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CHRISTUS Health Plan
2020 Formulary
Revised: November 30, 2020
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
MC2041
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Note to members:
When this drug list (formulary) refers to “we,” “us”, or “our,” it means CHRISTUS Health Plan. When it
refers to “plan” or “our plan,” it means CHRISTUS Health Plan.
This document includes a list of the drugs (formulary) for our plan, which is current as of formulary revision
date.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time
during the year.
What is the CHRISTUS Health Plan Formulary?
A formulary is a list of covered drugs selected by CHRISTUS Health Plan in consultation with a team of
health care providers, which represents the prescription therapies believed to be a necessary part of a quality
treatment program. CHRISTUS Health Plan will generally cover the drugs listed in our formulary as long
as the drug is medically necessary, the prescription is filled at a CHRISTUS Health Plan network
pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please
review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year,
we will not discontinue or reduce coverage of the drug during the 2020 coverage year except when a new,
less expensive generic drug becomes available or when new adverse information about the safety or
effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our
formulary, will not affect members who are currently taking the drug. It will remain available at the same
cost sharing for those members taking it for the remainder of the coverage year. We feel it is important that
you have continued access for the remainder of the coverage year to the formulary drugs that were available
when you chose our plan, except for cases in which you can save additional money or we can ensure your
safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy
restrictions on a drug, we must notify affected members of the change at least 60 days before the change
becomes effective, or at the time the member requests a refill of the drug, at which time the member will
receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary
to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove
the drug from our formulary and provide notice to members who take the drug. The enclosed formulary
is current as of December 01, 2020. To get updated information about the drugs covered by CHRISTUS
Health Plan, please contact our Member Services at 1-844-282-3025 or for TTY users, 711 or visit christushealthplan.org.
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How do I use the Formulary? There are two ways to find your drug within the formulary:
By Medical Condition:
The drugs in this formulary are grouped into categories depending on the type of medical conditions
that they are used to treat. For example, drugs used to treat a heart condition are listed under the
category, CARDIOVASCULAR, HYPERTENSION/LIPIDS. If you know, what your drug is used for,
look for the category name in the list that begins on page 8. Then look under the category name for
your drug.
By Alphabetical Listing:
If you are not sure what category to look under, you should look for your drug in the Index that begins
on page 102. The Index provides an alphabetical list of all of the drugs included in this document. Both
brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next
to your drug, you will see the page number where you can find coverage information. Turn to the page
listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
CHRISTUS Health Plan covers both brand name drugs and generic drugs. A generic drug is approved by
the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less
than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and
limits may include:
Prior Authorization: CHRISTUS Health Plan requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval from CHRISTUS
Health Plan before you fill your prescriptions. If you do not get approval, CHRISTUS Health Plan
may not cover the drug.
Quantity Limits: For certain drugs, CHRISTUS Health Plan limits the amount of the drug that
CHRISTUS Health Plan will cover. For example, CHRISTUS Health Plan provides 30 per 30
days per prescription for AFINITOR.
Step Therapy: In some cases, CHRISTUS Health Plan requires you to first try certain drugs to
treat your medical condition before we will cover another drug for that condition. For example,
if Drug A and Drug B both treat your medical condition, CHRISTUS Health Plan may not cover
Drug B unless you try Drug A first. If Drug A does not work for you, CHRISTUS Health Plan
will then cover Drug B.
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You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 9. You can also get more information about the restrictions applied to specific covered
drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and
step therapy restrictions. You may also ask us to send you a copy.
You can ask CHRISTUS Health Plan to make an exception to these restrictions or limits or for a list of
other, similar drugs that may treat your health condition. See the section in your Evidence of Coverage
“Prescription Drugs/Medications.”
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Member
Services and ask if your drug is covered.
If you learn that CHRISTUS Health Plan does not cover your drug, you have two options:
You can ask Member Services for a list of similar drugs that are covered by CHRISTUS Health
Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar
drug that is covered by CHRISTUS Health Plan.
You can ask CHRISTUS Health Plan to make an exception and cover your drug. See below for
information about how to request an exception.
How do I request an exception to the mandatory CHRISTUS Health Plan Formulary?
You can ask CHRISTUS Health Plan to make an exception to our coverage rules. There are several types
of exceptions that you can ask us to make.
You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will
be covered at a pre-determined cost-sharing level, and you would not be able to ask us to
provide the drug at a lower cost-sharing level.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain
drugs, CHRISTUS Health Plan limits the amount of the drug that we will cover. If your drug has a
quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, CHRISTUS Health Plan will only approve your request for an exception if the alternative drugs
included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating
your condition and/or would cause you to have adverse medical effects.
For requests for benefits that do not involve exceptions, the Plan will provide notice of its decision within
24 hours after receiving an expedited request or 72 hours after receiving a standard request. For requests
for benefits that involve exceptions, the adjudication timeframes do not begin until the member’s prescriber
submits his or her supporting statement to the Plan for review. For payment requests, including payment
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requests that involve exceptions, CHRISTUS Health Plan will provide written notice of its decision (and
make payment when appropriate) within 14 calendar days after receiving a request.
If CHRISTUS Health Plan coverage determination is unfavorable, the decision will contain the
information needed to file a request for appeal/ redetermination with the Plan.
What do I do before I can talk to my doctor about changing my drugs or requesting an
exception?
As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or,
you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you
may need a prior authorization from us before you can fill your prescription. You should talk to your
doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception
so that we will cover the drug you take. While you talk to your doctor to determine the right course of
action for you, we may cover your drug in certain cases during the first 90 days you are a member of our
plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we
will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you
go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you
have been a member of the plan less than 90 days.
For more information
For more detailed information about your CHRISTUS Health Plan prescription drug coverage, please
review your Evidence of Coverage and other plan materials.
If you have questions about CHRISTUS Health Plan, please contact our Member Services at
1-844-282-3025 or for TTY users, 711 or visit christushealthplan.org.
CHRISTUS Health Plan Formulary
The formulary that begins on page 9 provides coverage information about some of the drugs covered
by CHRISTUS Health Plan. If you have trouble finding your drug in the list, turn to the Index that
begins on page 102.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g.,
ACCUPRIL) and generic drugs are listed in lower-case italics (e.g. furosemide).
The information in the Requirements/Limits column tells you if CHRISTUS Health Plan has any special
requirements for coverage of your drug.
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Below is a list of abbreviations and that may appear on the following pages in the
Requirements/Limits column that tells you if there are any special requirements for coverage of your
drug.
List of Abbreviations
1: Preferred Generic
2: Non-Preferred Generic
3: Preferred Brand
4: Non-Preferred Brand
5: Specialty
ACA: Affordable Care Act.
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more
information, please call Customer Service.
OTC: Over the Counter. An OTC drug is a non-prescription drug.
PA : Prior Authorization. The Plan requires you or your physician to get prior authorization for certain
drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get
approval, we may not cover the drug.
QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.
ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and Drug B both
treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not
work for you, we will then cover Drug B.
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Legend:
Copay Amount by Drug Tier: You will pay either a copay or coinsurance amount for drugs in tiers 1
through 4. You will pay a coinsurance for tier 5. The amount you pay per prescription for drugs in tiers 1
through 5 may vary each time you fill a prescription. The copay and coinsurance amounts depend on the
plan and metal level you selected. The chart below shows the range of copays or coinsurance you may
pay. For your specific copay and coinsurance amounts please refer to your Summary of Benefits or visit
our website at www.christushealthplan.org
Tier
Number
Tier Name Copay for a one-month supply filled at a network
pharmacy with standard cost-sharing
0 ACA Drugs* $0
1 (Preventive) Preferred Generic Drugs
$0 or
40% after deductible
2 Non-Preferred Generic Drugs
$3-$25 or
40% after deductible
3 Preferred Brand Drugs
$20 or
$35-$100 after deductible or
40% after deductible
4 Non-Preferred Drugs
45% coinsurance or
$75-$95 after deductible or
40-50% after deductible
5 Specialty Drugs
45% coinsurance or
40-50% after deductible
Under $100 - $
$100 - $250 - $$
$251 - $500 - $$$
$501 - $1000 - $$$$
Over $1000 - $$$$$
*Preventive drugs (e.g. statins, aspirin, folic acid, fluoride, iron supplements, smoking cessation products
and FDA-approved contraceptives for women) are available at a zero-dollar cost share if prescribed under
certain medical criteria by your doctor.
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Table of Contents
ANTI - INFECTIVES ........................................................................................................................................ 9
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ..................................................................... 16
AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ....................................................................... 20
CARDIOVASCULAR, HYPERTENSION & LIPIDS ................................................................................. 35
DERMATOLOGICALS/TOPICAL THERAPY .......................................................................................... 43
DIAGNOSTICS & MISCELLANEOUS AGENTS ...................................................................................... 53
EAR, NOSE & THROAT MEDICATIONS .................................................................................................. 55
ENDOCRINE/DIABETES .............................................................................................................................. 56
