoEntresto 2 2 QL NoEnvarsus XR 3 3 YesEpaned enalapril maleate 1 1 NoEpclusa 2 2 PA, QL YesEpidiolex 3 3 PA, QL YesEpiduo * adapalene/benzoyl peroxide 1 1 NoEpiduo Forte 3 3 PA, QL NoEpifoam 2 2 NoEpinephrine auto-injector 2 2 QL NoEpipen 0.3mg auto-injector * epinephrine 1 1 QL NoEpivir * lamivudine 1 1 NoEpivir HBV * lamivudine 1 1 NoEpivir HBV solution 2 2 NoEpogen 3 3 PA YesEpzicom * abacavir sulfate/lamivudine 1 1 NoEquanil; Miltown * meprobamate 1 1 NoEquetro 3 3 NoErgoloid Mesylates * ergoloid mesylates 1 1 NoErgomar 2 2 QL NoErivedge 2 2 PA, QL YesErleada 2 2 PA, QL YesErtaczo 3 3 NoEryped 200mg/5ml 3 3 NoEryped 400mg/5ml erythromycin ethylsuccinate suspension 1 1 NoEry-tab * erythromycin base 1 1 NoEry-tab 500mg * erythromycin 1 1 NoErythromycin Base * erythromycin base 1 1 NoErythromycin Stearate * erythromycin stearate 1 1 NoErythromycin topical gel, solution, swab * erythromycin base in ethanol 1 1 NoEsbriet 2 2 PA, QL YesEsgic; Fioricet 50/325/40mg * butalb/acetaminophen/caffeine 1 1 QL NoEskalith, CR; Lithobid * lithium carbonate 1 1 NoEsomeprazole strontium 3 3 QL NoEstrace * estradiol 1 1 NoEstring 2 2 NoEstrogel 2 2 No
Estrostep Fe * norethindrone-e.estradiol-ironFree as
preventiveFree as
preventiveNo
Ethambutol * ethambutol hcl 1 1 NoEtrafon * perphenazine/amitriptyline hcl 1 1 No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Eucrisa 3 3 PA, QL NoEulexin * flutamide 1 1 NoEurax 2 2 NoEvamist 3 3 NoEvekeo * amphetamine sulfate 1 1 PA, QL No
Evista * raloxifene hclFree as
preventiveFree as
preventivePA, QL No
Evista * raloxifene hcl 1 1 QL NoEvotaz 2 2 QL NoEvoxac * cevimeline hcl 1 1 NoExalgo * hydromorphone hcl 1 1 QL NoExelderm 3 3 NoExelon capsule * rivastigmine tartrate 1 1 NoExelon patch * rivastigmine 1 1 No
Exforge * amlodipine besylate/valsartan 1Free as
preventiveNo
Exforge HCT * amlodipine/valsartan/hcthiazid 1Free as
preventiveNo
Exjade deferasirox 1 1 PA, QL YesExservan film 3 3 YesExtavia 3 3 QL YesExtina * ketoconazole 1 1 NoFabior 3 3 ST, QL NoFactive 3 3 NoFamvir * famciclovir 1 1 NoFanapt 3 3 ST NoFareston * toremifene citrate 1 1 NoFarxiga 2 2 QL NoFarydak 2 2 PA, QL YesFaslodex * fulvestrant 1 1 NoFazaclo * clozapine 1 1 NoFazaclo 150, 200mg 3 3 No
FC2 Female Condom Free as
preventiveFree as
preventiveQL No
Felbatol * felbamate 1 1 NoFeldene * piroxicam 1 1 NoFemara * letrozole 1 1 No
Femcon Fe * noreth-ethinyl estradiol/ironFree as
preventiveFree as
preventiveNo
FemHRT * norethindrone ac-eth estradiol 1Free as
preventiveNo
Femring 3 3 No
Fenofibric acid 1Free as
preventiveNo
Fenoglide * fenofibrate 1Free as
preventiveNo
Fenoprofen Calcium 200mg, 400mg 3 3 PA, QL NoFenortho 3 3 PA, QL NoFentora 3 3 PA, QL NoFerriprox * Deferiprone table 1 1 PA, QL YesFetzima 3 3 ST, QL NoFexmid * cyclobenzaprine hcl 1 1 NoFiasp, Flextouch, penfill 2 2 NoFinacea foam 3 3 ST, QL NoFinacea gel * azelaic acid 1 1 NoFioricet 50/300/40mg * butalb/acetaminophen/caffeine 1 1 NoFioricet w/codeine 50/300/30mg * butalbit/acetamin/caff/codeine 1 1 QL NoFioricet w/codeine 50/325/30mg * butalbit/acetamin/caff/codeine 1 1 QL NoFiorinal * butalbital/aspirin/caffeine/with codeine 1 1 NoFiorinal w/codeine * codeine/butalbital/asa/caffein 1 1 QL NoFirazyr * icatibant, Sajazir 1 1 PA, QL YesFirvanq 3 3 QL NoFlagyl * metronidazole 1 1 NoFlarex 3 3 NoFlector Patch 3 3 PA, QL NoFlexeril * cyclobenzaprine hcl 1 1 NoFlomax * tamsulosin hcl 1 1 NoFlonase (Rx Only) * fluticasone propionate 1 1 QL No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Florinef * fludrocortisone acetate 1 1 NoFlorone; Psorcon * diflorasone diacetate 1 1 NoFlovent HFA, Diskus 2 2 QL NoFloxin Otic * ofloxacin 1 1 NoFloxin tablet * ofloxacin 1 1 No
Fluad Free as
preventiveFree as
preventiveQL No
Fluarix Free as
preventiveFree as
preventiveQL No
Flublok Quad Free as
preventiveFree as
preventiveQL No
Flucelvax Quad Free as
preventiveFree as
preventiveQL No
Flulaval Free as
preventiveFree as
preventiveQL No
Flumadine * rimantadine hcl 1 1 No
Flumist Free as
preventiveFree as
preventiveQL No
Fluoroplex 3 3 NoFluorouracil 0.5% cream 3 3 ST, QL NoFluoxetine 60mg * fluoxetine hcl 1 1 QL NoFluphenazine decanoate * fluphenazine decanoate 1 1 NoFluphenazine liquid * fluphenazine hcl 1 1 NoFluticasone-salmeterol RespiClick 3 3 QL No
Fluzone Free as
preventiveFree as
preventiveQL No
Fluzone High-dose Free as
preventiveFree as
preventiveQL No
FML * fluorometholone 1 1 NoFML Forte, S.O.P. 2 2 NoFocalin, XR * dexmethylphenidate hcl 1 1 No
Folic Acid 0.4mg, 0.8mg (OTC) * folic acidFree as
preventiveFree as
preventiveNo
Folic Acid 1mg * folic acid 1 1 NoFollistim AQ 3 3 ST YesFortamet * metformin hcl 1 1 PA NoForteo 2 2 PA, QL YesFortesta * testosterone 1 1 ST, QL NoFosamax * alendronate sodium 1 1 QL NoFosamax Plus D 3 3 ST, QL NoFosrenol * lanthanum carbonate 1 1 NoFosrenol packet 3 3 NoFragmin 3 3 NoFrova * frovatriptan succinate 1 1 ST, QL NoFuradantin * nitrofurantoin 1 1 NoFuzeon 2 2 NoFycompa suspension 3 3 QL NoFycompa tablet 3 3 QL NoGabitril * tiagabine hcl 1 1 NoGalafold 2 2 PA, QL YesGalzin 3 3 NoGammagard liquid 3 3 PA YesGammaked 3 3 PA YesGamunex-C sub-q 3 3 PA Yesganirelix acetate syringe 1 1 NoGaramycin * gentamicin sulfate 1 1 No
Gardasil, 9* Free as
preventiveFree as
preventiveQL No
Gastrocrom * cromolyn sodium 1 1 NoGattex 2 2 PA, QL YesGelnique 3 3 ST, QL No
Generess Fe * noreth-ethinyl estradiol/ironFree as
preventiveFree as
preventiveNo
Gengraf; Neoral * cyclosporine, modified 1 1 YesGenotropin 2 2 PA YesGentamicin cream, ointment * gentamicin sulfate 1 1 NoGenvoya 2 2 QL NoGeodon * ziprasidone hcl 1 1 No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Gilenya 2 2 QL YesGilotrif 2 2 PA, QL YesGlassia 2 2 PA, QL YesGlatopa * glatiramer acetate 1 1 QL YesGleevec * imatinib mesylate 1 1 QL YesGleostine; Lomustine 2 2 NoGlucaGen HypoKit 2 2 NoGlucagon Emergency Kit 1 1 NoGlucophage, XR * metformin hcl 1 1 NoGlucotrol, XL * glipizide 1 1 NoGlucovance * glyburide/metformin hcl 1 1 No