GASTROENTEROLOGY .............................................................................................................................. 66
IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ............................................................................. 73
MUSCULOSKELETAL & RHEUMATOLOGY ......................................................................................... 76
OBSTETRICS & GYNECOLOGY ................................................................................................................ 78
OPHTHALMOLOGY ..................................................................................................................................... 84
RESPIRATORY, ALLERGY, COUGH & COLD ....................................................................................... 89
UROLOGICALS .............................................................................................................................................. 95
VITAMINS, HEMATINICS & ELECTROLYTES ..................................................................................... 96
Index ................................................................................................................................................................ 102
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
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Drug Name Drug
Tier
Requirements
/ Limits
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
ANCOBON 4
clotrimazole mucous
membrane
2
CRESEMBA ORAL 3 PA
DIFLUCAN ORAL
SUSPENSION FOR
RECONSTITUTIO
N
4
DIFLUCAN ORAL
TABLET 100 MG,
200 MG, 50 MG
4
DIFLUCAN ORAL
TABLET 150 MG
4 QL
fluconazole oral
suspension for
reconstitution
2
fluconazole oral
tablet 100 mg, 200
mg, 50 mg
2
fluconazole oral
tablet 150 mg
2 QL
flucytosine 2
griseofulvin
microsize
2
griseofulvin
ultramicrosize
2
itraconazole oral
capsule
2 QL
itraconazole oral
solution
2
ketoconazole oral 2
NOXAFIL ORAL
SUSPENSION
3 PA
Drug Name Drug
Tier
Requirements
/ Limits
nystatin oral
suspension
2
nystatin oral tablet 2
ORAVIG 4
posaconazole oral
tablet,delayed
release (dr/ec)
3 PA
SPORANOX ORAL
SOLUTION
4
SPORANOX
PULSEPAK
4 QL
terbinafine hcl oral 2
VFEND 4 PA
voriconazole oral 2 PA
ANTIVIRALS
abacavir 2
abacavir-lamivudine 2
abacavir-
lamivudine-
zidovudine
2
acyclovir oral
capsule
2
acyclovir oral
suspension 200 mg/5
ml
2
acyclovir oral tablet 2
adefovir 2
amantadine hcl 2
APTIVUS 3
APTIVUS (WITH
VITAMIN E)
3
atazanavir 2
BARACLUDE
ORAL SOLUTION
3
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
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Drug Name Drug
Tier
Requirements
/ Limits
BIKTARVY 3
CIMDUO 3
COMBIVIR 4
CRIXIVAN ORAL
CAPSULE 200 MG
3
DESCOVY 3
didanosine oral
capsule,delayed
release(dr/ec) 250
mg, 400 mg
2
DOVATO 3
EDURANT 3
efavirenz 2
efavirenz-
emtricitabin-tenofov
2
efavirenz-lamivu-
tenofov disop
2
emtricitabine 2
emtricitabine-
tenofovir (tdf)
1
EMTRIVA ORAL
CAPSULE
4
EMTRIVA ORAL
SOLUTION
3
entecavir 2
EPCLUSA ORAL
TABLET 200-50
MG
5 PA; QL
EPCLUSA ORAL
TABLET 400-100
MG
5 PA; $$$$$;
QL
EPIVIR 4
EPIVIR HBV
ORAL SOLUTION
3
EPIVIR HBV
ORAL TABLET
4
Drug Name Drug
Tier
Requirements
/ Limits
EPZICOM 4
EVOTAZ 4
famciclovir 2 QL
FLUMADINE
ORAL TABLET
4
fosamprenavir 2
FUZEON
SUBCUTANEOUS
RECON SOLN
5 $$$$
GENVOYA 3
HARVONI ORAL
PELLETS IN
PACKET
5 PA; QL
HARVONI ORAL
TABLET 45-200
MG
5 PA; QL
HARVONI ORAL
TABLET 90-400
MG
5 PA; $$$$$;
QL
HEPSERA 4
INTELENCE 3
INVIRASE ORAL
TABLET
3
ISENTRESS 3
ISENTRESS HD 3
JULUCA 3
KALETRA ORAL
SOLUTION
4 QL
KALETRA ORAL
TABLET
3 QL
lamivudine 2
lamivudine-
zidovudine
2
LEXIVA ORAL
SUSPENSION
3
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
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Drug Name Drug
Tier
Requirements
/ Limits
LEXIVA ORAL
TABLET
4
lopinavir-ritonavir 2 QL
nevirapine 2
NORVIR ORAL
POWDER IN
PACKET
3
NORVIR ORAL
SOLUTION
3
NORVIR ORAL
TABLET
4
ODEFSEY 3
oseltamivir 2 QL
PREVYMIS ORAL 3 QL
PREZISTA ORAL
SUSPENSION
3
PREZISTA ORAL
TABLET 150 MG,
600 MG, 75 MG,
800 MG
3
RELENZA
DISKHALER
4 QL
RETROVIR ORAL
CAPSULE
4
RETROVIR ORAL
SYRUP
4
REYATAZ ORAL
CAPSULE 150 MG,
200 MG, 300 MG
4
REYATAZ ORAL
POWDER IN
PACKET
3
ribavirin inhalation 2
rimantadine 2
ritonavir 2
SELZENTRY 3
Drug Name Drug
Tier
Requirements
/ Limits
stavudine oral
capsule
2
SUSTIVA 4
SYMFI 3
SYMFI LO 3
SYMTUZA 3
TAMIFLU 4 QL
TEMIXYS 3
tenofovir disoproxil
fumarate
2
TIVICAY 3
TIVICAY PD 3
TRIUMEQ 3
TRIZIVIR 4
TRUVADA 3
TYBOST 4
valacyclovir 2 QL
VALCYTE 4
valganciclovir 2
VEMLIDY 3
VIEKIRA PAK 5 PA; $$$$$;
QL
VIRACEPT ORAL
TABLET
3
VIRAMUNE 4
VIRAMUNE XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
400 MG
4
VIRAZOLE 4 $$$$
VIREAD ORAL
POWDER
3
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
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Drug Name Drug
Tier
Requirements
/ Limits
VIREAD ORAL
TABLET 150 MG,
200 MG, 250 MG
3
VIREAD ORAL
TABLET 300 MG
4
VOSEVI 5 PA; $$$$$;
QL
XOFLUZA 4 QL
ZEPATIER 5 PA; $$$$$;
QL
ZIAGEN 4
zidovudine 2
ZOVIRAX ORAL
SUSPENSION
4
CEPHALOSPORINS
cefaclor oral capsule 2
cefaclor oral
suspension for
reconstitution 125
mg/5 ml, 250 mg/5
ml, 375 mg/5 ml
2
cefaclor oral tablet
extended release 12
hr
2
cefadroxil oral
capsule
2
cefadroxil oral
suspension for
reconstitution 250
mg/5 ml, 500 mg/5
ml
2
cefadroxil oral tablet 2
cefdinir 2
cefditoren pivoxil 2
cefixime 2
cefpodoxime 2
cefprozil 2
Drug Name Drug
Tier
Requirements
/ Limits
cefuroxime axetil
oral tablet
2
cephalexin 2
KEFLEX ORAL
CAPSULE
4
SPECTRACEF
ORAL TABLET
400 MG
4
SUPRAX ORAL
CAPSULE
4
SUPRAX ORAL
SUSPENSION FOR
RECONSTITUTIO
N
4
SUPRAX ORAL
TABLET,CHEWAB
LE
4
ERYTHROMYCINS & OTHER
MACROLIDES
azithromycin oral 2 QL
clarithromycin 2
DIFICID 4 QL
e.e.s. 400 oral tablet 2
E.E.S. GRANULES 4
ERYPED 200 4
ERYPED 400 4
ery-tab oral
tablet,delayed
release (dr/ec) 250
mg, 333 mg
2
ERY-TAB ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 500 MG
4
erythrocin (as
stearate) oral tablet
250 mg
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
13
Drug Name Drug
Tier
Requirements
/ Limits
erythromycin
ethylsuccinate oral
suspension for
reconstitution
2
erythromycin
ethylsuccinate oral
tablet
2
erythromycin oral 2
ZITHROMAX
ORAL PACKET
4 QL
ZITHROMAX
ORAL
SUSPENSION FOR
RECONSTITUTIO
N
4 QL
ZITHROMAX
ORAL TABLET
250 MG, 500 MG
4 QL
ZITHROMAX TRI-
PAK
4 QL
ZITHROMAX Z-
PAK
4 QL
MISCELLANEOUS
ANTIINFECTIVES
AEMCOLO 4 QL
albendazole 2
ALBENZA 4 QL
ALINIA 3 QL
ARAKODA 4 QL
ARIKAYCE 5 PA
atovaquone 2
atovaquone-
proguanil
1 QL
BENZNIDAZOLE 3 QL
BETHKIS 5 PA; $$$$$;
QL
BILTRICIDE 4
Drug Name Drug
Tier
Requirements
/ Limits
CAYSTON 5 $$$$; LA; QL
chloroquine
phosphate
1 QL
CLEOCIN HCL 4
CLEOCIN
PEDIATRIC
4
clindamycin hcl 2
clindamycin
pediatric
2
COARTEM 3 QL
CYCLOSERINE 4
dapsone oral 2
DARAPRIM 5 PA
EMVERM 3 QL
ethambutol 2
FLAGYL ORAL
CAPSULE
4
FLAGYL ORAL
TABLET 500 MG
4
hydroxychloroquine 2 QL
IMPAVIDO 3 QL
isoniazid oral 2
ivermectin oral 2 QL
KITABIS PAK 5 PA; $$$$$;
QL
KRINTAFEL 4 QL
linezolid 2 PA
MALARONE 4 QL
MALARONE
PEDIATRIC
4 QL
mefloquine 1 QL
MEPRON 4
metronidazole oral 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
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Drug Name Drug
Tier
Requirements
/ Limits
MYAMBUTOL
ORAL TABLET
400 MG
4
MYCOBUTIN 4
NEBUPENT 4 QL
neomycin 2
paromomycin 2
PASER 4
pentamidine
inhalation
2 QL
praziquantel 2
PRETOMANID 4 PA
PRIFTIN 3
primaquine 1 QL
pyrazinamide 2
pyrimethamine 5 PA
QUALAQUIN 4 QL
quinine sulfate 2 QL
rifabutin 2
RIFADIN ORAL 4
RIFAMATE 4
rifampin oral 2
RIFATER 4
SIRTURO 3 PA; LA
SIVEXTRO ORAL 4 PA
SOLOSEC 3 QL
STROMECTOL 4 QL
tinidazole 2 QL
TOBI PODHALER
INHALATION
CAPSULE,
W/INHALATION
DEVICE
5 PA; $$$$$;
QL
Drug Name Drug
Tier
Requirements
/ Limits
tobramycin in 0.225
% nacl
5 PA; $$$$$;
QL
tobramycin
inhalation
5 PA; QL
TOBRAMYCIN
WITH NEBULIZER
5 PA; $$$$; QL
TRECATOR 4
XENLETA ORAL 4
XIFAXAN 3 QL
ZYVOX ORAL 4 PA
PENICILLINS
amoxicillin oral
capsule
2
amoxicillin oral
suspension for
reconstitution
2
amoxicillin oral
tablet
2
amoxicillin oral
tablet,chewable 125
mg, 250 mg
2
amoxicillin-pot
clavulanate
2
ampicillin oral
capsule 500 mg
2
AUGMENTIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N 125-31.25 MG/5
ML
3
AUGMENTIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N 250-62.5 MG/5
ML
4
AUGMENTIN XR 4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
15
Drug Name Drug
Tier
Requirements
/ Limits
dicloxacillin 2
MOXATAG 4
penicillin v
potassium
2
QUINOLONES
BAXDELA ORAL 3 QL
CIPRO ORAL
SUSPENSION,MIC
ROCAPSULE
RECON
4
CIPRO ORAL
TABLET 250 MG,
500 MG
4
ciprofloxacin 2
ciprofloxacin hcl
oral
2
FACTIVE 4
levofloxacin oral 2
moxifloxacin oral 2
ofloxacin oral tablet
300 mg, 400 mg
2
SULFA'S & RELATED AGENTS
BACTRIM 4
BACTRIM DS 4
sulfadiazine 2
sulfamethoxazole-
trimethoprim oral
2
sulfatrim 2
TETRACYCLINES
ACTICLATE 4 ST
avidoxy 2
AVIDOXY DK 4 ST
coremino 2
demeclocycline 2
Drug Name Drug
Tier
Requirements
/ Limits
DORYX MPC 4 ST
DORYX ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 200 MG,
50 MG
4 ST
doxycycline hyclate
oral capsule
2
doxycycline hyclate
oral tablet
2
doxycycline hyclate
oral tablet,delayed
release (dr/ec) 100
mg, 150 mg, 200 mg,
50 mg, 75 mg
2
doxycycline
monohydrate oral
capsule
2
doxycycline
monohydrate oral
suspension for
reconstitution
2
doxycycline
monohydrate oral
tablet
2
minocycline oral
capsule
2
minocycline oral
tablet
2
minocycline oral
tablet extended
release 24 hr
2 ST
MINOLIRA ER 4 ST
mondoxyne nl oral
capsule 100 mg, 75
mg
2
MONODOX 4 ST
MORGIDOX 1X 50 4 ST
MORGIDOX 2X100 4 ST
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
16
Drug Name Drug
Tier
Requirements
/ Limits
morgidox oral
capsule 100 mg
2
NUZYRA ORAL 4 QL
ORACEA 3 ST
SEYSARA 4 PA
SOLODYN ORAL
TABLET
EXTENDED
RELEASE 24 HR
105 MG, 115 MG,
55 MG, 65 MG, 80
MG
4 ST
TARGADOX 4 ST
tetracycline 2
VIBRAMYCIN
ORAL CAPSULE
100 MG
4 ST
VIBRAMYCIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N
4
VIBRAMYCIN
ORAL SYRUP
4
XERAVA
INTRAVENOUS
RECON SOLN 100
MG
4
URINARY TRACT AGENTS
fosfomycin
tromethamine
2
FURADANTIN 4
HIPREX 4
MACROBID 4
MACRODANTIN 4
methenamine
hippurate
2
Drug Name Drug
Tier
Requirements
/ Limits
methenamine
mandelate
2
MONUROL 4
nitrofurantoin 2
nitrofurantoin
macrocrystal
2
nitrofurantoin
monohyd/m-cryst
2
PRIMSOL 4
trimethoprim 2
VANCOMYCIN
FIRVANQ 4 QL
VANCOCIN 4 QL
vancomycin oral
capsule
2 QL
vancomycin oral
recon soln
2 QL
ANTINEOPLASTIC &
IMMUNOSUPPRESSANT
DRUGS
ADJUNCTIVE AGENTS
leucovorin calcium
oral
2
MESNEX ORAL 3
VISTOGARD 5 PA
XGEVA 5 PA; $$$$
ANTINEOPLASTIC &
IMMUNOSUPPRESSANT DRUGS
abiraterone 5 PA; QL
AFINITOR 5 PA; $$$$$;
QL
AFINITOR
DISPERZ
5 PA; $$$$$
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
17
Drug Name Drug
Tier
Requirements
/ Limits
ALECENSA 5 PA; $$$$$;
QL
ALKERAN 4
ALUNBRIG 5 PA; $$$$$;
QL
anastrozole 2 ACA
AROMASIN 4
ASTAGRAF XL 4 ST
AYVAKIT 5 PA; LA; QL
AZASAN 4
azathioprine 2
BALVERSA 5 PA; LA
bexarotene 5 PA
bicalutamide 2
BOSULIF 5 PA; $$$$$;
QL
BRAFTOVI 5 PA; QL
BRUKINSA 5 PA
BYNFEZIA 5
CABOMETYX 5 PA; $$$$$;
LA; QL
CALQUENCE 5 PA; $$$$$;
LA; QL
capecitabine 5 $$$$
CAPRELSA 5 PA; LA; QL
CASODEX 4
CELLCEPT 4
COMETRIQ 5 PA
COPIKTRA 5 PA; LA; QL
COTELLIC 5 PA; $$$$$;
LA; QL
cyclophosphamide
oral capsule
2
Drug Name Drug
Tier
Requirements
/ Limits
cyclosporine
modified
2
cyclosporine oral
capsule
2
DAURISMO 5 PA; QL
DROXIA 3
ELIGARD 5 PA; $$$
ELIGARD (3
MONTH)
5 PA; $$$
ELIGARD (4
MONTH)
5 PA; $$$
ELIGARD (6
MONTH)
5 PA; $$$
EMCYT 3
ENSPRYNG 5 PA
ENVARSUS XR 4 ST
ERIVEDGE 5 PA; $$$$$;
QL
ERLEADA 5 PA; $$$$$;
QL
erlotinib 5 PA; QL
etoposide oral 2
everolimus
(antineoplastic)
5 PA
everolimus
(immunosuppressive
)
2
exemestane 2 ACA
FARESTON 4
FARYDAK 5 PA; $$$$$;
QL
FEMARA 4
flutamide 2
gengraf oral capsule
100 mg, 25 mg
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
18
Drug Name Drug
Tier
Requirements
/ Limits
gengraf oral solution 2
GILOTRIF 5 PA; $$$$$;
QL
GLEOSTINE ORAL
CAPSULE 10 MG,
100 MG, 40 MG
3
GLIADEL WAFER 4
HYCAMTIN ORAL 5 PA; $$$$$
HYDREA 4
hydroxyurea 2
IBRANCE ORAL
CAPSULE
5 PA; $$$$$;
QL
IBRANCE ORAL
TABLET
5 PA; QL
ICLUSIG 5 PA; QL
IDHIFA 5 PA; $$$$$;
LA; QL
imatinib 5 PA; $$$$$;
QL
IMBRUVICA 5 PA; QL
IMURAN 4
INLYTA 5 PA; $$$$$;
QL
IRESSA 5 PA; $$$$$;
QL
JAKAFI 5 PA; $$$$$;
QL
JELMYTO 5 PA
KOSELUGO 5 PA
lapatinib 5 PA; QL
LENVIMA 5 PA; $$$$$
letrozole 2
LEUKERAN 3
leuprolide
subcutaneous kit
5 PA; $$$$$
Drug Name Drug
Tier
Requirements
/ Limits
LONSURF 5 PA; $$$$$
LORBRENA 5 PA; QL
LUPRON DEPOT 5 PA; $$$
LUPRON DEPOT
(3 MONTH)
5 PA; $$$
LUPRON DEPOT
(4 MONTH)
5 PA; $$$
LUPRON DEPOT
(6 MONTH)
5 PA; $$$
LUPRON DEPOT-
PED
5 PA; $$$$
LUPRON DEPOT-
PED (3 MONTH)
5 PA; $$$$
LYNPARZA ORAL
TABLET
5 PA; $$$$$;
QL
LYSODREN 3
MATULANE 5
megestrol oral
suspension 400
mg/10 ml (40
mg/ml), 625 mg/5 ml
(125 mg/ml)
2
megestrol oral tablet 2
MEKINIST 5 PA; $$$$$;
QL
MEKTOVI 5 PA; QL
melphalan 2
mercaptopurine 2
methotrexate sodium 2
methotrexate sodium
(pf)
2
mycophenolate
mofetil
2
mycophenolate
sodium
2
MYFORTIC 4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
19
Drug Name Drug
Tier
Requirements
/ Limits
MYLERAN 3
NEORAL 4
NERLYNX 5 PA; $$$$$;
LA
NEXAVAR 5 PA; $$$$$;
LA; QL
NILANDRON 4 PA
nilutamide 2 PA
NINLARO 5 PA; $$$$$;
QL
NUBEQA 5 PA; LA; QL
octreotide acetate 5 $$$$$
ODOMZO 5 PA; $$$$$;
LA; QL
PEMAZYRE 5 PA; LA; QL
POLIVY
INTRAVENOUS
RECON SOLN 30
MG
5 PA
PROGRAF ORAL
CAPSULE
4
PROGRAF ORAL
GRANULES IN
PACKET
3
PURIXAN 5
RAPAMUNE 4
RETEVMO 5 PA; LA; QL
ROZLYTREK 5 PA; LA; QL
RUBRACA 5 PA; $$$$$;
LA; QL
RYDAPT 5 PA; $$$$$
SANDIMMUNE
ORAL CAPSULE
4
SANDIMMUNE
ORAL SOLUTION
3
Drug Name Drug
Tier
Requirements
/ Limits
SANDOSTATIN
INJECTION
SOLUTION 100
MCG/ML, 50
MCG/ML, 500
MCG/ML
5 $$$$$
SIGNIFOR 5 PA; $$$$$
sirolimus 2
SOLTAMOX 4 ACA
SOMATULINE
DEPOT
5 PA; $$$$$
SPRYCEL 5 PA; $$$$$;
QL
STIVARGA 5 PA; $$$$$;
QL
SUPPRELIN LA 5 PA; $$$$
SUTENT 5 PA; $$$$$;
QL
SYNRIBO 5 PA
TABLOID 4
TABRECTA 5 PA
tacrolimus oral 2
TAFINLAR 5 PA; $$$$$;
QL
TAGRISSO 5 PA; $$$$$;
LA; QL
TALZENNA 5 PA; QL
tamoxifen 2 ACA
TARCEVA 5 PA; $$$$$;
QL
TARGRETIN
TOPICAL
5 PA
TASIGNA 5 PA; $$$$$;
QL
TAZVERIK 5 PA
TEMODAR ORAL 5 PA; $$$$$
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
20
Drug Name Drug
Tier
Requirements
/ Limits
temozolomide 5 PA; $$$$$
THALOMID 5 PA; $$$$$
TIBSOVO 5 PA
toremifene 2
tretinoin
(antineoplastic)
2
TREXALL 4
TUKYSA 5 PA; QL
TURALIO 5 PA; LA; QL
TYKERB 5 PA; $$$$$;
LA; QL
VANTAS 5 PA; $$$$$
VENCLEXTA
ORAL TABLET 10
MG, 50 MG
5 PA
VENCLEXTA
ORAL TABLET
100 MG
5 PA; LA
VENCLEXTA
STARTING PACK
5 PA; QL
VERZENIO 5 PA; $$$$$;
LA; QL
VITRAKVI 5 PA; LA
VIZIMPRO 5 PA; QL
VOTRIENT 5 PA; $$$$$;
QL
XALKORI 5 PA; $$$$$;
QL
XELODA 5 $$$$$
XERMELO 5 PA; QL
XOSPATA 5 PA; LA
XTANDI 5 PA; $$$$$;
QL
YONSA 5 PA; $$$$$;
QL
Drug Name Drug
Tier
Requirements
/ Limits
ZEJULA 5 PA; LA; QL
ZELBORAF 5 PA; $$$$$;
QL
ZOLINZA 5 PA; $$$$$
ZORTRESS ORAL
TABLET 0.25 MG,
0.5 MG, 0.75 MG
4
ZORTRESS ORAL
TABLET 1 MG
3
ZYDELIG 5 PA; $$$$$;
QL
ZYKADIA ORAL
TABLET
5 PA; QL
ZYTIGA ORAL
TABLET 500 MG
5 PA; $$$$$;
QL
AUTONOMIC & CNS DRUGS,
NEUROLOGY & PSYCH
ANTICONVULSANTS
APTIOM 4
BANZEL 3 PA
BRIVIACT ORAL 4
carbamazepine oral
capsule, er
multiphase 12 hr
2
carbamazepine oral
suspension 100 mg/5
ml
2
carbamazepine oral
tablet
2
carbamazepine oral
tablet extended
release 12 hr
2
carbamazepine oral
tablet,chewable
2
CARBATROL 4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
21
Drug Name Drug
Tier
Requirements
/ Limits
CELONTIN ORAL
CAPSULE 300 MG
3
clobazam 1 PA
clonazepam 2
DEPAKOTE 4 ST
DEPAKOTE ER 4 ST
DEPAKOTE
SPRINKLES
4 ST
DIACOMIT 5 PA
DIASTAT 4
DIASTAT
ACUDIAL
4
diazepam rectal 2
DILANTIN 3
DILANTIN
EXTENDED
4
DILANTIN
INFATABS
4
DILANTIN-125 4
divalproex 2
EPIDIOLEX 5 PA
epitol 2
EQUETRO 4
ethosuximide 2
felbamate 2
FELBATOL 4
FYCOMPA ORAL
SUSPENSION
3
FYCOMPA ORAL
TABLET
3
gabapentin oral
capsule
2
Drug Name Drug
Tier
Requirements
/ Limits
gabapentin oral
solution 250 mg/5
ml, 300 mg/6 ml (6
ml)
2
gabapentin oral
tablet 600 mg, 800
mg
2
GABITRIL 4
GRALISE 4 ST
KLONOPIN 4
LAMICTAL XR
STARTER (BLUE)
4 ST
LAMICTAL XR
STARTER
(GREEN)
4 ST
LAMICTAL XR
STARTER
(ORANGE)
4 ST
lamotrigine 2
levetiracetam oral 2
MYSOLINE 4
NAYZILAM 3 PA; QL
ONFI ORAL
SUSPENSION
4 PA
ONFI ORAL
TABLET 10 MG, 20
MG
4 PA
oxcarbazepine 2
OXTELLAR XR 4 ST
PEGANONE 3
phenobarbital 2
PHENYTEK 4
phenytoin oral
suspension
2
phenytoin oral
tablet,chewable
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
22
Drug Name Drug
Tier
Requirements
/ Limits
phenytoin sodium
extended
2
pregabalin 2
primidone 2
QUDEXY XR 3 ST
roweepra 2
SABRIL 5 PA; $$$$$;
LA
SPRITAM 4 ST
subvenite 2
subvenite starter
(blue) kit
2
subvenite starter
(green) kit
2
subvenite starter
(orange) kit
2
SYMPAZAN 4 PA
TEGRETOL ORAL
SUSPENSION
4
TEGRETOL ORAL
TABLET
4
TEGRETOL XR 4
tiagabine 2
topiramate oral
capsule, sprinkle
2
topiramate oral
tablet
2
TROKENDI XR 4 ST
valproic acid 2
valproic acid (as
sodium salt) oral
solution 250 mg/5
ml, 500 mg/10 ml
(10 ml)
2
VALTOCO 4 QL
Drug Name Drug
Tier
Requirements
/ Limits
vigabatrin oral
powder in packet
5 PA; $$$$$;
LA
vigabatrin oral
tablet
5 PA; LA
vigadrone 5 PA; $$$$$
VIMPAT ORAL
SOLUTION
3
VIMPAT ORAL
TABLET
3
XCOPRI 4 QL
XCOPRI
MAINTENANCE
PACK
4 QL
XCOPRI
TITRATION PACK
4 QL
ZARONTIN 4
zonisamide 2
ANTIPARKINSONISM AGENTS
APOKYN 5 $$$$$; LA
AZILECT 4 ST
benztropine oral 2
bromocriptine 2
carbidopa 2
carbidopa-levodopa 2
carbidopa-levodopa-
entacapone
2
COMTAN 4
DUOPA 5 $$$
entacapone 2
INBRIJA
INHALATION
CAPSULE,
W/INHALATION
DEVICE
5 PA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
23
Drug Name Drug
Tier
Requirements
/ Limits
KYNMOBI
SUBLINGUAL
FILM 10 MG, 15
MG, 20 MG, 25
MG, 30 MG
3 PA
LODOSYN 4
MIRAPEX ER 4
NEUPRO 4
NOURIANZ 5 PA; LA; QL
OSMOLEX ER 5 PA; QL
PARLODEL 4
pramipexole 2
rasagiline 2
REQUIP XL ORAL
TABLET
EXTENDED
RELEASE 24 HR
12 MG, 6 MG
4
ropinirole 2
RYTARY 4
selegiline hcl 2
SINEMET 4
STALEVO 100 4
STALEVO 125 4
STALEVO 150 4
STALEVO 200 4
STALEVO 50 4
STALEVO 75 4
TASMAR ORAL
TABLET 100 MG
4
tolcapone 2
trihexyphenidyl 2
MIGRAINE & CLUSTER
HEADACHE THERAPY
Drug Name Drug
Tier
Requirements
/ Limits
AIMOVIG
AUTOINJECTOR
3 PA; QL
AJOVY
AUTOINJECTOR
3 PA; QL
AJOVY SYRINGE 3 PA; QL
almotriptan malate 2 QL
AMERGE 4 ST; QL
CAFERGOT 4
D.H.E.45 4
dihydroergotamine
injection
2
dihydroergotamine
nasal
2 ST; QL
eletriptan 2 QL
EMGALITY PEN 3 PA; QL
EMGALITY
SYRINGE
3 PA; QL
ERGOMAR 4
ergotamine-caffeine 2
FROVA 4 ST
frovatriptan 2 QL
migergot 2
MIGRANAL 4 ST; QL
naratriptan 2 QL
NURTEC ODT 4 PA; QL
ONZETRA XSAIL 4 ST; QL
RELPAX 4 ST; QL
REYVOW 4 PA; QL
rizatriptan 2 QL
sumatriptan 2 QL
sumatriptan
succinate oral
2 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
24
Drug Name Drug
Tier
Requirements
/ Limits
sumatriptan
succinate
subcutaneous
cartridge
2 QL
sumatriptan
succinate
subcutaneous pen
injector
2 QL
sumatriptan
succinate
subcutaneous
solution
2 QL
sumatriptan
succinate
subcutaneous
syringe 6 mg/0.5 ml
1 QL
sumatriptan-
naproxen
2 ST; QL
TOSYMRA 4 ST; QL
UBRELVY 4 PA; QL
ZEMBRACE
SYMTOUCH
4 ST; QL
zolmitriptan 2 QL
ZOMIG NASAL 3 ST; QL
MISCELLANEOUS
NEUROLOGICAL THERAPY
ARICEPT 4 ST
AUSTEDO 5 PA; $$$$$;
LA; QL
dalfampridine 5 PA
donepezil oral tablet
10 mg, 5 mg
2
donepezil oral tablet
23 mg
2 ST
donepezil oral
tablet,disintegrating
2
EVRYSDI 5 PA; QL
Drug Name Drug
Tier
Requirements
/ Limits
EXELON
TRANSDERMAL
4 ST
FIRDAPSE 5 PA; LA
galantamine 2
HORIZANT 4 ST
KEVEYIS 5 PA
memantine oral
capsule,sprinkle,er
24hr
2
memantine oral
solution
2
memantine oral
tablet
2
MEMANTINE
ORAL
TABLETS,DOSE
PACK
4
NAMENDA ORAL
TABLET
4 ST
NAMENDA
TITRATION PAK
4
NAMENDA XR
ORAL
CAP,SPRINKLE,ER
24HR DOSE PACK
4
NAMZARIC 3 ST
NUEDEXTA 3 PA
RAZADYNE ER 4 ST
rivastigmine 2
rivastigmine tartrate 2
RUZURGI 5 PA
TEGSEDI 5 PA; LA
tetrabenazine 5 PA; $$$$; QL
MUSCLE RELAXANTS &
ANTISPASMODIC THERAPY
baclofen oral 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
25
Drug Name Drug
Tier
Requirements
/ Limits
carisoprodol 2
carisoprodol-aspirin 2
carisoprodol-
aspirin-codeine
2
chlorzoxazone 2
cyclobenzaprine 2
DANTRIUM ORAL
CAPSULE 25 MG,
50 MG
4
dantrolene oral 2
FEXMID 4 ST
LORZONE 4 ST
meprobamate 2
MESTINON ORAL 4
MESTINON
TIMESPAN
4
metaxall 2
metaxalone 2
methocarbamol oral 2
NORGESIC FORTE 4
orphenadrine citrate
oral
2
orphenadrine-asa-
caffeine oral tablet
50-770-60 mg
2
orphengesic forte 2
pyridostigmine
bromide oral syrup
2
PYRIDOSTIGMINE
BROMIDE ORAL
TABLET 30 MG
4
pyridostigmine
bromide oral tablet
60 mg
2
Drug Name Drug
Tier
Requirements
/ Limits
pyridostigmine
bromide oral tablet
extended release
2
ROBAXIN-750 4
SKELAXIN 4
SOMA 4
tizanidine 2
vanadom 2
ZANAFLEX 4
NARCOTIC ANALGESICS
acetaminophen-caff-
dihydrocod oral
capsule
2
acetaminophen-caff-
dihydrocod oral
tablet 325-30-16 mg
2 ST
acetaminophen-
codeine oral solution
120-12 mg/5 ml, 300
mg-30 mg /12.5 ml
2
acetaminophen-
codeine oral tablet
2
ACTIQ 4 PA; QL
ALLZITAL 4 ST
ARYMO ER 4 ST; QL
ascomp with codeine 2
BELBUCA
BUCCAL FILM 150
MCG, 450 MCG,
750 MCG, 900
MCG
3 PA; QL
BELBUCA
BUCCAL FILM 300
MCG, 600 MCG, 75
MCG
3 ST; QL
buprenorphine 2 ST
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
26
Drug Name Drug
Tier
Requirements
/ Limits
buprenorphine hcl
sublingual
2
butalbital compound
w/codeine
2
butalbital-
acetaminop-caf-cod
2
butalbital-
acetaminophen
2
butalbital-
acetaminophen-caff
oral capsule
2
butalbital-
acetaminophen-caff
oral tablet 50-325-
40 mg
2
butalbital-aspirin-
caffeine
2
codeine sulfate oral
tablet
2
codeine-butalbital-
asa-caff
2 ST
DILAUDID 4
diskets 2 PA
DOLOPHINE
ORAL TABLET 5
MG
4 PA
DSUVIA 4
DURAGESIC 4 PA; ST; QL
dvorah 1 ST
endocet oral tablet
10-325 mg, 2.5-325
mg, 5-325 mg, 7.5-
325 mg
2
ESGIC 4 ST
fentanyl 2 PA; ST; QL
Drug Name Drug
Tier
Requirements
/ Limits
fentanyl citrate
buccal lozenge on a
handle
2 PA; QL
FIORICET ORAL
CAPSULE
4 ST
FIORICET WITH
CODEINE ORAL
CAPSULE 50-300-
40-30 MG
4 ST
FIORINAL 4 ST
FIORINAL-
CODEINE #3
4 ST
hydrocodone
bitartrate
2 ST; QL
hydrocodone-
acetaminophen oral
solution 10-325
mg/15 ml(15 ml)
1 ST
hydrocodone-
acetaminophen oral
solution 7.5-325
mg/15 ml
2 ST
hydrocodone-
acetaminophen oral
tablet 10-300 mg,
10-325 mg, 5-300
mg, 5-325 mg, 7.5-
300 mg, 7.5-325 mg
2
hydrocodone-
ibuprofen oral tablet
10-200 mg, 5-200
mg, 7.5-200 mg
2
hydromorphone oral
liquid
2
hydromorphone oral
tablet
2
hydromorphone oral
tablet extended
release 24 hr
2 PA; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
27
Drug Name Drug
Tier
Requirements
/ Limits
hydromorphone
rectal
2
HYSINGLA ER 3 ST; QL
ibuprofen-oxycodone 2
KADIAN ORAL
CAPSULE,EXTEN
D.RELEASE
PELLETS 10 MG,
100 MG, 20 MG,
200 MG, 30 MG, 40
MG, 50 MG, 60
MG, 80 MG
4 ST; QL
levorphanol tartrate
oral tablet 2 mg
2
LEVORPHANOL
TARTRATE ORAL
TABLET 3 MG
4 ST
lorcet hd 2
LORTAB ELIXIR
ORAL SOLUTION
10-300 MG/15 ML
4
meperidine oral 2
methadone oral
concentrate
2 PA
methadone oral
solution
2 PA
methadone oral
tablet
2 PA
methadone oral
tablet,soluble
2 PA
methadose oral
concentrate
2 PA
methadose oral
tablet,soluble
2 PA
morphine
concentrate oral
solution
2
Drug Name Drug
Tier
Requirements
/ Limits
morphine in 0.9 %
sodium chlor
intravenous pt
controlled analgesia
syring 30 mg/30 ml
(1 mg/ml), 50 mg/50
ml (1 mg/ml)
2 ST
morphine oral
capsule, er
multiphase 24 hr
2 PA; QL
morphine oral
capsule,extend.relea
se pellets
2 PA; QL
morphine oral
solution
2
morphine oral tablet 2
morphine oral tablet
extended release
2 PA; QL
morphine rectal 2
MS CONTIN 4 PA; QL
NALOCET 4
OXAYDO 4
oxycodone oral
capsule
2
oxycodone oral
concentrate
2
oxycodone oral
solution
2
oxycodone oral
tablet
2
oxycodone-
acetaminophen oral
tablet 10-325 mg,
2.5-325 mg, 5-325
mg, 7.5-325 mg
2
oxycodone-
acetaminophen oral
tablet 2.5-300 mg
2 ST
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
28
Drug Name Drug
Tier
Requirements
/ Limits
oxycodone-aspirin 2
OXYCONTIN
ORAL
TABLET,ORAL
ONLY,EXT.REL.12
HR
3 ST; QL
oxymorphone oral
tablet
2
oxymorphone oral
tablet extended
release 12 hr
2 PA; ST; QL
prolate 2 ST
ROXICODONE 4
tencon oral tablet
50-325 mg
2
TREZIX ORAL
CAPSULE 320.5-
30-16 MG
4
VANATOL LQ 4 ST
VANATOL S 4 ST
vtol lq 2
zebutal oral capsule
50-325-40 mg
2
ZOHYDRO ER
ORAL CAPSULE,
ORAL ONLY, ER
12HR
4 ST; QL
NON-NARCOTIC ANALGESICS
adult aspirin
regimen
1 ACA; OTC
ANAPROX DS 4 ST
ARTHROTEC 50 4 ST
ARTHROTEC 75 4 ST
aspirin low dose 1 ACA; OTC
aspirin oral tablet 1 ACA; OTC
Drug Name Drug
Tier
Requirements
/ Limits
aspirin oral
tablet,chewable
1 ACA; OTC
aspirin oral
tablet,delayed
release (dr/ec) 325
mg, 81 mg
1 ACA; OTC
aspir-trin 1 ACA; OTC
bayer aspirin 1 ACA; OTC
buprenorphine-
naloxone sublingual
tablet
2 QL
butorphanol
injection
2
butorphanol nasal 2 QL
CAMBIA 4 ST; QL
celecoxib 2 ST
children's aspirin 1 ACA; OTC
choline,magnesium
salicylate
2
CONZIP 4 ST; QL
DAYPRO 4 ST
diclofenac potassium 2
diclofenac sodium
oral
2
diclofenac sodium
topical drops
2 QL
diclofenac sodium
topical gel 1 %
2 ST; QL
diclofenac-
misoprostol
2
diflunisal 2
DISALCID 4
DUEXIS 4 ST
e.c. prin 1 ACA; OTC
EC-NAPROSYN 4 ST
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
29
Drug Name Drug
Tier
Requirements
/ Limits
ecotrin 1 ACA; OTC
ecotrin low strength 1 ACA; OTC
etodolac 2
FELDENE 4 ST
fenoprofen oral
tablet
2 ST
FLECTOR 3 ST; QL
flurbiprofen oral
tablet 100 mg
2
ibu 2
ibuprofen oral
suspension
2
ibuprofen oral tablet
400 mg, 600 mg, 800
mg
2
INDOCIN RECTAL 4
indomethacin oral 2
ketoprofen oral
capsule 25 mg
2 ST
ketoprofen oral
capsule 50 mg, 75
mg
2
ketoprofen oral
capsule,ext rel.