Glycolax OTC * polyethylene glycol 3350Free as
preventiveFree as
preventiveQL No
Glynase * glyburide,micronized 1 1 NoGlyset * miglitol 1 1 NoGlyxambi 2 2 QL No
Golytely * peg3350/sod sulf,bicarb,cl/kclFree as
preventiveFree as
preventiveQL No
Golytely * peg3350/sod sulf,bicarb,cl/kcl 1 1 NoGolytely flavored 2 2 NoGonal-F, RFF, Redi-ject 2 2 YesGoNitro 3 3 NoGralise 3 3 ST, QL NoGranix 3 3 YesGrastek 3 3 PA, QL NoGrifulvin V * griseofulvin, microsize 1 1 NoGris-PEG * griseofulvin ultramicrosize 1 1 NoGuaitussin AC * codeine phosphate/guaifenesin 1 1 NoGuanidine hcl * guanidine hcl 1 1 NoGvoke Hypogen auto injector 2 2 NoGynazole-1 3 3 No
Gynol II * nonoxynol 9Free as
preventiveFree as
preventiveQL No
Haegarda 2 2 PA YesHalcion * triazolam 1 1 QL NoHaldol liquid * haloperidol lactate 1 1 NoHaldol tablet * haloperidol 1 1 NoHaldol vial * haloperidol decanoate 1 1 NoHalog * Halcinonide cream 1 1 NoHalog solution 3 3 NoHarvoni 3 3 PA, QL Yes
Havrix Free as
preventiveFree as
preventiveQL No
Hectorol * doxercalciferol 1 1 NoHemangeol 3 3 QL NoHeparin * heparin sodium,porcine/pf 1 1 NoHeparin sodium syringe 3 3 NoHepsera * adefovir dipivoxil 1 1 YesHetlioz 3 3 PA, QL YesHetlioz Lq 3 3 PA, QL YesHiprex/Urex * methenamine hippurate 1 1 NoHistex PD * carbinoxamine maleate 1 1 NoHizentra vial and syringe 3 3 PA YesHorizant 3 3 ST, QL NoHumatin * paromomycin sulfate 1 1 NoHumatrope 3 3 PA YesHumira 2 2 PA, QL YesHumira Pen pediatric 2 2 PA, QL YesHumulin R U-500 (all forms) 2 2 NoHycamtin capsule 2 2 YesHycet * hydrocodone/acetaminophen 1 1 QL NoHycodan * hydrocodone bit/homatrop me-br 1 1 NoHydrea * hydroxyurea 1 1 No
Hydrodiuril; Microzide * hydrochlorothiazide 1Free as
preventiveNo
Hygroton; Thalitone * chlorthalidone 1Free as
preventiveNo
Hyper-Sal 3 3 No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?HyQvia 3 3 PA YesHysingla ER* hydrocodone tablet 1 1 PA, QL No
Hytrin * terazosin hcl 1Free as
preventiveNo
Hyzaar * losartan/hydrochlorothiazide 1Free as
preventiveNo
Ibrance 2 2 PA, QL YesIbudone * hydrocodone/ibuprofen 1 1 QL NoIbudone 5mg/200mg 3 3 QL NoIclusig 2 2 PA, QL YesIdhifa 2 2 PA, QL YesIlevro 3 3 NoIlotycin * erythromycin base 1 1 No
Imbruvica capsule; 280mg, 420mg, 560mg tablet 2 2 PA, QL Yes
Imdur; Ismo; Monoket * isosorbide mononitrate 1 1 NoImitrex * sumatriptan succinate 1 1 QL NoImitrex nasal spray * sumatriptan 1 1 QL NoImodium * loperamide hcl 1 1 NoImpavido 2 2 QL NoImuran * azathioprine 1 1 NoImvexxy 3 3 QL NoInbrija capsule 3 3 QL NoIncrelex 3 3 PA YesIncruse Ellipta 3 3 QL No
Inderal, LA * propranolol hcl 1Free as
preventiveNo
Inderide * propranolol/hydrochlorothiazid 1Free as
preventiveNo
Indocin, SR * indomethacin 1 1 NoInflamase, Forte * prednisolone sod phosphate 1 1 NoIngrezza 3 3 PA, QL YesIngrezza initiation pack 3 3 PA, QL YesInlyta 2 2 PA, QL YesInqovi tablet 2 2 Yes
Inspra * eplerenone 1Free as
preventiveNo
Insulin Lispro Junior Kwikpen 3 3 NoIntal solution * cromolyn sodium 1 1 NoIntelence * etravirine 1 1 NoIntermezzo * zolpidem tartrate 1 1 PA, QL NoIntrarosa 3 3 QL NoIntron A 2 2 Yes
Intuniv * guanfacine hcl 1Free as
preventiveQL No
Invega * paliperidone 1 1 QL NoInveltys 3 3 PA, QL NoInvirase 2 2 NoInvokamet, XR 2 2 QL NoInvokana 2 2 QL NoIopidine droperette 3 3 NoIopidine drops * apraclonidine hcl 1 1 NoIrenka * duloxetine hcl 1 1 NoIressa 2 2 PA, QL YesIsentress 2 2 NoIsentress HD 2 2 NoIsoniazid * isoniazid 1 1 NoIsopto Atropine * atropine sulfate 1 1 NoIsopto Homatropine * homatropine hbr 1 1 NoIsopto-Carpine; Pilocar * pilocarpine hcl 1 1 NoIsordil * isosorbide dinitrate 1 1 NoIsordil 40mg 3 3 No
Istalol * timolol maleate 1Free as
preventiveNo
Isturisa Tablet 3 3 PA, QL YesJadenu* Deferasirox 1 1 PA, QL YesJakafi 2 2 PA, QL YesJalyn * dutasteride/tamsulosin hcl 1 1 QL No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Janumet 2 2 NoJanumet XR 2 2 QL NoJanuvia 2 2 QL NoJardiance 2 2 QL NoJatenzo 3 3 PA QL NoJentadueto, XR 2 2 QL NoJornay PM capsule 3 3 PA, QL NoJuluca 3 3 QL NoJuxtapid 3 3 PA, QL YesJynarque 2 2 PA, QL YesKadian * morphine sulfate 1 1 QL NoKadian 200mg 3 3 QL NoKaletra * lopinavir/ritonavir 1 1 NoKaletra tablet 2 2 NoKalydeco 2 2 PA, QL Yes
Kapvay * clonidine hcl 1Free as
preventiveQL No
Karbinal ER 3 3 ST, QL NoKayexalate * sodium polystyrene sulfonate 1 1 NoKeflex * cephalexin 1 1 NoKenalog 0.025% cream, lotion * triamcinolone acetonide 1 1 NoKenalog 0.025% ointment, 0.05%, 0.1% * triamcinolone acetonide 1 1 NoKenalog Spray * triamcinolone acetonide 1 1 NoKeppra, XR * levetiracetam 1 1 No
Kerlone * betaxolol hcl 1Free as
preventiveNo
Ketoprofen * ketoprofen 1 1 PA, QL NoKeveyis 3 3 PA, QL YesKevzara 3 3 PA, QL YesKhedezla 3 3 ST, QL NoKineret 3 3 PA, QL YesKisqali Femara co-pack 2 2 PA, QL YesKisqali, Femara co-pack 2 2 PA, QL YesKlaron * sulfacetamide sodium 1 1 NoKlonopin, Wafer * clonazepam 1 1 NoK-Lor; Klor-Con packet * potassium chloride 1 1 NoKlor-Con M15 * potassium chloride 1 1 NoKloxxado spray 2 2 QL NoK-Lyte; Klor-con/EF * potassium bicarbonate/cit ac 1 1 NoKorlym 2 2 PA, QL YesKrintafel 2 2 QL NoKristalose 20g packet 3 3 NoK-Sol; Potassium Chloride * potassium chloride 1 1 NoK-Tab 2 2 NoK-Tab; K-Dur; Slow-K; Kaon CL; Klor-con * potassium chloride 1 1 NoKuvan * Sapropterin Dihydrochloride powder pack and tablet 2 2 PA YesKytril * granisetron hcl 1 1 QL NoLac-Hydrin * ammonium lactate 1 1 NoLacrisert 2 2 NoLactulose * lactulose 1 1 NoLamictal dose pack * lamotrigine 1 1 NoLamictal ODT, XR * lamotrigine 1 1 NoLamictal XR dose pack 3 3 NoLamictal, dispertabs * lamotrigine 1 1 NoLamisil tablet * terbinafine hcl 1 1 NoLanoxin * digoxin 1 1 NoLanoxin 62.5, 187.5mcg 3 3 NoLantus, Solostar 2 2 NoLariam * mefloquine hcl 1 1 No
Lasix * furosemide 1Free as
preventiveNo
Lastacaft 3 3 NoLatuda 3 3 ST NoLedipasvir-sofosbuvir 2 2 PA, QL YesLenvima 2 2 PA, QL Yes
Lescol, XL * fluvastatin sodium 1Free as
preventiveQL No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?