pellets 24 hr 200 mg
2 ST
ketorolac oral 2 QL
LICART 3 ST; QL
lite coat aspirin 1 ACA; OTC
LODINE ORAL
TABLET
4 ST
meclofenamate 2
mefenamic acid 2
meloxicam oral
tablet 15 mg
2
Drug Name Drug
Tier
Requirements
/ Limits
meloxicam oral
tablet 7.5 mg
2 QL
MOBIC ORAL
TABLET 15 MG
4 ST
MOBIC ORAL
TABLET 7.5 MG
4 ST; QL
nabumetone 2
NALFON ORAL
TABLET
4 ST
naloxone injection
solution
2
naloxone injection
syringe
2
naltrexone 2
NAPRELAN CR 4 ST
NAPROSYN ORAL
SUSPENSION
4 ST
NAPROSYN ORAL
TABLET 500 MG
4 ST
naproxen oral
suspension
2 ST
naproxen oral tablet 2
naproxen oral
tablet,delayed
release (dr/ec)
2
naproxen sodium
oral tablet 275 mg,
550 mg
2
naproxen sodium
oral tablet, er
multiphase 24 hr
1 ST
naproxen-
esomeprazole
2 ST
NARCAN NASAL
SPRAY,NON-
AEROSOL 4
MG/ACTUATION
3 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
30
Drug Name Drug
Tier
Requirements
/ Limits
NUCYNTA 3 QL
NUCYNTA ER 3 PA; QL
oxaprozin 2
pentazocine-
naloxone
2
piroxicam 2
RELAFEN 4 ST
salsalate 2
SPRIX 5 ST; QL
st joseph aspirin 1 ACA; OTC
st. joseph aspirin 1 ACA; OTC
sulindac 2
tolmetin oral capsule 2 ST
tolmetin oral tablet
200 mg
2
tolmetin oral tablet
600 mg
2 ST
TRAMADOL
ORAL
CAPSULE,ER
BIPHASE 24 HR
17-83
4 ST; QL
TRAMADOL
ORAL
CAPSULE,ER
BIPHASE 24 HR
25-75
4 ST; QL
TRAMADOL
ORAL TABLET
100 MG
4 ST
tramadol oral tablet
50 mg
2 QL
tramadol oral tablet
extended release 24
hr
2 PA; QL
tramadol oral tablet,
er multiphase 24 hr
2 ST; QL
Drug Name Drug
Tier
Requirements
/ Limits
tramadol-
acetaminophen
2 QL
ULTRACET 4 QL
ULTRAM 4 QL
VIMOVO 4 ST
VOLTAREN
TOPICAL
4 ST; QL
PSYCHOTHERAPEUTIC DRUGS
ABILIFY MYCITE 4 QL
ADASUVE 4
ADDERALL XR 4 PA; ST
ADDYI 4 PA
ADHANSIA XR 4 PA
ADZENYS ER 4 ST
ADZENYS XR-
ODT
4 ST
alprazolam 2
alprazolam intensol 2
amitriptyline 2
amitriptyline-
chlordiazepoxide
2
amoxapine 2
amphetamine sulfate 2 PA
ANAFRANIL 4
APLENZIN 4 ST; QL
APTENSIO XR 4 PA; ST
aripiprazole oral
solution
2
aripiprazole oral
tablet
2 QL
aripiprazole oral
tablet,disintegrating
2 QL
armodafinil 2 ST; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
31
Drug Name Drug
Tier
Requirements
/ Limits
ATIVAN ORAL 4
atomoxetine 2 PA
BELSOMRA 4 ST; QL
bupropion hcl oral
tablet
2
bupropion hcl oral
tablet extended
release 24 hr 150
mg, 300 mg
2 QL
BUPROPION HCL
ORAL TABLET
EXTENDED
RELEASE 24 HR
450 MG
4 ST
bupropion hcl oral
tablet sustained-
release 12 hr
2 QL
buspirone 2
chlordiazepoxide hcl 2
chlorpromazine oral 2
citalopram oral
solution
1
citalopram oral
tablet
1 QL
clomipramine 2
clonidine hcl oral
tablet extended
release 12 hr
2 PA
clorazepate
dipotassium
2
clozapine 2
CLOZARIL 4
CONCERTA 4 PA; ST
COTEMPLA XR-
ODT
4 ST
DAYTRANA 3 PA; ST
Drug Name Drug
Tier
Requirements
/ Limits
DAYVIGO 4 ST
desipramine 2
DESOXYN 4 ST
DESVENLAFAXIN
E ORAL TABLET
EXTENDED
RELEASE 24 HR
4 ST; QL
desvenlafaxine
succinate
2 ST; QL
DEXEDRINE
SPANSULE ORAL
CAPSULE,
EXTENDED
RELEASE 10 MG, 5
MG
4 ST
DEXEDRINE
SPANSULE ORAL
CAPSULE,
EXTENDED
RELEASE 15 MG
4 PA; ST
dexmethylphenidate 2 PA
dextroamphetamine 2 PA
dextroamphetamine-
amphetamine
2 PA
diazepam intensol 2
diazepam oral
solution 5 mg/5 ml
(1 mg/ml)
2
diazepam oral tablet 2
doxepin oral capsule 2
doxepin oral
concentrate
2
doxepin oral tablet 2 ST; QL
duloxetine oral
capsule,delayed
release(dr/ec) 20
mg, 30 mg, 60 mg
2 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
32
Drug Name Drug
Tier
Requirements
/ Limits
duloxetine oral
capsule,delayed
release(dr/ec) 40 mg
2 ST; QL
DYANAVEL XR 3 PA; ST
EDLUAR 4 ST; QL
EMSAM 4
ergoloid 2
escitalopram oxalate
oral solution
1
escitalopram oxalate
oral tablet
1 QL
estazolam 2
eszopiclone 2 QL
EVEKEO 4 PA
EVEKEO ODT 4 PA
FANAPT 4 QL
FETZIMA 3 ST; QL
fluoxetine oral
capsule 10 mg, 40
mg
1 QL
fluoxetine oral
capsule 20 mg
1
fluoxetine oral
capsule,delayed
release(dr/ec)
1 QL
fluoxetine oral
solution
1
fluoxetine oral tablet
10 mg
1 PA; QL
fluoxetine oral tablet
20 mg, 60 mg
1 PA
fluphenazine hcl oral 2
flurazepam 2
fluvoxamine oral
capsule,extended
release 24hr
1 PA; QL
Drug Name Drug
Tier
Requirements
/ Limits
fluvoxamine oral
tablet
1 QL
FORFIVO XL 4 ST; QL
GEODON ORAL 4 QL
guanfacine oral
tablet extended
release 24 hr
2 PA
guanidine 2
HALCION ORAL
TABLET 0.25 MG
4
haloperidol 2
haloperidol lactate
oral
2
HETLIOZ 5 PA; $$$$$;
QL
imipramine hcl 2
imipramine pamoate 2
INTERMEZZO
SUBLINGUAL
TABLET 1.75 MG
4 ST; QL
INVEGA 4 QL
JORNAY PM 4 ST
KAPVAY 4 PA
KETAMINE
SUBLINGUAL
4
LATUDA 3 QL
lithium carbonate 2
lithium citrate oral
solution 8 meq/5 ml
2
LITHOBID 4
lorazepam intensol 2
lorazepam oral
concentrate
2
lorazepam oral
tablet
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
33
Drug Name Drug
Tier
Requirements
/ Limits
loxapine succinate 2
maprotiline 2
MARPLAN 4
methamphetamine 2 PA
METHYLIN ORAL
SOLUTION
4 PA
methylphenidate hcl
oral cap,er
sprinkle,biphasic 40-
60
2 PA
methylphenidate hcl
oral capsule, er
biphasic 30-70
2 PA
methylphenidate hcl
oral capsule,er
biphasic 50-50
2 PA
methylphenidate hcl
oral solution
2 PA
methylphenidate hcl
oral tablet
2 PA
methylphenidate hcl
oral tablet extended
release
2 PA
methylphenidate hcl
oral tablet extended
release 24hr 18 mg,
27 mg, 36 mg, 54 mg
2 PA
METHYLPHENID
ATE HCL ORAL
TABLET
EXTENDED
RELEASE 24HR 72
MG
4 ST
methylphenidate hcl
oral tablet,chewable
2 PA
midazolam oral
syrup 2 mg/ml
1
mirtazapine 2
Drug Name Drug
Tier
Requirements
/ Limits
MKO
(MIDAZOLAM-
KETAMINE-
ONDAN)
4
modafinil 2 ST; QL
molindone 1
MYDAYIS 3 ST
NARDIL 4
nefazodone 2
NORPRAMIN
ORAL TABLET 10
MG, 25 MG
4
nortriptyline 2
NUPLAZID ORAL
CAPSULE
5 PA; $$$$$;
QL
NUPLAZID ORAL
TABLET 10 MG
5 PA; $$$$$;
QL
olanzapine oral 2 QL
olanzapine-
fluoxetine
2
oxazepam 2
paliperidone 2 QL
PAMELOR 4
PARNATE 4
paroxetine hcl oral
tablet
1 QL
paroxetine hcl oral
tablet extended
release 24 hr
1 PA; QL
paroxetine
mesylate(menop.sym
)
2 PA; QL
PAXIL CR 4 ST; QL
PAXIL ORAL
SUSPENSION
4 ST
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
34
Drug Name Drug
Tier
Requirements
/ Limits
PAXIL ORAL
TABLET
4 ST; QL
perphenazine 2
perphenazine-
amitriptyline
2
PEXEVA 4 ST; QL
phenelzine 2
pimozide 2
procentra 2 PA
protriptyline 2
QUAZEPAM 4
quetiapine 2 QL
QUILLICHEW ER 3 ST
QUILLIVANT XR 3 PA; ST
ramelteon 2 QL
RELEXXII 4 PA
REMERON ORAL
TABLET 15 MG, 30
MG
4
REMERON
SOLTAB
4
RESTORIL 4
REXULTI 4 QL
RISPERDAL ORAL
SOLUTION
4
RISPERDAL ORAL
TABLET 0.5 MG, 1
MG, 2 MG, 3 MG, 4
MG
4 QL
risperidone oral
solution
2
risperidone oral
tablet
2 QL
risperidone oral
tablet,disintegrating
2 QL
Drug Name Drug
Tier
Requirements
/ Limits
RITALIN 4 PA
RITALIN LA
ORAL
CAPSULE,ER
BIPHASIC 50-50 10
MG, 20 MG, 30
MG, 40 MG
4 PA; ST
SAPHRIS 4 QL
SARAFEM ORAL
TABLET 10 MG, 20
MG
4 ST; QL
seconal sodium 2 QL
SECUADO 4 QL
sertraline oral
concentrate
1
sertraline oral tablet 1 QL
SILENOR 4 ST; QL
SUNOSI 3 ST; QL
SYMBYAX ORAL
CAPSULE 12-50
MG, 3-25 MG, 6-25
MG, 6-50 MG
4
temazepam 2
thioridazine 2
thiothixene 2
TRANXENE T-
TAB ORAL
TABLET 7.5 MG
4
tranylcypromine 2
trazodone 2
triazolam 2
trifluoperazine 2
trimipramine 2
TRINTELLIX 4 ST; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
35
Drug Name Drug
Tier
Requirements
/ Limits
venlafaxine oral
capsule,extended
release 24hr
2 QL
venlafaxine oral
tablet
2 QL
venlafaxine oral
tablet extended
release 24hr
2 ST; QL
VERSACLOZ 4
VIIBRYD ORAL
TABLET
3 QL
VIIBRYD ORAL
TABLETS,DOSE
PACK 10 MG (7)-
20 MG (23)
3 QL
VRAYLAR 4 QL
VYLEESI 5 PA; QL
VYVANSE ORAL
CAPSULE
3 PA; ST
VYVANSE ORAL
TABLET,CHEWAB
LE
3 ST
WAKIX 5 ST; LA; QL
WELLBUTRIN XL 4 ST; QL
XYREM 5 LA
XYWAV 5
zaleplon 2 QL
zenzedi oral tablet
10 mg, 5 mg
2 PA
ZENZEDI ORAL
TABLET 15 MG,
2.5 MG, 20 MG, 30
MG, 7.5 MG
4 PA
ziprasidone hcl 2 QL
zolpidem 2 QL
ZOLPIMIST 4 ST; QL
Drug Name Drug
Tier
Requirements
/ Limits
ZYPREXA ORAL 4 QL
ZYPREXA ZYDIS 4 QL
CARDIOVASCULAR,
HYPERTENSION & LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone oral 2
BETAPACE 4 ST
BETAPACE AF 4 ST
disopyramide
phosphate oral
capsule
2
dofetilide 2
flecainide 2
mexiletine 2
MULTAQ 4
NORPACE 4
NORPACE CR 4
pacerone oral tablet
100 mg, 200 mg, 400
mg
2
propafenone 2
quinidine gluconate
oral
2
quinidine sulfate
oral tablet
2
RYTHMOL SR 4
sotalol af 2
sotalol oral 2
SOTYLIZE 3
ANTIHYPERTENSIVE THERAPY
ACCUPRIL 4
ACCURETIC 4
acebutolol 1
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
36
Drug Name Drug
Tier
Requirements
/ Limits
ADALAT CC 4 ST
ALDACTAZIDE 4
ALDACTONE 4
aliskiren 2
ALTACE 4
amiloride 2
amiloride-
hydrochlorothiazide
2
amlodipine 1
amlodipine-
benazepril
1
amlodipine-
olmesartan
1
amlodipine-
valsartan
1
amlodipine-
valsartan-hcthiazid
1
atenolol 1
atenolol-
chlorthalidone
1
benazepril 1
benazepril-
hydrochlorothiazide
1
betaxolol oral 1
BIDIL 4
bisoprolol fumarate 1
bisoprolol-
hydrochlorothiazide
1
bumetanide oral 2
BYSTOLIC 3 ST
CALAN SR 4
candesartan 1
candesartan-
hydrochlorothiazid
1
Drug Name Drug
Tier
Requirements
/ Limits
captopril 1
captopril-
hydrochlorothiazide
1
CARDIZEM CD 4
CARDIZEM LA 4
CARDIZEM ORAL
TABLET 120 MG,
30 MG, 60 MG
4
CARDURA 4 ST; QL
CARDURA XL 4 ST; QL
CAROSPIR 4 ST
cartia xt 1
carvedilol 2
carvedilol phosphate 2
CATAPRES 4
CATAPRES-TTS-1 4 QL
CATAPRES-TTS-2 4 QL
CATAPRES-TTS-3 4 QL
chlorthalidone oral
tablet 25 mg, 50 mg
1
clonidine 2 QL
clonidine hcl oral
tablet
2
CONSENSI 4
COREG CR 4 ST
CORGARD 4 ST
DEMSER 4 PA
DIBENZYLINE 4 PA
diltiazem hcl oral
capsule,ext.rel 24h
degradable
1
diltiazem hcl oral
capsule,extended
release 12 hr
1
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
37
Drug Name Drug
Tier
Requirements
/ Limits
diltiazem hcl oral
capsule,extended
release 24 hr 180
mg, 240 mg, 300 mg,
360 mg, 420 mg
1
diltiazem hcl oral
capsule,extended
release 24hr
1
diltiazem hcl oral
tablet
1
diltiazem hcl oral
tablet extended
release 24 hr
1
dilt-xr 1
DIURIL 4
doxazosin 2 QL
DYAZIDE 4
DYRENIUM 4
EDARBI 3 ST
EDARBYCLOR 3 ST
EDECRIN 4
enalapril maleate 1
enalapril-
hydrochlorothiazide
1
eplerenone 2
eprosartan 1
ethacrynic acid 2
felodipine 1
fosinopril 1
fosinopril-
hydrochlorothiazide
1
furosemide oral
solution 10 mg/ml,
40 mg/5 ml (8
mg/ml)
2
Drug Name Drug
Tier
Requirements
/ Limits
furosemide oral
tablet
2
guanfacine oral
tablet
2
HEMANGEOL 5
hydralazine oral 2
hydrochlorothiazide 1
indapamide 1
INDERAL XL 4 ST
INNOPRAN XL 4 ST
INSPRA 4
irbesartan 1
irbesartan-
hydrochlorothiazide
1
isradipine 1
labetalol oral 2
LASIX 4
lisinopril 1
lisinopril-
hydrochlorothiazide
1
LOPRESSOR
ORAL
4 ST
losartan 1
losartan-
hydrochlorothiazide
1
LOTENSIN HCT 4
LOTENSIN ORAL
TABLET 10 MG, 20
MG, 40 MG
4
matzim la 1
MAXZIDE 4
MAXZIDE-25MG 4
methyldopa 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
38
Drug Name Drug
Tier
Requirements
/ Limits
methyldopa-
hydrochlorothiazide
2
metolazone 1
metoprolol succinate 1
metoprolol ta-
hydrochlorothiaz
1
metoprolol tartrate
oral
1
metyrosine 2 PA
MINIPRESS 4
minoxidil oral 2
moexipril 1
nadolol 1
nadolol-
bendroflumethiazide
oral tablet 80-5 mg
1
nicardipine oral 1
nifedipine 1
nimodipine 2
nisoldipine 1
NYMALIZE ORAL
SYRINGE
4
olmesartan 1
olmesartan-
amlodipin-hcthiazid
1
olmesartan-
hydrochlorothiazide
1
ORENITRAM 5 PA; $$$$$
perindopril
erbumine
1
phenoxybenzamine 2 PA
pindolol 1
prazosin 2
PRESTALIA 4 ST
Drug Name Drug
Tier
Requirements
/ Limits
PRINIVIL ORAL
TABLET 10 MG, 20
MG
4
PROCARDIA 4 ST
PROCARDIA XL 4 ST
propranolol oral 1
propranolol-
hydrochlorothiazid
1
quinapril 1
quinapril-
hydrochlorothiazide
1
ramipril 1
spironolactone 2
spironolacton-
hydrochlorothiaz
2
SULAR ORAL
TABLET
EXTENDED
RELEASE 24 HR
17 MG, 34 MG, 8.5
MG
4 ST
TARKA ORAL
TABLET, IR - ER,
BIPHASIC 24HR 2-
180 MG, 2-240 MG,
4-240 MG
4
taztia xt 1
TEKTURNA 4
TEKTURNA HCT 3
telmisartan 1
telmisartan-
amlodipine
1
telmisartan-
hydrochlorothiazid
1
TENORETIC 100 4 ST
TENORETIC 50 4 ST
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
39
Drug Name Drug
Tier
Requirements
/ Limits
TENORMIN 4 ST
terazosin 2 QL
tiadylt er 1
TIAZAC 4
timolol maleate oral 1
torsemide oral 2
trandolapril 1
trandolapril-
verapamil
1
triamterene 2
triamterene-
hydrochlorothiazid
oral capsule 37.5-25
mg
2
triamterene-
hydrochlorothiazid
oral tablet
2
UPTRAVI 5 PA; $$$$$;
LA
valsartan 1
valsartan-
hydrochlorothiazide
1
VASERETIC 4
VASOTEC 4
verapamil oral 1
VERELAN 4
VERELAN PM 4
ZESTORETIC 4
ZESTRIL 4
ZIAC 4 ST
CARDIAC GLYCOSIDES
digitek 2
digox 2
Drug Name Drug
Tier
Requirements
/ Limits
digoxin oral solution
50 mcg/ml (0.05
mg/ml)
2
digoxin oral tablet 2
LANOXIN ORAL
TABLET 125 MCG
(0.125 MG), 250
MCG (0.25 MG),
62.5 MCG (0.0625
MG)
4
COAGULATION THERAPY
ADVATE 5 PA; $$$$$
ADYNOVATE 5 PA; $$$$$
AFSTYLA 5 PA; $$$$$
ALPROLIX 5 PA; $$$$$
AMICAR 4
aminocaproic acid
oral solution
2
aminocaproic acid
oral tablet
1
ARIXTRA 5 $$$$$
aspirin-dipyridamole 1
ASPIRIN-
OMEPRAZOLE
4 PA
BENEFIX 5 PA; $$$$$
BRILINTA 3
CABLIVI
INJECTION KIT
5 PA
CEPROTIN (BLUE
BAR)
5
CEPROTIN
(GREEN BAR)
5
cilostazol 2
clopidogrel 1
COAGADEX 5 PA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
40
Drug Name Drug
Tier
Requirements
/ Limits
dipyridamole oral 1
DOPTELET (15
TAB PACK)
5 PA; $$$$$;
QL
EFFIENT 4
ELIQUIS 3 PA
ELIQUIS DVT-PE
TREAT 30D
START
3 PA
ELOCTATE 5 PA; $$$$$
enoxaparin 5 $$$$
ESPEROCT 5 PA
fondaparinux 5 $$$$
FRAGMIN
SUBCUTANEOUS
SOLUTION
5 $$$$$
FRAGMIN
SUBCUTANEOUS
SYRINGE
5 $$$$$
HEMLIBRA 5 PA; $$$$$
hep flush-10 (pf) 2
HEPARIN
(PORCINE) IN
0.9% NACL
INTRAVENOUS
PARENTERAL
SOLUTION 2,500
UNIT/500 ML (5
UNIT/ML), 30,000
UNIT/1,000 ML,
5,000 UNIT/1,000
ML, 5,000
UNIT/500 ML (10
UNIT/ML)
4
Drug Name Drug
Tier
Requirements
/ Limits
heparin (porcine) in
5 % dex intravenous
parenteral solution
20,000 unit/500 ml
(40 unit/ml), 25,000
unit/250 ml(100
unit/ml), 25,000
unit/500 ml (50
unit/ml)
2
heparin (porcine) in
nacl (pf)
2
heparin (porcine)
injection cartridge
2
heparin (porcine)
injection solution
2
heparin (porcine)
injection syringe
5,000 unit/ml
2
heparin
flush(porcine)-
0.9nacl
2
heparin lock flush 2
heparin lock flush
(porcine)
intravenous solution
100 unit/ml
2
heparin
lockflush(porcine)(pf
)
2
HEPARIN(PORCIN
E) IN 0.45% NACL
INTRAVENOUS
PARENTERAL
SOLUTION 12,500
UNIT/250 ML
4
heparin(porcine) in
0.45% nacl
intravenous
parenteral solution
25,000 unit/250 ml,
25,000 unit/500 ml
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
41
Drug Name Drug
Tier
Requirements
/ Limits
heparin, porcine (pf)
injection solution
2
heparin, porcine (pf)
injection syringe
5,000 unit/0.5 ml
2
HEPARIN,
PORCINE (PF)
INJECTION
SYRINGE 5,000
UNIT/ML
4
heparin, porcine (pf)
intravenous solution
100 unit/ml (1 ml)
2
heparin, porcine (pf)
intravenous syringe
1 unit/ml, 100
unit/ml
2
HEPARIN,
PORCINE (PF)
SUBCUTANEOUS
4
IDELVION 5 PA; $$$$$
IXINITY 5 PA; $$$$$
jantoven 1
JIVI 5 PA; $$$$$
KOGENATE FS 5 PA; $$$$$
KOVALTRY 5 PA; $$$$$
MEPHYTON 4 QL
NOVOEIGHT 5 PA; $$$$$
NOVOSEVEN RT 5 PA; $$$$$
pentoxifylline 2
phytonadione
(vitamin k1)
injection solution
2
PHYTONADIONE
(VITAMIN K1)
INJECTION
SYRINGE
3
Drug Name Drug
Tier
Requirements
/ Limits
phytonadione
(vitamin k1) oral
tablet 5 mg
2 QL
prasugrel 1
PROMACTA
ORAL POWDER IN
PACKET
5 PA; LA
PROMACTA
ORAL TABLET
5 PA; $$$$$;
LA
REBINYN 5 PA; $$$$$
RIXUBIS 5 PA; $$$$$
vitamin k 2
vitamin k1 injection 2
warfarin 1
WILATE
INTRAVENOUS
RECON SOLN
1,000-1,000 UNIT,
500-500 UNIT
5 PA; $$$$$
XARELTO 3 PA
XARELTO DVT-PE
TREAT 30D
START
3 PA
YOSPRALA 4 ST
ZONTIVITY 4 PA
LIPID/CHOLESTEROL LOWERING
AGENTS
amlodipine-
atorvastatin
1 QL
ANTARA ORAL
CAPSULE 30 MG,
90 MG
4 ST
atorvastatin oral
tablet 10 mg, 20 mg
1 ACA; QL
atorvastatin oral
tablet 40 mg, 80 mg
1 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
42
Drug Name Drug
Tier
Requirements
/ Limits
CADUET ORAL
TABLET 10-10
MG, 10-20 MG, 10-
40 MG, 10-80 MG,
5-10 MG, 5-20 MG,
5-40 MG, 5-80 MG
4 ST; QL
cholestyramine (with
sugar)
1
cholestyramine light 1
colesevelam 1
COLESTID
FLAVORED ORAL
PACKET
4 ST
COLESTID ORAL
GRANULES
4 PA; ST
COLESTID ORAL
PACKET
4 PA
COLESTID ORAL
TABLET
4 ST
colestipol 1
ezetimibe 1 ST
ezetimibe-
simvastatin
1 QL
fenofibrate
micronized
1
fenofibrate
nanocrystallized
oral tablet 145 mg,
48 mg
1
FENOFIBRATE
ORAL CAPSULE
4 ST
fenofibrate oral
tablet
1
fenofibric acid 1
fenofibric acid
(choline)
1
FENOGLIDE 4 ST
Drug Name Drug
Tier
Requirements
/ Limits
FIBRICOR 4 ST
FLOLIPID 4 ST; QL
fluvastatin 1 ACA; QL
gemfibrozil 1
JUXTAPID 5 PA; $$$$$;
LA
LESCOL XL 4 ST; QL
LIPOFEN 3
LIVALO 3 ST; QL
LOPID 4
lovastatin 1 ACA; QL
LOVAZA 4 PA
NEXLETOL 3 PA
NEXLIZET 3 PA
niacin oral tablet
500 mg
1
niacin oral tablet
extended release 24
hr
1
NIASPAN
EXTENDED-
RELEASE
4
omega-3 acid ethyl
esters
2 PA
PRALUENT PEN 5 PA; $$$$; QL
pravastatin 1 ACA; QL
prevalite 1
QUESTRAN 4 ST
QUESTRAN
LIGHT ORAL
POWDER
4 ST
REPATHA
PUSHTRONEX
3 PA; $$$; QL
REPATHA
SURECLICK
3 PA; $$$$; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
43
Drug Name Drug
Tier
Requirements
/ Limits
REPATHA
SYRINGE
3 PA; $$$$; QL
rosuvastatin oral
tablet 10 mg, 5 mg
1 ACA; QL
rosuvastatin oral
tablet 20 mg, 40 mg
1 QL
simvastatin oral
tablet 10 mg, 20 mg,
40 mg, 5 mg
1 ACA; QL
simvastatin oral
tablet 80 mg
1 QL
TRILIPIX 4 ST
VASCEPA 3 PA
WELCHOL ORAL
POWDER IN
PACKET
4 PA
WELCHOL ORAL
TABLET
4 ST
ZYPITAMAG
ORAL TABLET 2
MG, 4 MG
4 ST; QL
MISCELLANEOUS
CARDIOVASCULAR AGENTS
CORLANOR 3 PA
ENTRESTO 3 QL
ranolazine 2
VECAMYL 4
VYNDAMAX 5 PA
VYNDAQEL 5 PA
NITRATES
DILATRATE-SR 3
GONITRO 4
ISORDIL 4
Drug Name Drug
Tier
Requirements
/ Limits
ISORDIL
TITRADOSE
ORAL TABLET 5
MG
4
isosorbide dinitrate
oral tablet
2
isosorbide
mononitrate
2
MINITRAN 4
nitro-bid 2
NITRO-DUR 4
nitroglycerin oral 2
nitroglycerin
sublingual
2
nitroglycerin
transdermal patch
24 hour
2
nitroglycerin
translingual
spray,non-aerosol
2
NITROLINGUAL 4
NITROMIST 4
NITROSTAT 4
nitro-time 2
DERMATOLOGICALS/TOPICA
L THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
acitretin 2
ANALPRAM-HC
TOPICAL
4 ST