Lescol, XL* (all strengths) * fluvastatin sodiumFree as
preventiveFree as
preventiveQL No
Letairis Ambrisentan 1 1 PA, QL YesLeucovorin tablet * leucovorin calcium 1 1 NoLeukeran 2 2 NoLeukine 2 2 YesLevalbuterol Tartrate HFA 3 3 QL NoLevaquin * levofloxacin, isotretinoin 1 1 NoLevbid * hyoscyamine sulfate 1 1 NoLevemir, Flextouch 2 2 NoLevitra * vardenafil hcl 1 1 PA, QL No
Levlen; Nordette * levonorgestrel-ethin estradiol, AyunaFree as
preventiveFree as
preventiveNo
Levorphanol Tartrate * levorphanol tartrate 1 1 QL NoLevorphanol Tartrate 3mg 3 3 QL NoLevoxyl; Synthroid * levothyroxine sodium 1 1 NoLevsin, SL * hyoscyamine sulfate 1 1 NoLexapro * escitalopram oxalate 1 1 NoLexiva * fosamprenavir calcium 1 1 NoLexiva suspension 2 2 NoLialda * mesalamine 1 1 QL NoLibrax * chlordiazepoxide/clidinium br 1 1 NoLibrium * chlordiazepoxide hcl 1 1 NoLidex * fluocinonide 1 1 QL NoLidex E * fluocinonide/emollient base 1 1 NoLidocort cream 1 1 NoLidoderm patch * lidocaine 1 1 NoLimbitrol, DS * amitriptyline/chlordiazepoxide 1 1 NoLindane * lindane 1 1 NoLinzess 2 2 QL No
Lipitor * atorvastatin calcium 1Free as
preventiveQL No
Lipitor 10mg, 20mg * atorvastatin calciumFree as
preventiveFree as
preventiveQL No
Lipofen; Fenofibrate capsule 3 3 NoLithium Citrate * lithium citrate 1 1 NoLithostat 3 3 NoLivalo 3 3 ST, QL NoLo Loestrin Fe 3 3 No
Lo/Ovral * norgestrel-ethinyl estradiolFree as
preventiveFree as
preventiveNo
Locoid cream, ointment, solution * hydrocortisone butyrate 1 1 NoLocoid Lipocream * hydrocortisone butyrate/emoll 1 1 NoLodine, XL * etodolac 1 1 NoLodosyn * carbidopa 1 1 No
Loestrin * norethindrone ac-eth estradiol, Aurovela, HaileyFree as
preventiveFree as
preventiveNo
Loestrin 24 Fe * norethindrone-e.estradiol-iron, Hailey 24 FeFree as
preventiveFree as
preventiveNo
Loestrin Fe *norethindrone-e.estradiol-iron, Aurovela Fe, Hailey Fe
Free as preventive
Free as preventive
No
Lofibra capsule * fenofibrate,micronized 1Free as
preventiveNo
Lofibra tablet * fenofibrate 1Free as
preventiveNo
Lokelma 3 3 PA, QL NoLomaira 3 3 NoLomotil * diphenoxylate hcl/atropine 1 1 NoLonhala Magnair 3 3 QL No
Loniten * minoxidil 1Free as
preventiveNo
Lonsurf 2 2 PA, QL Yes
Lopid * gemfibrozil 1Free as
preventiveNo
Lopressor * metoprolol tartrate 1Free as
preventiveNo
Lopressor HCT * metoprolol/hydrochlorothiazide 1Free as
preventiveNo
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Loprox cream, suspension * ciclopirox olamine 1 1 NoLoprox gel, shampoo * ciclopirox 1 1 NoLorazepam intensol * lorazepam 1 1 NoLorbrena 3 3 PA, QL YesLortab solution 3 3 QL No
Loseasonique * l-norgest/e.estradiol-e.estrad, Lojaimiess tabletFree as
preventiveFree as
preventiveQL No
Lotemax * Loteprednol Etabonate 1 1 PA, QL No
Lotensin * benazepril hcl 1Free as
preventiveNo
Lotensin HCT * benazepril/hydrochlorothiazide 1Free as
preventiveNo
Lotrel * amlodipine besylate/benazepril 1Free as
preventiveNo
Lotrimin * clotrimazole 1 1 NoLotrisone * clotrimazole/betamethasone dip 1 1 NoLotronex * alosetron hcl 1 1 No
Lovaza * omega-3 acid ethyl esters 1Free as
preventiveQL No
Lovenox * enoxaparin sodium 1 1 NoLoxitane * loxapine succinate 1 1 No
Lozol * indapamide 1Free as
preventiveNo
Lucemyra 2 2 QL NoLumigan * bimatoprost 1 1 NoLumigan 0.01% 2 2 NoLunesta * eszopiclone 1 1 QL NoLupaneta Pack 3 3 YesLupron * leuprolide acetate 1 1 YesLupron Depot 3.75mg, 11.25mg 2 2 YesLupron Depot-PED 2 2 YesLuvox * fluvoxamine maleate 1 1 NoLuvox CR * fluvoxamine maleate 1 1 NoLuxiq * betamethasone valerate 1 1 NoLuzu, Luliconazole 1% cream 3 3 PA, QL No
Lybrel * levonorgestrel-ethin estradiol, dolishaleFree as
preventiveFree as
preventiveNo
Lynparza 2 2 PA, QL YesLyrica * pregabalin 1 1 PA, QL NoLyrica CR progabalin ER 3 3 PA, QL NoLysodren 2 2 NoLysteda * tranexamic acid 1 1 PA, QL NoMacrobid * nitrofurantoin monohyd/m-cryst 1 1 NoMacrodantin * nitrofurantoin macrocrystal 1 1 NoMalarone * atovaquone/proguanil hcl 1 1 NoMaprotiline hcl * maprotiline hcl 1 1 NoMarinol * dronabinol 1 1 NoMarplan 3 3 NoMatulane 2 2 YesMavenclad 3 3 Yes
Mavik * trandolapril 1Free as
preventiveNo
Mavyret 3 3 PA, QL YesMaxalt, MLT * rizatriptan benzoate 1 1 QL NoMaxidex 3 3 NoMaxitrol * neomycin/polymyxin b/dexametha 1 1 NoMayzent tablet 3 3 YesMeclomen * meclofenamate sodium 1 1 NoMedrol 2mg 3 3 NoMedrol, dose pack * methylprednisolone, methylpred dp 1 1 NoMegace, ES * megestrol acetate 1 1 NoMekinist 2 2 PA, QL YesMektovi 2 2 PA, QL YesMellaril * thioridazine hcl 1 1 No
Menactra Free as
preventiveFree as
preventiveQL No
Menest 3 3 NoMenopur 2 2 Yes
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Menostar 3 3 NoMentax 2 2 No
Menveo Free as
preventiveFree as
preventiveQL No
Mephyton * phytonadione (vit k1) 1 1 NoMepron * atovaquone 1 1 NoMepron blister pak 2 2 NoMesnex tablet 2 2 NoMestinon syrup pyridostigmine bromide syrup 1 1 NoMestinon, Timespan * pyridostigmine bromide 1 1 NoMetadate CD * methylphenidate hcl 1 1 NoMetaglip * glipizide/metformin hcl 1 1 NoMethadone * methadone hcl 1 1 QL NoMethergine * methylergonovine maleate 1 1 QL NoMethitest 3 3 QL NoMethotrexate * methotrexate sodium 1 1 NoMethotrexate PF injection * methotrexate sodium/pf 1 1 NoMethylin, ER * methylphenidate hcl 1 1 NoMethylphenidate ER 72mg 3 3 QL NoMetozolv ODT * metoclopramide hcl 1 1 NoMetrocream, gel, lotion 0.75% * metronidazole 1 1 NoMetrogel 1% * metronidazole 1 1 NoMetrogel-Vaginal * metronidazole 1 1 No
Mevacor * lovastatin 1Free as
preventiveQL No
Mevacor* (all strengths) * lovastatinFree as
preventiveFree as
preventiveQL No
Mexitil * mexiletine hcl 1 1 NoMiacalcin injection 2 2 NoMiacalcin nasal spray * calcitonin,salmon,synthetic 1 1 No
Micardis * telmisartan 1Free as
preventiveNo
Micardis HCT * telmisartan/hydrochlorothiazid 1Free as
preventiveNo
Micro-K * potassium chloride 1 1 No
Midamor * amiloride hcl 1Free as
preventiveNo
Migergot * ergotamine tartrate/caffeine 1 1 NoMigranal * dihydroergotamine mesylate 1 1 QL No
Milk of Magnesia OTC * magnesium hydroxideFree as
preventiveFree as
preventiveQL No
Millipred solution * prednisolone sod phosphate 1 1 NoMillipred tablet, dose pack * prednisolone 1 1 No