calcipotriene scalp 2 QL
calcipotriene topical
cream
2 QL
calcipotriene topical
ointment
2 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
44
Drug Name Drug
Tier
Requirements
/ Limits
calcipotriene-
betamethasone
2 QL
calcitriol topical 2
COSENTYX 5 PA; $$$$$;
QL
COSENTYX (2
SYRINGES)
5 PA; $$$$$;
QL
COSENTYX PEN 5 PA; $$$$$;
QL
COSENTYX PEN
(2 PENS)
5 PA; $$$$$;
QL
DOVONEX
TOPICAL
4 QL
ENSTILAR 3 QL
EPIFOAM 4 ST
hydrocortisone-
pramoxine topical
2 ST
OVACE 4
OVACE PLUS
SHAMPOO
4
OVACE PLUS
TOPICAL
CLEANSER
4
OVACE PLUS
TOPICAL CREAM
4
OVACE PLUS
TOPICAL FOAM
4
OVACE PLUS
TOPICAL LOTION
4
OVACE PLUS
WASH
4
PRAMOSONE 4 ST
selenium sulfide
topical lotion
2
selenium sulfide
topical shampoo
2.25 %, 2.3 %
2
Drug Name Drug
Tier
Requirements
/ Limits
SELRX 4
SKYRIZI
SUBCUTANEOUS
SYRINGE KIT
5 PA; QL
SORIATANE
ORAL CAPSULE
10 MG, 25 MG
4
SORILUX 4 QL
STELARA
SUBCUTANEOUS
5 PA; $$$$$;
QL
sulfacetamide
sodium topical
2
TACLONEX 4 QL
TERSI FOAM 4
TREMFYA
SUBCUTANEOUS
AUTO-INJECTOR
5 PA; QL
TREMFYA
SUBCUTANEOUS
SYRINGE
5 PA; $$$$$;
QL
VECTICAL 4
BURN THERAPY
SILVADENE 4
silver sulfadiazine 2
ssd 2
KERATOLYTICS
INOVA 4-1 4 ST
INOVA 8-2 4 ST
MISCELLANEOUS
DERMATOLOGICALS
AMELUZ 4
ammonium lactate 2
CANTHARIDIN IN
ACETONE
4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
45
Drug Name Drug
Tier
Requirements
/ Limits
CONDYLOX
TOPICAL GEL
4
CORTANE-B
TOPICAL
4
diclofenac sodium
topical gel 3 %
2 PA; QL
doxepin topical 2 PA; QL
DUPIXENT PEN 5 PA; QL
DUPIXENT
SYRINGE
SUBCUTANEOUS
SYRINGE 200
MG/1.14 ML
5 PA; QL
DUPIXENT
SYRINGE
SUBCUTANEOUS
SYRINGE 300
MG/2 ML
5 PA; $$$$$;
QL
EFUDEX TOPICAL
CREAM
4
ESKATA 4
EUCRISA 4 ST; QL
FLUOROPLEX 4
fluorouracil topical
cream 5 %
2
fluorouracil topical
solution
2
iodine-sodium iodide
topical tincture 2 %
2
IODOFLEX 4
IODOSORB 4
LEVULAN 4
methoxsalen 2
methyl salicylate 2
methyl salicylate
topical liquid
2
Drug Name Drug
Tier
Requirements
/ Limits
OXSORALEN
ULTRA
4
PANRETIN 4
PICATO 3
pimecrolimus 2 QL
podofilox 2
PROTOPIC 4 ST; QL
prudoxin 2 PA; QL
QBREXZA 3 PA
REGRANEX 3 QL
tacrolimus topical 2 ST; QL
TOLAK 4
VALCHLOR 5 PA; $$$$$
VEREGEN 4 PA; QL
wintergreen oil 2
ZONALON 4 PA; QL
THERAPY FOR ACNE
ABSORICA 4
ABSORICA LD 4
ACZONE 4 ST
adapalene topical
cream
2
adapalene topical
gel 0.3 %
2
adapalene topical
gel with pump
2
ADAPALENE
TOPICAL LOTION
4 ST
adapalene topical
solution
2
adapalene topical
swab
2
adapalene-benzoyl
peroxide
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
46
Drug Name Drug
Tier
Requirements
/ Limits
AKLIEF 4 ST
ALTRENO 4 PA
amnesteem 2
AMZEEQ 3 ST
ARAZLO 4 PA
AVAR LS 4 ST
avar topical cleanser 2
AVAR TOPICAL
PADS,
MEDICATED
4 ST
AVAR-E GREEN 4 ST
AVAR-E LS 4 ST
avita topical cream 2 PA
AVITA TOPICAL
GEL
4 PA
azelaic acid 2
AZELEX 4 ST
BENZACLIN 4 ST
BENZACLIN
PUMP
4 ST
BENZAMYCIN 4 ST
BENZEPRO
(MICROSPHERES)
4 ST
benzepro topical
towelette
2
benzoyl peroxide
topical cleanser 7 %
2
benzoyl peroxide
topical foam 9.8 %
2
bp 10-1 2 ST
claravis 2
CLEOCIN T
TOPICAL LOTION
4 ST; QL
Drug Name Drug
Tier
Requirements
/ Limits
CLINDACIN ETZ
TOPICAL KIT
4 ST
clindacin p 2
CLINDACIN PAC 4 ST
clindamycin
phosphate topical
foam
2 QL
clindamycin
phosphate topical
gel
2 QL
clindamycin
phosphate topical
lotion
2 QL
clindamycin
phosphate topical
solution
2 QL
clindamycin
phosphate topical
swab
2
clindamycin-benzoyl
peroxide
2
clindamycin-
tretinoin
2 PA
dapsone topical gel 2
DAPSONE
TOPICAL GEL
WITH PUMP
4 ST
DIFFERIN
TOPICAL CREAM
4 ST
DIFFERIN
TOPICAL GEL
WITH PUMP
4 ST
DIFFERIN
TOPICAL LOTION
4 ST
ENZOCLEAR 4 ST
ery pads 2
erygel 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
47
Drug Name Drug
Tier
Requirements
/ Limits
erythromycin with
ethanol topical gel
2
erythromycin with
ethanol topical
solution
2
erythromycin-
benzoyl peroxide
2
EVOCLIN 4 ST; QL
FABIOR 4 PA
FINACEA
TOPICAL FOAM
3 ST
FINACEA
TOPICAL GEL
4 ST
INOVA 4 ST
isotretinoin 2
METROCREAM 4 ST
METROGEL
TOPICAL GEL 1 %
4 ST
metronidazole
topical
2
MIRVASO
TOPICAL GEL
WITH PUMP
3 PA
myorisan 2
neuac 2
NEUAC KIT 4 ST
NORITATE 4 ST
ONEXTON
TOPICAL GEL
WITH PUMP
3 ST
PACNEX 4 ST
PLEXION 4 ST
PLEXION
CLEANSING
CLOTHS
4 ST
Drug Name Drug
Tier
Requirements
/ Limits
PR BENZOYL
PEROXIDE
4 ST
RETIN-A 4 PA
RETIN-A MICRO 4 PA
RETIN-A MICRO
PUMP
4 PA
RHOFADE 4 PA
rosadan topical
cream
2
rosadan topical gel 2
ROSADAN
TOPICAL KIT,
CLEANSER AND
GEL
4 ST
ROSADAN
TOPICAL
KIT,CLEANSER
AND CREAM
4 ST
ROSANIL 4 ST
ROSULA 4 ST
rosula cleansing
cloths
2
SOOLANTRA 4 ST; QL
sss 10-5 2
sulfacetamide
sodium-sulfur
topical cleanser
2
sulfacetamide
sodium-sulfur
topical cream
2
sulfacetamide
sodium-sulfur
topical lotion
2
sulfacetamide
sodium-sulfur
topical pads,
medicated 10-4 %
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
48
Drug Name Drug
Tier
Requirements
/ Limits
sulfacetamide
sodium-sulfur
topical suspension
2
sulfacetamide-
sulfur-cleansr23
2
sulfacleanse 8-4 2 ST
SUMADAN 4 ST
SUMADAN XLT 4 ST
SUMAXIN 4 ST
SUMAXIN CP 4 ST
SUMAXIN TS 4 ST
tazarotene 2 PA
TAZORAC
TOPICAL CREAM
0.05 %
3 PA
TAZORAC
TOPICAL CREAM
0.1 %
4 PA
TAZORAC
TOPICAL GEL
3 PA
tretinoin 2 PA
tretinoin
microspheres
2 PA
TRETIN-X CREAM
KIT
4 PA
TRETIN-X
TOPICAL CREAM
0.075 %
4 PA
VANOXIDE-HC 4 ST
zenatane 2
ZIANA 4 PA; ST
ZILXI 4 ST
TOPICAL ANESTHETICS
COCAINE NASAL 4
glydo 2 QL
Drug Name Drug
Tier
Requirements
/ Limits
GOPRELTO 4
lidocaine hcl
laryngotracheal
2
lidocaine hcl mucous
membrane jelly
2 QL
lidocaine hcl mucous
membrane jelly in
applicator
2 QL
lidocaine hcl mucous
membrane solution 4
% (40 mg/ml)
2
lidocaine hcl-
hydrocortison ac
topical
2
lidocaine topical
adhesive
patch,medicated 5 %
2 ST
lidocaine topical
ointment
2 QL
lidocaine viscous 2
lidocaine-prilocaine
topical cream
2 QL
lidocaine-prilocaine
topical kit
2
lta pre-attached 2
NUMBRINO 4
PLIAGLIS 4 ST; QL
SYNERA 4
ZTLIDO 3 PA
TOPICAL ANTIBACTERIALS
ALTABAX 4 ST; QL
CENTANY 4 ST; QL
CENTANY AT 4 ST; QL
CORTISPORIN
TOPICAL
4
gentamicin topical 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
49
Drug Name Drug
Tier
Requirements
/ Limits
KLARON 4 ST
lugols topical 2
mafenide acetate 2
mupirocin 2 QL
mupirocin calcium 2 ST; QL
NEO-SYNALAR 4
NEO-SYNALAR
KIT
4
strong iodine topical 2
sulfacetamide
sodium (acne)
2
SULFAMYLON
TOPICAL CREAM
3
SULFAMYLON
TOPICAL PACKET
4
XEPI 4 ST; QL
TOPICAL ANTIFUNGALS
CICLODAN KIT
TOPICAL COMBO
PACK
4
CICLODAN KIT
TOPICAL
SOLUTION
4 ST
ciclodan topical
cream
2 QL
ciclodan topical
solution
2
ciclopirox topical
cream
2 QL
ciclopirox topical
gel
2 QL
ciclopirox topical
shampoo
2 QL
ciclopirox topical
solution
2
Drug Name Drug
Tier
Requirements
/ Limits
ciclopirox topical
suspension
2 QL
ciclopirox-ure-
camph-menth-euc
2
clotrimazole topical 2 QL
clotrimazole-
betamethasone
2 QL
econazole 2 QL
ECOZA 4 QL
ERTACZO 4 QL
EXELDERM 4 QL
EXTINA 4 QL
JUBLIA 4 ST
KERYDIN 4 ST
ketoconazole topical 2 QL
ketodan 2 QL
ketodan kit 2
LOPROX (AS
OLAMINE)
4 QL
LOPROX KIT 4 QL
LOPROX TOPICAL
SHAMPOO
4 QL
LUZU 4 QL
MENTAX 4 QL
MICONAZOLE
NITRATE-ZINC
OX-PET
4 QL
naftifine 2 QL
NAFTIN TOPICAL
CREAM 2 %
4 QL
NAFTIN TOPICAL
GEL
4 QL
nyamyc 2 QL
nystatin topical 2 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
50
Drug Name Drug
Tier
Requirements
/ Limits
nystatin-
triamcinolone
2 QL
nystop 2 QL
oxiconazole 2 QL
OXISTAT 4 QL
tavaborole 2
VUSION 4 QL
XOLEGEL 4 QL
TOPICAL ANTIVIRALS
acyclovir topical 2 PA; QL
DENAVIR 4
XERESE 4
ZOVIRAX
TOPICAL CREAM
4 PA; QL
TOPICAL CORTICOSTEROIDS
ala-cort topical
cream 1 %
2
ALA-SCALP 4 ST
alclometasone 2
amcinonide topical
cream
2 ST
amcinonide topical
lotion
2 ST
apexicon e 2 ST
beser 2 ST
betamethasone
dipropionate
2
betamethasone
valerate topical
cream
2
betamethasone
valerate topical
foam
2 ST
Drug Name Drug
Tier
Requirements
/ Limits
betamethasone
valerate topical
lotion
2
betamethasone
valerate topical
ointment
2
betamethasone,
augmented
2
BRYHALI 4 ST
CAPEX 4 ST
clobetasol scalp 2 QL
clobetasol topical
cream
2 QL
clobetasol topical
foam
2 ST; QL
clobetasol topical
gel
2 QL
clobetasol topical
lotion
2 ST; QL
clobetasol topical
ointment
2 QL
clobetasol topical
shampoo
2 ST; QL
clobetasol topical
spray,non-aerosol
2 ST; QL
clobetasol-emollient
topical cream
2 QL
clobetasol-emollient
topical foam
2 ST; QL
CLOBEX 4 ST; QL
clodan 2 ST; QL
CLODAN KIT 4 ST
CLODERM 4 ST
CORDRAN TAPE
LARGE ROLL
4 ST
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
51
Drug Name Drug
Tier
Requirements
/ Limits
CORDRAN
TOPICAL CREAM
4 ST; QL
CORDRAN
TOPICAL LOTION
4 ST; QL
CORDRAN
TOPICAL
OINTMENT
4 ST; QL
CUTIVATE
TOPICAL CREAM
4 ST
CUTIVATE
TOPICAL LOTION
4 ST
DERMA-
SMOOTHE/FS
BODY OIL
4 ST
DERMA-
SMOOTHE/FS
SCALP OIL
4 ST
DESONATE 4 ST
desonide topical
cream
2
desonide topical gel 2 ST
desonide topical
lotion
2 ST
desonide topical
ointment
2
DESOWEN
TOPICAL LOTION
4 ST
desoximetasone 2 ST
diflorasone 2 ST; QL
DIPROLENE
(AUGMENTED)
TOPICAL
OINTMENT
4 ST
DUOBRII 4 ST; QL
fluocinolone 2
fluocinolone and
shower cap