Minastrin 24 Fe * norethindrone-e.estradiol-iron, charlotte 24 FeFree as
preventiveFree as
preventiveNo
Minipress * prazosin hcl 1Free as
preventiveNo
Minitran 3 3 NoMinivelle, Vivelle-Dot * estradiol, dotti/Lyllana transdermal patch 1 1 NoMinocin capsule * minocycline hcl 1 1 NoMirapex ER * pramipexole di-hcl 1 1 QL NoMirapex immediate-release * pramipexole di-hcl 1 1 QL NoMircera 3 3 PA, QL Yes
Mircette * desog-e.estradiol/e.estradiol, Simliya, Volnea tabletFree as
preventiveFree as
preventiveNo
Mitigare 3 3 NoM-Natal Plus tablet 1 1 NoMobic * meloxicam 1 1 No
Modicon * norethindrone-ethinyl estradFree as
preventiveFree as
preventiveNo
Moduretic * amiloride/hydrochlorothiazide 1 1 NoMolindone * molindone hcl 1 1 QL NoMonistat 3 * miconazole nitrate 1 1 NoMonodox * doxycycline monohydrate 1 1 No
Monopril * fosinopril sodium 1Free as
preventiveNo
Monopril HCT * fosinopril/hydrochlorothiazide 1Free as
preventiveNo
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Monurol * Fosfomycin Tromethamine 1 1 NoMotofen 3 3 NoMotrin (Rx Only) * ibuprofen 1 1 NoMovantik 3 3 PA, QL NoMoviprep * Peg3350-Sod Sul-Nacl-K powder pack 1 1 NoMoxatag 3 3 NoMoxeza * Moxifloxacin drops 1 1 NoMS Contin * morphine sulfate 1 1 QL NoMSIR * morphine sulfate 1 1 QL NoMucomyst * acetylcysteine 1 1 NoMulpleta 2 2 PA, QL YesMultaq 2 2 QL NoMupirocin Calcium 1 1 NoMuse 2 2 PA, QL NoMyalept 3 3 PA, QL YesMycapssa capsule 3 3 YesMycelex Troche * clotrimazole 1 1 NoMycobutin * rifabutin 1 1 NoMycostatin * nystatin 1 1 NoMydriacyl * tropicamide 1 1 NoMyfortic * mycophenolate sodium 1 1 YesMyleran 2 2 NoMyrbetriq 3 3 PA, ST, QL NoMysoline * primidone 1 1 NoMytesi 2 2 PA, QL NoNaftin * naftifine hcl 1 1 PA, QL NoNaftin gel 3 3 PA, QL NoNalfon * fenoprofen calcium 1 1 PA, QL NoNalfon 400mg 3 3 PA, QL NoNaloxone hcl injection * naloxone hcl 1 1 NoNamenda * memantine hcl 1 1 QL NoNamenda dose pack 2 2 QL NoNamenda XR * memantine hcl 1 1 QL NoNamenda XR dose pack 3 3 QL NoNamzaric 3 3 ST, QL NoNaprosyn (Rx Only) * naproxen 1 1 NoNaprosyn suspension (Rx Only) * naproxen 1 1 NoNaprosyn tablet (Rx Only) * naproxen 1 1 NoNarcan nasal spray 2 2 QL NoNardil * phenelzine sulfate 1 1 NoNasalide * flunisolide 1 1 QL NoNasonex * mometasone furoate 1 1 ST, QL NoNatacyn 2 2 NoNatazia 3 3 NoNatesto 3 3 ST, QL NoNatpara 2 2 PA, QL YesNatroba * spinosad 1 1 NoNature-Throid * thyroid,pork 1 1 NoNavane * thiothixene 1 1 NoNayzilam spray 2 2 NoNebupent aerosol 2 2 NoNebusal 3 3 NoNeomycin * neomycin sulfate 1 1 NoNeosporin ophthalmic ointment * neomycin sulf/bacitracin/poly 1 1 NoNeosporin ophthalmic solution * neomycin/polymyxn b/gramicidin 1 1 NoNeo-Synalar 3 3 NoNeo-Synephrine * phenylephrine hcl 1 1 NoNeptazane * methazolamide 1 1 NoNerlynx 2 2 PA, QL YesNeulasta 3 3 QL YesNeupogen 3 3 YesNeupro 3 3 PA, QL NoNeurontin * gabapentin 1 1 No
Neutragard * fluoride (sodium) 1Free as
preventiveNo
Nevanac 3 3 NoNexavar 2 2 PA, QL YesNexium * esomeprazole magnesium 1 1 No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Nexium suspension 3 3 ST NoNexlizet 3 3 No
Niaspan * niacin 1Free as
preventiveNo
Nicorette lozenge * nicotine polacrilexFree as
preventiveFree as
preventiveQL No
Nicotine gum; Nicorette * nicotine polacrilexFree as
preventiveFree as
preventiveQL No
Nicotine patch * nicotineFree as
preventiveFree as
preventiveQL No
Nicotrol, NS 3 3 QL No
Nicotrol, NS Free as
preventiveFree as
preventiveST, QL No
Nilandron * nilutamide 1 1 PA, QL No
Nimotop * nimodipine 1Free as
preventiveNo
Ninlaro 2 2 PA, QL YesNiravam * alprazolam 1 1 NoNitro-bid ointment * nitroglycerin 1 1 NoNitro-Dur * nitroglycerin 2 2 NoNitroglycerin capsule, patch * nitroglycerin 1 1 NoNitrostat * nitroglycerin 1 1 NoNityr 3 3 PA YesNizoral * ketoconazole 1 1 NoNizoral cream, shampoo 2% * ketoconazole 1 1 NoNocdurna 3 3 PA, QL NoNoctiva 3 3 PA, QL NoNorco; Vicodin; Xodol * hydrocodone/acetaminophen 1 1 QL NoNorditropin FlexPro 2 2 PA YesNorflex * orphenadrine citrate 1 1 No
Norinyl 1/35; Ortho-novum 1/35 * norethindrone-ethinyl estrad, Nortrel, NyliaFree as
preventiveFree as
preventiveNo
Noritate 3 3 No
Normodyne * labetalol hcl 1Free as
preventiveNo
Norpace * disopyramide phosphate 1 1 NoNorpace CR 2 2 NoNorpramin * desipramine hcl 1 1 NoNorthera * Droxidopa 1 1 PA, QL Yes
Norvasc * amlodipine besylate 1Free as
preventiveNo
Norvir * ritonavir 1 1 NoNorvir capsule, solution, packet 2 2 NoNovarel 3 3 PA YesNovolin; 70/30 vial 2 2 NoNovolog, Mix (all forms) 2 2 NoNoxafil suspension 2 2 QL NoNoxafil tablet * Posaconazole tablet 1 1 QL NoNP Thyroid * thyroid,pork 1 1 NoNubain * nalbuphine hcl 1 1 QL NoNucynta, ER 3 3 PA, QL NoNuedexta 2 2 PA, QL No
Nulytely * sodium chloride/nahco3/kcl/pegFree as
preventiveFree as
preventiveQL No
Nulytely * sodium chloride/nahco3/kcl/peg 1 1 NoNulytely Soln Recon 3 3 NoNuplazid 3 3 PA, QL NoNutropin AQ Nuspin 2 2 PA Yes
Nuvaring * Eluryng, Etonosgestrel-Ethinyl EFree as
preventiveFree as
preventiveQL No
Nuvessa 3 3 NoNuvigil * armodafinil 1 1 QL NoNuzyra tablet 3 3 QL NoNymalize 3 3 QL NoNystatin * nystatin 1 1 NoNystatin w/Triamcinolone * nystatin/triamcin 1 1 NoObredon 3 3 QL NoOcaliva 2 2 PA, QL Yes
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Ocufen * flurbiprofen sodium 1 1 NoOcuflox * ofloxacin 1 1 NoOcupress * carteolol hcl 1 1 NoOdactra 3 3 PA, QL NoOdefsey 2 2 QL NoOdomzo 2 2 PA, QL YesOfev 2 2 PA, QL YesOlumiant 3 3 PA, QL YesOlux * clobetasol propionate 1 1 No
Olux-E * clobetasol propionate/emoll/tovet emollient 1 1 No
Omeclamox-pak 3 3 NoOmnaris 3 3 ST, QL NoOmnicef * cefdinir 1 1 NoOmnitrope 3 3 PA YesOnfi * clobazam 1 1 QL NoOngentys capsule 3 3 PA, QL NoOnzetra Xsail 3 3 ST, QL NoOpana * oxymorphone hcl 1 1 QL NoOpana ER * oxymorphone hcl 1 1 PA, QL NoOpsumit 2 2 PA, QL YesOpticrom * cromolyn sodium 1 1 NoOptipranolol * metipranolol 1 1 NoOptivar * azelastine hcl 1 1 NoOracea 3 3 PA No
Oral Saline Laxative liquid OTC * sodium phosphate,mono-dibasicFree as
preventiveFree as
preventiveQL No
Oralair 3 3 PA, QL NoOralone paste * triamcinolone acetonide 1 1 NoOrap * pimozide 1 1 NoOrapred ODT * prednisolone sod phosphate 1 1 NoOrapred solution * prednisolone sod phosphate 1 1 NoOravig 3 3 QL NoOrencia Clickject, sub-q 3 3 PA, QL YesOrenitram ER 2 2 PA, QL YesOrfadin * Nitisinone 1 1 PA YesOrilissa 3 3 PA, QL NoOrinase * tolbutamide 1 1 NoOrkambi 2 2 PA, QL Yes