2
Drug Name Drug
Tier
Requirements
/ Limits
fluocinonide topical
cream 0.05 %
2 QL
fluocinonide topical
cream 0.1 %
2 ST; QL
fluocinonide topical
gel
2 QL
fluocinonide topical
ointment
2 QL
fluocinonide topical
solution
2 QL
fluocinonide-e 2 QL
flurandrenolide 2 ST; QL
fluticasone
propionate topical
cream
2
fluticasone
propionate topical
lotion
2 ST
fluticasone
propionate topical
ointment
2
halcinonide 2 ST
halobetasol
propionate topical
cream
2
HALOBETASOL
PROPIONATE
TOPICAL FOAM
4 ST
halobetasol
propionate topical
ointment
2
HALOG 4 ST
hydrocortisone
butyrate topical
cream
2 QL
hydrocortisone
butyrate topical
lotion
2 ST; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
52
Drug Name Drug
Tier
Requirements
/ Limits
hydrocortisone
butyrate topical
ointment
2 ST
hydrocortisone
butyrate topical
solution
2 ST; QL
hydrocortisone
butyr-emollient
2 QL
hydrocortisone
topical cream 1 %,
2.5 %
2
hydrocortisone
topical lotion 2.5 %
2
hydrocortisone
topical ointment 1
%, 2.5 %
2
hydrocortisone
valerate
2
IMPOYZ 4 ST; QL
KENALOG
TOPICAL
4 ST; QL
LEXETTE 4 ST
LUXIQ 4 ST
mometasone topical 2
nolix 2 ST; QL
NUCORT 4 ST
OLUX 4 ST; QL
OLUX-E 4 ST; QL
PANDEL 4 ST
prednicarbate 2
PROCTOCORT
TOPICAL
4 ST
PSORCON 4 ST; QL
scalacort 2
SCALACORT DK 4 ST
Drug Name Drug
Tier
Requirements
/ Limits
SERNIVO 4 ST
SYNALAR 4 ST
SYNALAR
CREAM KIT
4 ST
SYNALAR
OINTMENT KIT
4 ST
SYNALAR TS 4 ST
TEMOVATE
TOPICAL CREAM
4 ST; QL
TEMOVATE
TOPICAL
OINTMENT
4 ST; QL
TEXACORT 4 ST
TOPICORT
TOPICAL CREAM
4 ST
TOPICORT
TOPICAL GEL
4 ST
TOPICORT
TOPICAL
OINTMENT
4 ST
tovet emollient 2 ST; QL
triamcinolone
acetonide topical
aerosol
2 ST; QL
triamcinolone
acetonide topical
cream
2
triamcinolone
acetonide topical
lotion
2
triamcinolone
acetonide topical
ointment 0.025 %,
0.1 %, 0.5 %
2
triamcinolone
acetonide topical
ointment 0.05 %
2 ST
trianex 2 ST
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
53
Drug Name Drug
Tier
Requirements
/ Limits
triderm topical
cream 0.1 %
2
triderm topical
cream 0.5 %
2 ST
TRIDESILON 4 ST
ULTRAVATE
TOPICAL LOTION
4 ST
TOPICAL ENZYMES
SANTYL 3 QL
TOPICAL SCABICIDES /
PEDICULICIDES
crotan 2
ELIMITE 4
EURAX 4
lindane topical
shampoo
2
malathion 2
NATROBA 4
OVIDE 4
permethrin topical
cream
2
SKLICE 4
spinosad 2
ULESFIA 4
DIAGNOSTICS &
MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
lactated ringers
irrigation
2
neomycin-polymyxin
b gu
2
PHYSIOLYTE 4
PHYSIOSOL
IRRIGATION
4
Drug Name Drug
Tier
Requirements
/ Limits
ringer's irrigation 2
SORBITOL
IRRIGATION
4
SORBITOL-
MANNITOL
4
tis-u-sol pentalyte 2
MISCELLANEOUS AGENTS
acamprosate 2
acetic acid irrigation 2
AGRYLIN 4
anagrelide 2
aqua care sodium
chloride
2
aqua care sterile
water
2
BUPHENYL 4
caffeine citrate oral 2
CARBAGLU 5 $$$$$; LA
CARNITOR
(SUGAR-FREE)
4
CARNITOR ORAL 4
cevimeline 2
CHEMET 3 PA
clovique 2 PA
deferasirox 5 PA
deferiprone 5 PA
disulfiram 2
EVOXAC 4
FERRIPROX 5 PA
GLASSIA 5 PA; $$$$$;
LA
GLEOLAN 4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
54
Drug Name Drug
Tier
Requirements
/ Limits
INCRELEX 5 PA; $$$$$;
LA
INFASURF 4
levocarnitine (with
sugar)
2
levocarnitine oral
solution 100 mg/ml
2
levocarnitine oral
tablet
2
LITHOSTAT 4
METOPIRONE 4
midodrine 2
nitisinone 5 PA
NITYR 5 PA; LA
NORTHERA 5 PA; $$$$$
ORFADIN ORAL
CAPSULE 10 MG,
2 MG, 5 MG
5 PA; LA
ORFADIN ORAL
CAPSULE 20 MG
5 PA; $$$$$;
LA
ORFADIN ORAL
SUSPENSION
5 PA; LA
pilocarpine hcl oral
tablet 5 mg
2
RADIOGARDASE 4
RAVICTI 5 $$$$$
RILUTEK 4 PA
riluzole 2 PA
risedronate oral
tablet 30 mg
1 QL
SALAGEN
(PILOCARPINE)
ORAL TABLET 5
MG
4
sodium chloride 0.9
%
2
Drug Name Drug
Tier
Requirements
/ Limits
sodium chloride 0.9
% (flush) injection
syringe
2
sodium chloride
injection
2
sodium chloride
irrigation
2
sodium
phenylbutyrate
2
SURVANTA 4
SYPRINE 4 PA
THIOLA 5
THIOLA EC 5
TIGLUTIK 4 PA
trientine 2 PA
ULTOMIRIS
INTRAVENOUS
SOLUTION 100
MG/ML
5 PA
water for irrigation,
sterile
2
XURIDEN 5
SMOKING DETERRENTS
bupropion hcl
(smoking deter)
1 ACA
CHANTIX 3 ACA
CHANTIX
CONTINUING
MONTH BOX
3 ACA
CHANTIX
STARTING
MONTH BOX
3 ACA
nicorette buccal gum
4 mg
1 ACA; OTC
nicotine (polacrilex) 1 ACA; OTC
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
55
Drug Name Drug
Tier
Requirements
/ Limits
nicotine transdermal
patch 24 hour 14
mg/24 hr, 21 mg/24
hr, 7 mg/24 hr
1 ACA; OTC
nicotine transdermal
patch, td daily,
sequential
1 ACA; OTC
NICOTROL 4 ACA
NICOTROL NS 4 ACA
quit 2 1 ACA; OTC
quit 4 1 ACA; OTC
stop smoking aid 1 ACA; OTC
EAR, NOSE & THROAT
MEDICATIONS
MISCELLANEOUS AGENTS
ARESTIN 5
azelastine nasal
aerosol,spray
2 QL
azelastine nasal
spray,non-aerosol
2
chlorhexidine
gluconate mucous
membrane
2
CLINPRO 5000 4
denta 5000 plus 1
dentagel 1
EPISIL 4
fluoride (sodium)
dental cream
1
fluoride (sodium)
dental gel
1
fluoride (sodium)
dental paste
1
FLUORIDEX
DAILY DEFENSE
DENTAL PASTE
4
Drug Name Drug
Tier
Requirements
/ Limits
FLUORIDEX
SENSITIVITY
RELIEF DENTAL
PASTE
4
GELCLAIR 4
GELX 4
ipratropium bromide
nasal
2 QL
MUGARD 4
olopatadine nasal 2 QL
oralone 2
ORAMAGICRX 4
paroex oral rinse 2
PATANASE 4 QL
PERIDEX 4
periogard 2
pilocarpine hcl oral
tablet 7.5 mg
2
PREVIDENT 4
PREVIDENT 5000
BOOSTER PLUS
4
PREVIDENT 5000
DRY MOUTH
4
PREVIDENT 5000
ENAMEL
PROTECT
4
PREVIDENT 5000
ORTHO DEFENSE
4
PREVIDENT 5000
PLUS
4
PREVIDENT 5000
SENSITIVE
4
PROTHELIAL 5
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
56
Drug Name Drug
Tier
Requirements
/ Limits
SALAGEN
(PILOCARPINE)
ORAL TABLET 7.5
MG
4
sf 1
sf 5000 plus 1
sodium fluoride
5000 plus
1
sodium fluoride-pot
nitrate
1
triamcinolone
acetonide dental
2
MISCELLANEOUS OTIC
PREPARATIONS
acetic acid otic (ear) 2
ciprofloxacin hcl
otic (ear)
2
DERMOTIC OIL 4
flac otic oil 2
fluocinolone
acetonide oil
2
hydrocortisone-
acetic acid
2
ofloxacin otic (ear) 2
OTIPRIO 4 QL
OTIC STEROID / ANTIBIOTIC
CIPRO HC 4
CIPRODEX 4
ciprofloxacin-
dexamethasone
2
CORTISPORIN-TC 4
neomycin-
polymyxin-hc otic
(ear)
2
OTOVEL 3
Drug Name Drug
Tier
Requirements
/ Limits
ENDOCRINE/DIABETES
ADRENAL HORMONES
ACTHAR 5 PA; $$$$$
CORTEF 4
cortisone 2
decadron oral tablet 2
dexabliss 2 PA
dexamethasone
intensol
2
dexamethasone oral
elixir
2
dexamethasone oral
solution
2
dexamethasone oral
tablet
2
dexamethasone oral
tablets,dose pack
2 ST
DXEVO 4 PA
fludrocortisone 2
hidex 2 PA
hydrocortisone oral 2
MEDROL 4
MEDROL (PAK) 4
methylprednisolone 2
millipred dp 2
millipred oral tablet 2
ORAPRED ODT 4
prednisolone oral
solution 15 mg/5 ml
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
57
Drug Name Drug
Tier
Requirements
/ Limits
prednisolone sodium
phosphate oral
solution 10 mg/5 ml,
15 mg/5 ml (3
mg/ml), 20 mg/5 ml
(4 mg/ml), 25 mg/5
ml (5 mg/ml), 5 mg
base/5 ml (6.7 mg/5
ml)
2
prednisolone sodium
phosphate oral
tablet,disintegrating
2
prednisone 2
prednisone intensol 2
RAYOS 4 ST
TAPERDEX ORAL
TABLETS,DOSE
PACK 1.5 MG (21
TABS), 1.5 MG (49
TABS)
4 ST
TAPERDEX ORAL
TABLETS,DOSE
PACK 1.5 MG (27
TABS)
4 PA
TRIESENCE (PF) 4
ZCORT 4 ST
ANTITHYROID AGENTS
methimazole oral
tablet 10 mg, 5 mg
2
propylthiouracil 2
SSKI 4
TAPAZOLE 4
BLOOD GLUCOSE MONITORING
DEVICES & SUPPLIES
FREESTYLE
INSULINX STRIP
3 OTC
Drug Name Drug
Tier
Requirements
/ Limits
FREESTYLE
INSULINX TEST
STRIPS
3 OTC
FREESTYLE LITE
STRIPS
3 OTC
FREESTYLE TEST 3 OTC
ONETOUCH
ULTRA BLUE
TEST STRIP
3 OTC
ONETOUCH
VERIO TEST
STRIPS
3 OTC
PRECISION XTRA
TEST
3 OTC
DIABETES, SUPPLIES, & DURABLE
MEDICAL EQUIPMENT
GLUCAGEN
DIAGNOSTIC KIT
3
GLUCAGON HCL 4
INSULIN
SYRINGE-
NEEDLE U-100
SYRINGE 0.5 ML
29 GAUGE X 1/2"
4
GLUCOSE ELEVATING AGENTS
BAQSIMI 3 QL
diazoxide 2
GLUCAGEN
HYPOKIT
3 QL
GLUCAGON
(HCL)
EMERGENCY KIT
3 QL
GLUCAGON
EMERGENCY KIT
(HUMAN)
3 QL
GVOKE HYPOPEN
2-PACK
3 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
58
Drug Name Drug
Tier
Requirements
/ Limits
GVOKE PFS 2-
PACK SYRINGE
3 QL
PROGLYCEM 4
INSULIN
SYRINGES/MISCELLANEOUS
DURABLE MEDICAL EQU
ACCU-CHEK
GUIDE L1-L2
CTRL SOL
4 OTC
ACCU-CHEK
SMARTVIEW
CONTRL SOL
4 OTC
ACCUTREND
GLUCOSE
CONTROL
4 OTC
ADVOCATE LOW
CONTROL
4 OTC
ADVOCATE REDI-
CODE+ CTRL
LOW
4 OTC
AGAMATRIX
CONTROL HIGH
4 OTC
ASSURE 4
CONTROL
SOLUTION
4 OTC
ASSURE DOSE
NORMAL
CONTROL
4 OTC
ASSURE PRISM
CONTROL 1-2
SOLN
4 OTC
AT HOME A1C 4 OTC
AUTOJECT 2
INJECTION
DEVICE
3 OTC
AUTOPEN 1 TO 21
UNITS
3 OTC
AUTOSOFT 30 3
Drug Name Drug
Tier
Requirements
/ Limits
AUTOSOFT 90 3
AUTOSOFT XC
INFUSION SET 23"
3
BD INTEGRA
NEEDLE
3
BD
MICROTAINER
LANCET 30
GAUGE
3 OTC
BD SPECIALTY
USE NEEDLES
NEEDLE 30
GAUGE X 1/2"
3
BD ULTRA FINE
LANCETS
3 OTC
BD ULTRA-FINE
NANO PEN
NEEDLE
3 OTC
BLOOD GLUCOSE
CONTROL,
NORMAL
4 OTC
BREEZE 2
CONTROL
SOLUTION,HIGH
4 OTC
CARESENS
CONTROL A
NORMAL
4 OTC
CEQUR
SIMPLICITY
4
CLEO 90
INFUSION SET 24"
3
CLEVER CHOICE
LEVEL 2
CONTROL
4 OTC
COMFORT
INFUSION SET 43"
3
COMFORT SHORT
INSULIN PUMP
23"
3
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
59
Drug Name Drug
Tier
Requirements
/ Limits
CONTACT
DETACH INFUS
SET 23"