Ortho Evra * norelgestromin/ethin.estradiol/zafemyFree as
preventiveFree as
preventiveQL No
Ortho Micronor; Nor-QD * norethindrone, LyleqFree as
preventiveFree as
preventiveNo
Ortho Tri-Cyclen * norgestimate-ethinyl estradiol, Tri-NymyoFree as
preventiveFree as
preventiveNo
Ortho Tri-Cyclen Lo * norgestimate-ethinyl estradiol, tri-lo-miliFree as
preventiveFree as
preventiveNo
Ortho-Cyclen * norgestimate-ethinyl estradiol, NymyoFree as
preventiveFree as
preventiveNo
Ortho-Novum 7/7/7 * norethindrone-ethinyl estrad, Nortrel, NyliaFree as
preventiveFree as
preventiveNo
Osmoprep 3 3 NoOsphena 3 3 NoOtezla 2 2 PA, QL YesOtovel 2 2 NoOtrexup 3 3 PA, QL Yes
Ovcon 35 * norethindrone-ethinyl estradFree as
preventiveFree as
preventiveNo
Ovide * malathion 1 1 NoOvidrel 2 2 Yes
Ovral * norgestrel-ethinyl estradiolFree as
preventiveFree as
preventiveNo
Oxandrin * oxandrolone 1 1 PA NoOxervate 2 2 PA, QL YesOxistat * oxiconazole nitrate 1 1 PA, QL NoOxistat lotion 3 3 PA, QL NoOxsoralen-Ultra * methoxsalen 1 1 NoOxtellar XR 3 3 PA, QL No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Oxycodone hcl ER 3 3 PA, QL NoOxycodone immediate release, solution * oxycodone hcl 1 1 QL NoOxycontin 3 3 PA, QL NoOzempic 2 2 QL NoPalynziq 2 2 PA, QL YesPamine, Forte * methscopolamine bromide 1 1 NoPancreaze 3 3 NoPanretin 2 2 NoParafon Forte DSC 500mg * chlorzoxazone 1 1 NoParcopa * carbidopa/levodopa 1 1 NoParemyd 3 3 NoParlodel * bromocriptine mesylate 1 1 NoParnate * tranylcypromine sulfate 1 1 NoPaser 3 3 NoPataday * olopatadine hcl 1 1 NoPatanase * olopatadine hcl 1 1 QL NoPatanol * olopatadine hcl 1 1 NoPaxil * paroxetine hcl 1 1 NoPaxil CR * paroxetine hcl 1 1 NoPaxil suspension 3 3 NoPazeo 3 3 QL NoPediapred solution * prednisolone sod phosphate 1 1 NoPeganone 2 2 NoPegasys, Proclick 2 2 QL YesPeg-Intron, Redipen 2 2 QL Yes
Peg-Prep * bisac/nacl/nahco3/kcl/peg 3350Free as
preventiveFree as
preventiveQL No
Penicillin VK * penicillin v potassium 1 1 NoPenlac * ciclopirox 1 1 NoPennsaid 1.5% * diclofenac sodium 1 1 QL NoPennsaid 2% 3 3 ST, QL NoPentasa 2 2 NoPepcid (Rx Only) * famotidine 1 1 NoPercocet * oxycodone hcl/acetaminophen 1 1 QL NoPercodan * oxycodone hcl/aspirin 1 1 QL NoPerforomist * formoterol fumarate vial-neb 1 1 NoPeriactin * cyproheptadine hcl 1 1 NoPeridex * chlorhexidine gluconate 1 1 NoPeriostat * doxycycline hyclate 1 1 NoPerphenazine * perphenazine 1 1 NoPersantine * dipyridamole 1 1 NoPertzye 3 3 NoPexeva 3 3 ST NoPhenergan * promethazine hcl 1 1 NoPhenergan DM * promethazine/dextromethorphan 1 1 NoPhenergan VC * phenylephrine hcl/prometh hcl 1 1 NoPhenergan VC w/Codeine * promethazine/phenyleph/codeine 1 1 NoPhenergan w/Codeine * promethazine hcl/codeine 1 1 NoPhenobarbital * phenobarbital 1 1 NoPhoslo * calcium acetate 1 1 NoPhoslyra 3 3 NoPhospholine Iodide 2 2 NoPhrenilin 50mg/325mg * butalbital/acetaminophen 1 1 NoPhrenilin Forte * butalb/acetaminophen/caffeine 1 1 NoPicato 3 3 PA, QL NoPifeltro 2 2 QL No
Plan B One-step * levonorgestrel, After PillFree as
preventiveFree as
preventiveQL No
Plaquenil * hydroxychloroquine sulfate 1 1 NoPlavix * clopidogrel bisulfate 1 1 NoPlegridy 2 2 QL Yes
Plendil * felodipine 1Free as
preventiveNo
Plenvu 3 3 NoPletal * cilostazol 1 1 NoPlixda 3 3 No
Pneumovax 23 Free as
preventiveFree as
preventiveQL No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Polysporin * bacitracin/polymyxin b sulfate 1 1 NoPolytrim * polymyxin b sulf/trimethoprim 1 1 NoPomalyst 3 3 PA, QL YesPonstel * mefenamic acid 1 1 NoPosaconazole tablet (authorized generic) 2 2 NoPotassium Chloride effervescent * pot chloride/pot bicarb/cit ac 1 1 NoPradaxa 3 3 QL NoPraluent 2 2 PA, QL NoPramosone cream * hydrocortisone/pramoxine 1 1 NoPramosone ointment 2.5%-1% 3 3 NoPrandiMet * repaglinide/metformin hcl 1 1 NoPrandin * repaglinide 1 1 No
Pravachol * pravastatin sodium 1Free as
preventiveQL No
Pravachol* (all strengths) * pravastatin sodiumFree as
preventiveFree as
preventiveQL No
Precose * acarbose 1 1 NoPred Forte * prednisolone acetate 1 1 NoPred Mild 2 2 NoPred-G 3 3 NoPrednisolone solution, tablet * prednisolone 1 1 NoPrednisone * prednisone 1 1 NoPrefest 3 3 NoPregnyl 2 2 PA YesPremarin, cream, Low Dose 2 2 NoPrempro, Low Dose; Premphase 2 2 NoPrepopik 3 3 NoPrestalia 3 3 QL NoPretomanid tablet 2 2 NoPrevacid capsule (Rx Only) * lansoprazole 1 1 No
Prevident * fluoride (sodium), sodium fluoride 5000 1Free as
preventiveNo
Prevident 5000 Plus *sodium fluoride 5000, sodium fluoride sensitive, sodium fluoride enamel
1 1 No
Prevnar 13* Free as
preventiveFree as
preventiveQL No
Prevpac * lansoprazole/amoxiciln/clarith 1 1 NoPrevymis tablet 3 3 QL NoPrezcobix 2 2 QL NoPrezista 2 2 NoPriftin 3 3 NoPrilosec capsule (Rx Only) * omeprazole 1 1 NoPrilosec suspension 3 3 NoPrimaquine (branded version) 2 2 NoPrimaquine (generic version) 1 1 NoPrimsol 3 3 No
Prinivil; Zestril * lisinopril 1Free as
preventiveNo
Prinzide; Zestoretic * lisinopril/hydrochlorothiazide 1Free as
preventiveNo
Pristiq * desvenlafaxine succinate 1 1 QL NoProAir HFA; 2 2 QL NoProamatine * midodrine hcl 1 1 NoPro-Banthine * propantheline bromide 1 1 NoProbenecid * probenecid 1 1 NoProcentra * dextroamphetamine sulfate 1 1 NoProcrit 2 2 PA YesProctocort * hydrocortisone 1 1 NoProctocort suppository * hydrocortisone acetate 1 1 NoProctofoam-HC 2 2 NoProcto-pak * hydrocortisone 1 1 NoProctosol-HC suppository * hydrocortisone acetate 1 1 NoProcysbi 3 3 PA, QL YesProgesterone In Oil (inj) * progesterone 1 1 NoProglycem * Diazoxide suspension 1 1 NoPrograf * tacrolimus 1 1 YesPrograf granule packet 3 3 YesProlensa 3 3 No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Prolixin * fluphenazine hcl 1 1 NoPromacta 2 2 PA YesPrometrium * progesterone, micronized 1 1 NoPropylthiouracil * propylthiouracil 1 1 NoProscar * finasteride 1 1 NoProsom * estazolam 1 1 QL NoProtonix suspension 3 3 NoProtonix tablet * pantoprazole sodium 1 1 NoProtopic * tacrolimus 1 1 NoProventil HFA 3 3 QL NoProventil solution * albuterol sulfate 1 1 NoProventil albuterol sulfate 1 1 No
Provera * medroxyprogesterone acetate 1Free as
preventiveNo
Provigil * modafinil 1 1 QL NoProzac * fluoxetine hcl 1 1 QL NoProzac weekly * fluoxetine hcl 1 1 QL NoPrudoxin, Zonalon * doxepin hcl 1 1 PA, QL NoPulmicort Flexhaler 2 2 QL NoPulmicort solution * budesonide 1 1 NoPulmozyme 2 2 PA YesPurinethol * mercaptopurine 1 1 NoPurixan 3 3 YesPyrazinamide * pyrazinamide 1 1 NoQbrelis 3 3 QL NoQbrexza 2 2 PA, QL NoQnasl 3 3 ST, QL NoQsymia 3 3 PA, QL NoQtern 2 2 QL NoQualaquin * quinine sulfate 1 1 No
Quartette * l-norgest/e.estradiol-e.estradFree as
preventiveFree as
preventiveQL No
Quazepam 3 3 QL NoQudexy XR * topiramate ER 1 1 PA, QL No
Questran * cholestyramine (with sugar) 1Free as
preventiveNo
Questran Light * cholestyramine/aspartame 1Free as
preventiveNo
QuilliChew ER 3 3 PA, QL NoQuillivant XR 3 3 ST, QL NoQuinidex * quinidine sulfate 1 1 NoQuinidine Gluconate SA * quinidine gluconate 1 1 NoQuixin * levofloxacin 1 1 NoQvar RediHaler 2 2 QL NoRadiogardase 2 2 NoRagwitek 3 3 PA, QL NoRanexa * ranolazine ER 1 1 NoRapaflo * silodosin 1 1 QL NoRapamune * sirolimus 1 1 YesRasuvo 3 3 PA, QL YesRavicti 3 3 PA, QL YesRayaldee 3 3 QL NoRayos 3 3 PA, QL NoRazadyne, ER * galantamine hbr 1 1 NoRebetol * ribavirin 1 1 YesRebetol solution 2 2 YesRebif, Rebidose 2 2 QL YesRectiv 3 3 QL NoReditrex syringe 3 3 PA, QL YesReglan * metoclopramide hcl 1 1 NoRegranex 3 3 QL NoRelafen * nabumetone 1 1 NoRelcof C * codeine phosphate/guaifenesin 1 1 NoRelenza 2 2 QL NoRelexxii 3 3 QL NoRelistor tablet 3 3 PA, QL NoRelpax * eletriptan hydrobromide 1 1 ST, QL NoRemeron * mirtazapine 1 1 No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Renacidin 2 2 NoRenagel * sevelamer hcl 1 1 NoRenvela * sevelamer carbonate 1 1 NoRepatha 2 2 PA, QL NoRequip * ropinirole hcl 1 1 NoRequip XL * ropinirole hcl 1 1 NoRestasis 2 2 NoRestoril * temazepam 1 1 QL NoRetacrit vial 2 2 NoRetin-A; Avita * tretinoin 1 1 NoRetrovir * zidovudine 1 1 NoRevatio * sildenafil citrate 1 1 QL NoRevatio suspension 2 2 PA, QL NoRevia * naltrexone hcl 1 1 NoRevlimid 3 3 QL YesRexulti 3 3 PA, QL NoReyataz * atazanavir sulfate 1 1 NoReyataz packet 2 2 NoRhopressa 3 3 PA, QL NoRibapak; Ribatab * ribavirin 1 1 YesRibasphere Ribapak tablet * ribavirin 1 1 YesRidaura 2 2 NoRifadin * rifampin 1 1 NoRifamate 3 3 NoRifater 3 3 NoRilutek * riluzole 1 1 NoRinvoq 2 2 NoRiomet * Metformin Hcl solution 1 1 NoRiomet ER 3 3 NoRisperdal, M-Tab * risperidone 1 1 NoRitalin, LA, SR * methylphenidate hcl 1 1 NoRMS Suppository * morphine sulfate 1 1 QL NoRobaxin * methocarbamol 1 1 NoRobinul tablet, Forte * glycopyrrolate 1 1 No
Robitussin AC * codeine phosphate/guaifenesin, maxi-tuss Ac 1 1 No
Rocaltrol * calcitriol 1 1 NoRoxanol * morphine sulfate 1 1 QL NoRozorem * ramelteon 1 1 QL NoRubraca 2 2 PA, QL YesRuconest 3 3 PA, QL YesRuzurgi tablet 3 3 YesRydapt 2 2 PA, QL YesRynatan * phenylephrine/chlor-tan 1 1 NoRytary 3 3 ST, QL NoRythmol, SR * propafenone hcl 1 1 NoRyzolt * tramadol hcl 1 1 QL NoSabril packet * vigabatrin 1 1 PA, QL YesSabril tablet * vigabatrin 1 1 ST, QL Yes
Safyral * drospir/eth estra/levomefol caFree as
preventiveFree as
preventiveNo
Saizen 3 3 PA YesSaizenprep 3 3 PA YesSalagen * pilocarpine hcl 1 1 NoSamsca * tolvaptan 2 2 QL YesSanctura * trospium chloride 1 1 QL NoSanctura XR * trospium chloride 1 1 QL NoSancuso 3 3 PA, QL NoSandimmune capsule * cyclosporine 1 1 YesSandimmune solution 3 3 YesSandostatin * octreotide acetate 1 1 YesSandostatin LAR Depot 2 2 PA YesSantyl 2 2 NoSaphris* Asenapine Maleate sublingual tablets 1 1 ST, QL NoSavaysa 3 3 QL NoSavella 3 3 PA, QL NoSavella dose pack 3 3 PA NoSaxenda 3 3 PA, QL No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?
Seasonale * levonorgestrel-ethin estradiol, icleviaFree as
preventiveFree as
preventiveQL No
Seasonique *l-norgest/e.estradiol-e.estrad, simpesse, Jaimiess tablet
Free as preventive
Free as preventive
QL No
Seconal * secobarbital sodium 1 1 No
Sectral * acebutolol hcl 1Free as
preventiveNo
Secuado patch 3 3 PA QL NoSeebri Neohaler 3 3 QL NoSegluromet 3 3 QL NoSelsun 2.5% (Rx Only) * selenium sulfide 1 1 NoSelzentry 2 2 NoSemprex-D 3 3 NoSe-Natal 19 tablet 1 1 NoSensipar 2 2 YesSerax * oxazepam 1 1 NoSerevent Diskus 2 2 QL NoSeroquel * quetiapine fumarate 1 1 NoSeroquel XR * quetiapine fumarate 1 1 QL NoSerostim 3 3 PA YesSerzone * nefazodone hcl 1 1 NoSevenfact vial 2 NoSfRowasa enema * mesalamine 1 1 No
Shingrix* Free as
preventiveFree as
preventiveQL No
Signifor 2 2 PA, QL YesSignifor LAR 3 3 PA, QL YesSiklos 3 3 PA NoSilenor * Doxepin 3 3 ST, QL NoSilvadene * silver sulfadiazine 1 1 NoSilver Nitrate * silver nitrate applicator 1 1 NoSimbrinza 3 3 NoSimponi 3 3 PA, QL YesSinemet, CR * carbidopa/levodopa 1 1 NoSingulair * montelukast sodium 1 1 QL NoSirturo 2 2 PA, QL NoSitavig 3 3 ST, QL NoSivextro 2 2 QL NoSkelaxin * metaxalone 1 1 NoSklice * Ivermectin lotion 1 1 QL NoSkyrizi pen and syringe kit 2 2 YesSodium Chloride flush syringe 1 1 NoSodium Chloride syringe 1 1 No
Sodium Fluoride 0.25mg, 0.5mg, 1mg * fluoride (sodium)Free as
preventiveFree as
preventiveNo
Sodium Fluoride 0.25mg, 0.5mg, 1mg * fluoride (sodium) 1Free as
preventiveNo
Sofosbuvir-velpatasvir 2 2 PA, QL YesSolaraze * diclofenac sodium 1 1 PA, QL NoSoliqua 100-33 3 3 PA, QL NoSoltamox 3 3 NoSolu-cortef * hydrocortisone sod succinate 1 1 NoSolu-cortef (pf) 3 3 NoSoma * carisoprodol 1 1 NoSoma * vanadom 1 1 NoSoma Compound * carisoprodol/aspirin 1 1 NoSoma Compound w/codeine * carisoprodol/aspirin/codeine 1 1 QL NoSomatuline Depot 2 2 PA, QL YesSomavert 2 2 PA YesSonata * zaleplon 1 1 QL NoSoolantra * ivermectin cream 1 1 ST, QL NoSoriatane * acitretin 1 1 NoSorilux 3 3 NoSotylize 3 3 NoSovaldi 3 3 PA, QL YesSpectazole * econazole nitrate 1 1 QL NoSpectracef * cefditoren pivoxil 1 1 NoSpiriva, Respimat 2 2 QL No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Sporanox * itraconazole 1 1 NoSpritam 3 3 PA, QL NoSprycel 2 2 PA, QL YesSPS (sorbitol free) * sodium polystyrene sulfon/sorb 1 1 NoSPS * sodium polystyrene sulfonate 1 1 NoSPS 50g/200ml enema 3 3 NoSSKI 3 3 NoStadol NS * butorphanol tartrate 1 1 QL NoStalevo * carbidopa/levodopa/entacapone 1 1 NoStarlix * nateglinide 1 1 NoStaxyn * vardenafil hcl 1 1 PA, QL NoSteglatro 3 3 QL NoStelara 45mg, 90mg 2 2 PA, QL YesStelazine * trifluoperazine hcl 1 1 NoStendra 3 3 PA, QL NoStimate 2 2 YesStiolto Respimat 2 2 QL NoStivarga 2 2 PA, QL YesStrattera * atomoxetine hcl 1 1 NoStrensiq 2 2 PA, QL YesStriant 3 3 ST, QL NoStribild 2 2 QL NoStriverdi Respimat 3 3 QL NoStromectol * ivermectin 1 1 NoStrong Iodine * potassium iodide/iodine 1 1 NoSuboxone * buprenorphine hcl/naloxone hcl 1 1 QL NoSuboxone film * buprenorphine hcl/naloxone hcl film 1 1 QL NoSubsys 3 3 PA, QL NoSubutex * buprenorphine hcl 1 1 PA, QL NoSucraid 3 3 PA, QL Yes
Sular * nisoldipine 1Free as
preventiveNo
Sulconazole Nitrate cream and solution 3 3 NoSulfadiazine * sulfadiazine 1 1 NoSulfamylon * mafenide acetate 1 1 NoSulfamylon cream 3 3 NoSumavel DosePro 3 3 ST, QL NoSunosi tablet 3 3 PA, QL NoSuprax * cefixime 1 1 No
Suprax capsule, chew tablet, 500mg/5ml suspension 3 3 No
Suprep 3 3 NoSurmontil * trimipramine maleate 1 1 NoSustiva * efavirenz 1 1 NoSutent * sunitinib 1 1 PA, QL YesSylatron 3 3 QL YesSymbicort 2 2 QL NoSymbyax * olanzapine/fluoxetine hcl 1 1 QL NoSymdeko 2 2 PA, QL YesSymfi* Efavirenz-Lamivu-Tenofov Disop 1 1 QL NoSymfi Lo * Efavirenz-Lamivu-Tenofov Disop 1 1 QL NoSymjepi 2 2 QL NoSymlinpen 3 3 NoSymmetrel * amantadine hcl 1 1 NoSympazan 3 3 PA, QL NoSymproic 3 3 PA, QL NoSymtuza 2 2 QL NoSynalar 0.01% * fluocinolone acetonide 1 1 NoSynalar 0.025% * fluocinolone acetonide 1 1 NoSynarel 2 2 NoSyndros 3 3 NoSynjardy, XR 2 2 QL NoSyprine * trientine hcl, clorique 1 1 PA, QL YesTabloid 2 2 NoTaclonex ointment * calcipotriene/betamethasone 3 3 PA NoTaclonex topical suspension 3 3 PA NoTafinlar 2 2 PA, QL YesTagamet (Rx only) * cimetidine 1 1 No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Tagamet liquid (Rx only) * cimetidine hcl 1 1 NoTagrisso 2 2 PA, QL YesTakhzyro 3 3 PA, QL YesTalicia capsule 3 3 QL NoTaltz 3 3 PA, QL YesTalwin NX * pentazocine hcl/naloxone hcl 1 1 QL NoTalzenna 3 3 PA, QL YesTambocor * flecainide acetate 1 1 NoTamiflu * oseltamivir phosphate 1 1 QL No
Tamoxifen * tamoxifen citrateFree as
preventiveFree as
preventivePA, QL No
Tamoxifen * tamoxifen citrate 1 1 QL NoTapazole * methimazole 1 1 NoTarceva* Erlotinib 1 1 PA, QL YesTargretin capsule * bexarotene 1 1 PA, QL YesTargretin gel 3 3 PA Yes
Tarka * trandolapril/verapamil hcl 1Free as
preventiveNo
Tasigna 2 2 PA, QL YesTasmar * tolcapone 1 1 NoTavalisse 3 3 PA, QL Yes
Taytulla* Gemmily capsule/Noresthin-Eth-Estra-Ferrous Fum, Merzee, Taysofy
Free as preventive
Free as preventive
No
Tazorac * tazarotene 1 1 NoTazorac 0.05%; 0.1% gel 2 2 NoTecfidera * Dimethyl Fumarate 1 1 QL YesTechnivie 3 3 PA, QL YesTegretol * carbamazepine 1 1 NoTegretol XR * carbamazepine 1 1 NoTekturna, HCT aliskiren 3 3 NoTemixys 2 2 NoTemodar * temozolomide 1 1 YesTemovate Emollient * clobetasol propionate/emoll 1 1 No
Tenex * guanfacine hcl 1Free as
preventiveNo
Tenoretic * atenolol/chlorthalidone 1Free as
preventiveNo
Tenormin * atenolol 1Free as
preventiveNo
Tenuate * diethylpropion hcl 1Free as
preventiveNo
Terazol- 3, 7 * terconazole 1 1 NoTessalon, Perles * benzonatate 1 1 NoTestim * testosterone 1 1 ST, QL NoTestosterone (Brand) pump 3 3 PA, QL NoTestosterone (Brand) 1% packet 3 3 ST, QL NoTetracycline * tetracycline hcl 1 1 No
Teveten * eprosartan mesylate 1Free as
preventiveNo
Texacort 3 3 NoThalomid 2 2 YesTheo-24 2 2 NoTheophylline anhydrous * theophylline anhydrous 1 1 NoThiola * tiopronin 1 1 PA NoThorazine * chlorpromazine hcl 1 1 NoThyrolar 2 2 No
Tiazac * diltiazem hcl 1Free as
preventiveNo
Tiazac * Tiadylt Er 1 1 NoTibsovo 2 2 PA, QL YesTigan * trimethobenzamide hcl 1 1 NoTiglutik 3 3 PA, QL YesTikosyn * dofetilide 1 1 NoTimoptic Ocudose Timolo Maleate dropperette 1 1 No
Timoptic, XE * timolol maleate 1Free as
preventiveNo
Tindamax * tinidazole 1 1 QL NoTirosint 3 3 No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Tirosint-Sol solution 3 3 NoTivicay 2 2 NoTivorbex 3 3 ST, QL NoTobi * tobramycin in 0.225% sod chlor 1 1 QL YesTobi Podhaler 3 3 PA, QL YesTobradex ointment 2 2 NoTobradex ST 3 3 NoTobradex suspension * tobramycin/dexamethasone 1 1 NoTobrex drops * tobramycin 1 1 NoTobrex ointment 3 3 No
Today contraceptive sponge Free as
preventiveFree as
preventiveQL No
Tofranil * imipramine hcl 1 1 NoTofranil-PM * imipramine pamoate 1 1 NoTolak 2 2 QL NoTolectin, DS * tolmetin sodium 1 1 NoTolinase * tolazamide 1 1 NoTopamax, Sprinkle * topiramate 1 1 NoTopicort 0.05% cream, ointment * desoximetasone 1 1 NoTopicort 0.25%; 0.05% gel * desoximetasone 1 1 NoTopiramate ER 3 3 PA, QL No
Toprol XL * metoprolol succinate 1Free as
preventiveNo
Toradol injection * ketorolac tromethamine 1 1 NoToradol tablet * ketorolac tromethamine 1 1 QL NoToujeo, Max Solostar 2 2 NoToviaz 3 3 ST, QL NoTracleer * Bosentan 1 1 PA, QL YesTracleer tablet for suspension 2 2 PA YesTradjenta 2 2 QL NoTramadol hcl ER 3 3 QL NoTransderm-Scop * scopolamine 1 1 NoTranxene T-Tab * clorazepate dipotassium 1 1 NoTravatan Z * Travoprost 1 1 NoTrecator 3 3 NoTrelegy Ellipta 2 2 QL NoTremfya 3 3 PA, QL YesTremfya auto injector 3 3 PA NoTrental * pentoxifylline 1 1 NoTresiba, Flextouch 2 2 NoTretin-X 3 3 NoTrexall 2 2 NoTreximet * sumatriptan succ/naproxen sod 1 1 PA, QL NoTrezix 3 3 QL No
Tribenzor * olmesartan/amlodipin/hcthiazid 1Free as
preventiveQL No
Tricor * fenofibrate nanocrystallized 1Free as
preventiveNo
Triglide 3 3 NoTrikafta 3 3 PA, QL YesTrileptal suspension * oxcarbazepine 1 1 NoTrileptal tablet * oxcarbazepine 1 1 No
Trilevlen * levonorgestrel-ethin estradiolFree as
preventiveFree as
preventiveNo
Trilipix * fenofibric acid (choline) 1Free as
preventiveNo
Trimethoprim * trimethoprim 1 1 NoTrimpex 3 3 No
Tri-Norinyl * norethindrone-ethinyl estradFree as
preventiveFree as
preventiveNo
Trintellix 3 3 ST, QL NoTritocin Kenalog ointment 1 1 NoTriumeq 2 2 QL NoTrokendi XR 3 3 PA, QL NoTrulicity 2 2 QL NoTrusopt * dorzolamide hcl 1 1 NoTrust Natal DHA combo pack 2 2Truvada* Emtricitabine-Tenofovir Disop 1 1 PA, QL No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?
Truvada 200mg/300mgFree as
preventiveFree as
preventivePA, QL No
Tudorza Pressair 3 3 QL NoTuralio 3 3 NoTussicaps 2 2 QL NoTussionex * hydrocodone/chlorphen p-stirex 1 1 NoTuxarin ER tablet 3 3 NoTuzistra XR 3 3 QL No
Twinrix Free as
preventiveFree as
preventiveQL No
Twynsta * telmisartan/amlodipine 1Free as
preventiveNo
Tyblume 3 3 NoTybost 2 2 QL NoTykerb * Lapatinib 1 1 PA YesTylenol w/codeine * acetaminophen with codeine 1 1 QL NoTylenol w/codeine solution * acetaminophen with codeine 1 1 QL NoTymlos 2 2 PA, QL YesTyvaso 2 2 PA, QL YesTyzine 3 3 NoUceris foam 3 3 ST NoUceris tablet * budesonide 1 1 PA, QL NoUlesfia 3 3 NoUloric * febuxostat 1 1 ST, QL NoUltracet * tramadol hcl/acetaminophen 1 1 QL NoUltram, ER * tramadol hcl 1 1 QL NoUltravate cream, ointment * halobetasol propionate 1 1 No
Univasc * moexipril hcl 1Free as
preventiveNo
Upneeq dropperette 2 2 NoUptravi 2 2 PA, QL YesUrecholine * bethanechol chloride 1 1 NoUrispas * flavoxate hcl 1 1 NoUrocit-K * potassium citrate, potassium citrate ER 1 1 NoUroxatral * alfuzosin hcl 1 1 NoUrso; Forte * ursodiol 1 1 NoUtibron Neohaler 3 3 QL NoVagifem * estradiol 1 1 NoValchlor 3 3 PA, QL YesValcyte * valganciclovir hcl 1 1 NoValisone lotion * betamethasone valerate 1 1 NoValisone ointment * betamethasone valerate 1 1 NoValium * diazepam 1 1 NoValtrex * valacyclovir hcl 1 1 NoVancocin * vancomycin hcl 1 1 NoVantin * cefpodoxime proxetil 1 1 No
Vaqta Free as
preventiveFree as
preventiveQL No
Varenicline Tartrate $2 $2 QL NoVarubi 3 3 PA, QL NoVascepa* Icosapent Ethyl capsule 1 1 PA, QL No
Vaseretic * enalapril/hydrochlorothiazide 1Free as
preventiveNo
Vasocidin * sulfacetamide/prednisolone sp 1 1 No
Vasotec * enalapril maleate 1Free as
preventiveNo
VCF film, gel Free as
preventiveFree as
preventiveQL No
VCF foam * nonoxynol 9Free as
preventiveFree as
preventiveQL No
Vecamyl 3 3 PA, QL NoVectical * calcitriol 1 1 NoVelphoro 3 3 NoVeltassa 2 2 QL NoVemlidy 2 2 QL YesVenclexta 2 2 PA, QL YesVentavis 2 2 PA, QL YesVepesid * etoposide 1 1 No
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Verdeso 3 3 NoVeregen 3 3 No
Verelan, PM * verapamil hcl 1Free as
preventiveNo
Versacloz 3 3 NoVersed syrup * midazolam hcl 1 1 NoVerzenio 2 2 PA, QL YesVesanoid * tretinoin 1 1 NoVesicare Solifenacin Succinate 1 1 ST, QL NoVfend * voriconazole 1 1 NoViagra * sildenafil citrate 1 1 PA, QL NoViberzi 3 3 PA, QL NoVibramycin * doxycycline hyclate 1 1 NoVibramycin suspension * doxycycline monohydrate 1 1 NoVibramycin syrup 3 3 NoVicoprofen * hydrocodone/ibuprofen 1 1 QL NoVictoza 2 2 QL NoVigamox * moxifloxacin hcl 1 1 NoViibryd, dose pack 3 3 ST, QL NoVimpat 2 2 PA, QL NoViokace 2 2 NoViramune, XR * nevirapine 1 1 NoViread * tenofovir disoproxil fumarate 1 1 NoViread 150mg, 200mg, 250mg tablet; packet 2 2 NoViroptic * trifluridine 1 1 NoVirtussin DAC * pseudoephed/codeine/guaifen 1 1 No
Visken * pindolol 1Free as
preventiveNo
Vistaril * hydroxyzine pamoate 1 1 NoVistogard 2 2 QL YesVitafol Fe Plus 3 3Vitamin K ampule * phytonadione (vit k1) 1 1 NoVitrakvi 3 3 PA, QL YesVivactil * protriptyline hcl 1 1 NoVivlodex * meloxicam 1 1 PA, QL NoVizimpro 2 2 PA, QL YesVogelxo 3 3 ST, QL NoVoltaren gel * diclofenac sodium 1 1 QL NoVoltaren ophthalmic solution * diclofenac sodium 1 1 NoVoltaren tablet * diclofenac sodium 1 1 NoVoltaren-XR * diclofenac sodium 1 1 NoVosevi 3 3 PA, QL YesVosol * acetic acid 1 1 NoVospire ER * albuterol sulfate 1 1 NoVotrient 2 2 PA, QL YesVraylar 3 3 ST, QL NoVusion 3 3 QL NoVyndamax capsule 2 2 No
Vytorin * ezetimibe/simvastatin 1Free as
preventiveQL No
Vyvanse 3 3 QL NoVyzulta 3 3 PA, QL No
Welchol * colesevelam hcl 1Free as
preventiveNo
Wellbutrin, SR, XL * bupropion hcl, burpropion xl 1 1 NoWestab Plus 1 1 NoWestcort * hydrocortisone valerate 1 1 NoWesthroid * thyroid,pork 1 1 NoWinlevi cream 2 2 NoWP Thyroid * thyroid,pork 1 1 NoWP Thyroid 32.5mg, 65mg, 81.25mg, 130mg 3 3 NoXadago 3 3 QL NoXalatan * latanoprost 1 1 NoXalkori 2 2 PA, QL YesXanax, XR * alprazolam 1 1 NoXarelto, starter kit 2 2 PA, QL NoXcopri 3 3Xatmep 3 3 Yes
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Xeljanz, XR 2 2 PA, QL YesXeloda * capecitabine 1 1 YesXelpros 3 3 PA, QL NoXembify 3 3 PA YesXenazine * tetrabenazine 1 1 PA, QL YesXenical 3 3 NoXenleta tablet 3 3 QL NoXepi 3 3 PA, QL NoXermelo 2 2 PA, QL YesXifaxan 200mg 3 3 NoXifaxan 550mg 3 3 PA, QL NoXigduo XR 2 2 QL NoXiidra 2 2 PA, QL NoXofluza 3 3 QL NoXolair 3 3 PA, QL YesXolegel 3 3 PA, QL NoXopenex HFA 3 3 QL NoXopenex solution * levalbuterol hcl 1 1 NoXospata 3 3 PA, QL YesXpovio tablet 2 2 QL YesXtandi 2 2 PA, QL YesXultophy 100-3.6 2 2 QL NoXuriden 2 2 PA, QL YesXylocaine Viscous Solution (Rx Only) * lidocaine hcl 1 1 NoXyntha Solofuse 2 2 NoXyosted 3 3 PA, QL NoXyrem 3 3 PA, QL YesXyzal * levocetirizine dihydrochloride 1 1 QL No
Yasmin 28 * ethinyl estradiol/drospirenone, zumandimineFree as
preventiveFree as
preventiveNo
Yaz *ethinyl estradiol/drospirenone, Jasmiel, lo-zumandimine
Free as preventive
Free as preventive
No
Zanaflex * tizanidine hcl 1 1 NoZantac (Rx Only) * ranitidine hcl 1 1 NoZarontin * ethosuximide 1 1 No
Zaroxolyn * metolazone 1Free as
preventiveNo
Zarxio 3 3 YesZavesca * miglustat 1 1 PA, QL Yes
Zebeta * bisoprolol fumarate 1Free as
preventiveNo
Zejula 2 2 PA, QL YesZelapar 3 3 QL NoZelboraf 2 2 PA, QL YesZelnorm tablet 3 3 PA, QL NoZembrace SymTouch 3 3 ST, QL NoZemplar * paricalcitol 1 1 NoZenpep 2 2 NoZenzedi * dextroamphetamine sulfate 1 1 NoZepatier 2 2 PA, QL Yes
Zetia * ezetimibe 1Free as
preventiveQL No
Zetonna 3 3 ST, QL No
Ziac * bisoprolol/hydrochlorothiazide 1Free as
preventiveNo
Ziagen * abacavir sulfate 1 1 NoZioptan 3 3 NoZipsor 3 3 PA, QL NoZirgan 2 2 NoZithromax * azithromycin 1 1 No
Zocor * simvastatin 1Free as
preventiveQL No
Zocor* (5mg, 10mg, 20mg, 40mg) * simvastatinFree as
preventiveFree as
preventiveQL No
Zofran * ondansetron hcl 1 1 QL NoZofran ODT * ondansetron 1 1 QL NoZohydro ER * Hydrocodone Bitartrate 1 1 PA, QL NoZolinza 2 2 PA, QL Yes
Updated 9/24/2021
Drug name Generic name Choices Tier ABC Tier Limits Specialty
drug?Zoloft * sertraline hcl 1 1 NoZomacton 3 3 PA YesZomig nasal spray 3 3 ST, QL NoZomig, ZMT * zolmitriptan 1 1 QL NoZonalon 30g 3 3 PA, QL NoZonatuss * benzonatate 1 1 NoZonegran * zonisamide 1 1 NoZontivity 3 3 QL NoZorbtive 3 3 PA YesZortress * Everolimius 2 2 YesZorvolex 3 3 PA, QL NoZovirax * acyclovir 1 1 NoZubsolv 2 2 QL NoZutripro * hydrocodone/cpm/pseudoephed 1 1 QL No
Zyban * bupropion hclFree as
preventiveFree as
preventiveQL No
Zyclara * imiquimod cream pack 1 1 PA, QL NoZydelig 2 2 PA, QL YesZyflo 3 3 QL NoZyflo CR * zileuton 1 1 QL NoZykadia 2 2 PA, QL YesZylet 3 3 NoZyloprim * allopurinol 1 1 NoZymaxid * gatifloxacin 1 1 NoZyprexa, Zydis * olanzapine 1 1 NoZyrtec solution (Rx Only) * cetirizine hcl 1 1 NoZyvox * linezolid 1 1 No