3
CONTOUR
CONTROL
SOLUTION, NML
4 OTC
CONTOUR NEXT
LEV 2 CONTROL
SOL
4 OTC
COOL CONTROL
A SOLUTION
4 OTC
DEXCOM G4
RECEIVER
3 PA
DEXCOM G5
RECEIVER
3 PA
DEXCOM G6
RECEIVER
3 PA
DEXCOM
RECEIVER
3 PA
DIATRUE
CONTROL SOLN
NORMAL
4 OTC
EASY PLUS II
HIGH CONTROL
4 OTC
EASY STEP HIGH
CONTROL SOLN
4 OTC
EASY TALK HIGH
CONTROL
4 OTC
EASY TRAK II
CTRL SOLN-
NORMAL
4 OTC
EASY TRAK LOW
CONTROL
4 OTC
EASYGLUCO
PLUS NORMAL
CONTROL
4 OTC
EASYMAX LOW
CONTROL
4 OTC
Drug Name Drug
Tier
Requirements
/ Limits
EASYMAX
NORMAL
CONTROL
4 OTC
ECLIPSE NEEDLE
NEEDLE 27
GAUGE X 1/2"
4
ELEMENT
COMPACT
NORMAL
CONTROL
4 OTC
ELEMENT
NORMAL
CONTROL
4 OTC
EMBRACE EVO
LEVEL 1
4 OTC
EMBRACE
GLUCOSE
CONTROL LOW
4 OTC
EMBRACE TALK
CONTROL-LOW
(L1)
4 OTC
ENLITE SYSTEM 4 PA
EVERSENSE
SENSOR-HOLDER
4 PA
EVOLUTION
NORMAL
CONTROL
4 OTC
FORA GTEL
MULTI-FUNCTN
MONITOR
4 OTC
FORA NORMAL
CONTROL
4 OTC
FORACARE GDH
LOW CONTROL
4 OTC
FORTISCARE
NORMAL
4 OTC
FREESTYLE
CONTROL
3 OTC
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
60
Drug Name Drug
Tier
Requirements
/ Limits
FREESTYLE
FREEDOM
3 OTC
FREESTYLE
FREEDOM LITE
3 OTC
FREESTYLE
INSULINX
3 OTC
FREESTYLE
LIBRE 14 DAY
READER
3 PA
FREESTYLE
LIBRE 14 DAY
SENSOR
3 PA; QL
FREESTYLE LITE
METER
3 OTC
GE100 CONTROL
SOLUTION
NORMAL
4 OTC
GENTEEL
VACUUM
LANCING DEVICE
4 OTC
GLUCOCARD 01
NORMAL
CONTROL
4 OTC
GLUCOCOM
CONTROL
NORMAL
4 OTC
GLUCOSE
CONTROL
4 OTC
GOJJI GLUCOSE
CNTRL SOL-
NORMAL
4 OTC
GOJJI KETONE
CONTROL SOLN-
L1
4 OTC
GOJJI MULTI-
FUNCTIONAL
METER KIT
4 OTC
Drug Name Drug
Tier
Requirements
/ Limits
GUARDIAN
REAL-TIME GLU
MONITOR
4 PA
HEALTHPRO
HIGH-LOW
CONTROL
4 OTC
INFINITY
CONTROL
SOLUTION NORM
4 OTC
INFINITY VOICE
CTRL SOLN-LVL 2
4 OTC
INPEN (FOR
HUMALOG)
4
INPEN (FOR
NOVOLOG OR
FIASP)
4
LANCETS 33
GAUGE
3 OTC
LANCING DEVICE 3 OTC
MEDISENSE 3 OTC
MEDISENSE
GLUCOSE
KETONE
3 OTC
MINIMED
INFUSION SET-
MMT 390
3
MINIMED MIO 32" 3
MINIMED MIO
ADVANCE INF
SET23"
3 OTC
MINIMED QUICK
SET 43"
3
MINIMED
SILHOUETTE 23"
3
MINIMED SURE T
32"
3
MIO INFUSION
SET
3
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
61
Drug Name Drug
Tier
Requirements
/ Limits
MYGLUCOHEALT
H CONTROL
SOLUTION
4 OTC
NOVA MAX
GLUCOSE
CONTROL
4 OTC
NOVAMAX PLUS
GLU-KET
4 OTC
NOVOPEN ECHO 4
OMNIPOD DASH 5
PACK POD
3
ON CALL
EXPRESS
CONTROL
4 OTC
ON CALL PLUS
CONTROL
4 OTC
ON CALL VIVID
CONTROL
4 OTC
ONETOUCH
ULTRA CONTROL
3 OTC
ONETOUCH
ULTRA2 METER
3 OTC
ONETOUCH
ULTRAMINI
3 OTC
ONETOUCH
VERIO FLEX
METER
3 OTC
ONETOUCH
VERIO IQ METER
3 OTC
ONETOUCH
VERIO METER
3 OTC
ONETOUCH
VERIO REFLECT
METER
3 OTC
PEN NEEDLE,
DIABETIC
NEEDLE 29
GAUGE X 1/2"
4 OTC
Drug Name Drug
Tier
Requirements
/ Limits
PRECISION XTRA
KETONE-
GLUCOSE
3 OTC
PRECISION XTRA
MONITOR
3 OTC
PRODIGY
CONTROL
SOLUTION, LOW
4 OTC
PRODIGY
CONTROL
SOLUTION,HIGH
4 OTC
QUICK-SET
PARADIGM
3
REFUAH PLUS
GLUCOSE
CONTROL
4 OTC
RIGHTEST
CONTROL
SOLUTION HIGH
4 OTC
SAFE-CLIP BY
3 OTC
SILHOUETTE
INFUSION SET
3
SMARTEST
CONTROL
4 OTC
SOLUS V2
CONTROL
SOLUTION,HIGH
4 OTC
SURE-T
PARADIGM
3
T:30 INFUSION
SET
3
T:90 INFUSION
SET 23"
3
T:SLIM 3
T:SLIM G4 3
TELCARE
CONTROL
4 OTC
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
62
Drug Name Drug
Tier
Requirements
/ Limits
TRUE METRIX
LEVEL 1
4 OTC
TRUECONTROL
LEVEL 0
4 OTC
TRUSTEEL
INFUSION SET 32"
3
UNISTRIP LOW
CONTROL
4 OTC
VARISOFT
INFUSION SET 43"
3
VERASENS
CONTROL SOLN-
LEVEL 1
4 OTC
V-GO 20 3
V-GO 30 3
V-GO 40 3
VIVAGUARD INO
CTRL SOLN-L1,2,3
4 OTC
WAVESENSE
CONTROL
SOLUTION
4 OTC
INSULIN THERAPY
AFREZZA
INHALATION
CARTRIDGE
WITH INHALER 12
UNIT, 4 UNIT, 4
UNIT (90)/ 8 UNIT
(90), 4 UNIT/8
UNIT/ 12 UNIT
(60), 8 UNIT, 8
UNIT (90)/ 12 UNIT
(90)
4
BASAGLAR
KWIKPEN U-100
INSULIN
4
HUMALOG
JUNIOR KWIKPEN
U-100
3
Drug Name Drug
Tier
Requirements
/ Limits
HUMALOG
KWIKPEN
INSULIN
3
HUMALOG MIX
50-50 INSULN U-
100
3
HUMALOG MIX
50-50 KWIKPEN
3
HUMALOG MIX
75-25 KWIKPEN
3
HUMALOG MIX
75-25(U-
100)INSULN
3
HUMALOG U-100
INSULIN
3
HUMULIN 70/30
U-100 INSULIN
3
HUMULIN 70/30
U-100 KWIKPEN
3
HUMULIN N NPH
INSULIN
KWIKPEN
3
HUMULIN N NPH
U-100 INSULIN
3
HUMULIN R
REGULAR U-100
INSULN
3
HUMULIN R U-500
(CONC) INSULIN
3
HUMULIN R U-500
(CONC) KWIKPEN
3
LANTUS
SOLOSTAR U-100
INSULIN
3
LANTUS U-100
INSULIN
3
LEVEMIR
FLEXTOUCH U-
100 INSULN
3
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
63
Drug Name Drug
Tier
Requirements
/ Limits
LEVEMIR U-100
INSULIN
3
LYUMJEV
KWIKPEN U-100
INSULIN
3
LYUMJEV
KWIKPEN U-200
INSULIN
3
LYUMJEV U-100
INSULIN
3
SOLIQUA 100/33 3 QL
TOUJEO MAX U-
300 SOLOSTAR
3
TOUJEO
SOLOSTAR U-300
INSULIN
3
TRESIBA
FLEXTOUCH U-
100
3
TRESIBA
FLEXTOUCH U-
200
3
TRESIBA U-100
INSULIN
3
XULTOPHY
100/3.6
3 QL
MISCELLANEOUS HORMONES
ANADROL-50 4
ANDRODERM 3 PA; QL
ANDROGEL
TRANSDERMAL
GEL IN
METERED-DOSE
PUMP 20.25
MG/1.25 GRAM
(1.62 %)
4 PA; QL
Drug Name Drug
Tier
Requirements
/ Limits
ANDROGEL
TRANSDERMAL
GEL IN PACKET
1.62 % (20.25
MG/1.25 GRAM),
1.62 % (40.5
MG/2.5 GRAM)
4 PA; QL
ANDROID 4 ST
cabergoline 2 QL
calcitonin (salmon) 2
calcitriol
intravenous solution
1 mcg/ml
2
calcitriol oral 2
CERDELGA 5 PA; $$$$$
cinacalcet 1 ST
danazol 2
DDAVP NASAL
SOLUTION
3
DDAVP ORAL 4
DEPO-
TESTOSTERONE
4 PA
desmopressin nasal
spray,non-aerosol
2
desmopressin oral 2
doxercalciferol oral 2
FORTESTA 4 PA; ST; QL
GALAFOLD 5 PA; $$$$$;
QL
JYNARQUE ORAL
TABLET
5 PA; LA; QL
JYNARQUE ORAL
TABLETS,
SEQUENTIAL 15
MG (AM)/ 15 MG
(PM), 30 MG (AM)/
15 MG (PM)
5 PA; LA; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
64
Drug Name Drug
Tier
Requirements
/ Limits
JYNARQUE ORAL
TABLETS,
SEQUENTIAL 45
MG (AM)/ 15 MG
(PM), 60 MG (AM)/
30 MG (PM), 90
MG (AM)/ 30 MG
(PM)
5 PA; QL
KUVAN 5 PA; $$$$$
METHITEST 3
methyltestosterone
oral capsule
2
MIACALCIN
INJECTION
3
miglustat 5 PA; $$$$$
MYALEPT 5 PA; $$$$$;
LA
NATESTO 3 PA; ST; QL
NATPARA 5 PA; $$$$$;
LA
NOCDURNA
(MEN)
4 PA; QL
NOCDURNA
(WOMEN)
4 PA; QL
ORILISSA 3 PA; QL
oxandrolone 2
PALYNZIQ 5 PA; $$$$$;
QL
paricalcitol
intravenous
2
paricalcitol oral 2
RAYALDEE 4
ROCALTROL 4
SAMSCA 5 PA; $$$$$;
QL
sapropterin 5 PA
Drug Name Drug
Tier
Requirements
/ Limits
SOMAVERT 5 $$$$$
STRENSIQ 5 PA; LA
SYNAREL 3
TESTOPEL 5 PA
testosterone
cypionate
intramuscular oil
100 mg/ml, 200
mg/ml
2 PA
testosterone
enanthate
2 PA
TESTOSTERONE
IMPLANT
4 PA
testosterone
transdermal gel
2 PA; QL
testosterone
transdermal gel in
metered-dose pump
10 mg/0.5 gram
/actuation
1 PA; ST; QL
testosterone
transdermal gel in
metered-dose pump
12.5 mg/ 1.25 gram
(1 %)
2 PA; QL
testosterone
transdermal gel in
metered-dose pump
20.25 mg/1.25 gram
(1.62 %)
2 PA
testosterone
transdermal gel in
packet 1 % (25
mg/2.5gram), 1 %
(50 mg/5 gram)
2 PA; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
65
Drug Name Drug
Tier
Requirements
/ Limits
testosterone
transdermal gel in
packet 1.62 %
(20.25 mg/1.25
gram), 1.62 % (40.5
mg/2.5 gram)
2 PA
testosterone
transdermal solution
in metered pump
w/app
2 PA; QL
TESTRED 4 ST
tolvaptan oral tablet
30 mg
5 PA; QL
VOGELXO 4 PA; ST; QL
XYOSTED 4 PA
ZEMPLAR
INTRAVENOUS
4
ZEMPLAR ORAL
CAPSULE 1 MCG,
2 MCG
4
NON-INSULIN HYPOGLYCEMIC
AGENTS
acarbose 1
ACTOPLUS MET 4 ST; QL
ACTOS 4 ST; QL
AMARYL 4
AVANDIA ORAL
TABLET 2 MG, 4
MG
4 ST; QL
BYDUREON
BCISE
3 PA; QL
BYDUREON
SUBCUTANEOUS
PEN INJECTOR
3 PA; QL
BYETTA 3 PA; QL
CYCLOSET 4
DUETACT 4 ST; QL
Drug Name Drug
Tier
Requirements
/ Limits
FARXIGA 3 ST; QL
FORTAMET 4 ST; QL
glimepiride 1
glipizide 1
glipizide-metformin 1
GLUCOTROL 4
GLUCOTROL XL 4
glyburide 1
glyburide
micronized
1
glyburide-metformin 1
GLYNASE 4
GLYSET 4
GLYXAMBI 3 ST; QL
INVOKAMET 3 ST; QL
INVOKAMET XR 3 ST; QL
INVOKANA 3 ST; QL
JANUMET 3 QL
JANUMET XR 3 QL
JANUVIA 3 QL
JARDIANCE 3 ST; QL
JENTADUETO 3 QL
JENTADUETO XR 3 QL
metformin oral
solution
1
metformin oral
tablet
1
metformin oral
tablet extended
release 24 hr
1 QL
metformin oral
tablet extended
release 24hr
1 ST; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
66
Drug Name Drug
Tier
Requirements
/ Limits
metformin oral
tablet,er
gast.retention 24 hr
1 ST; QL
miglitol 1
nateglinide 1
OSENI 4 QL
OZEMPIC 3 PA; QL
pioglitazone 1 QL
pioglitazone-
glimepiride
1 QL
pioglitazone-
metformin
1 QL
PRANDIN ORAL
TABLET 1 MG, 2
MG
4
PRECOSE 4
QTERN 4 ST
repaglinide 1
repaglinide-
metformin
1 QL
RIOMET 4 ST
RIOMET ER 4 ST
RYBELSUS 3 PA; QL
SEGLUROMET 3 ST; QL
STARLIX 4
STEGLATRO 3 ST; QL
STEGLUJAN 4 ST; QL
SYMLINPEN 120 3 PA; QL
SYMLINPEN 60 3 PA; QL
SYNJARDY 3 ST; QL
SYNJARDY XR 3 ST; QL
TRADJENTA 3 QL
TRIJARDY XR 3 ST
Drug Name Drug
Tier
Requirements
/ Limits
TRULICITY 3 PA; QL
XIGDUO XR 3 ST; QL
THYROID HORMONES
ARMOUR
THYROID
3
euthyrox 2
levo-t 2
levothyroxine oral 2
levoxyl oral tablet
100 mcg, 112 mcg,
125 mcg, 137 mcg,
150 mcg, 175 mcg,
200 mcg, 25 mcg, 50
mcg, 75 mcg, 88 mcg
2
liothyronine oral 2
np thyroid 2
SYNTHROID 4
THYROLAR-1 4
THYROLAR-1/2 4
THYROLAR-1/4 4
THYROLAR-2 4
THYROLAR-3 4
TIROSINT 4
TIROSINT-SOL 4
unithroid 2
westhroid oral tablet
130 mg, 195 mg,
32.5 mg, 65 mg, 97.5
mg
2
GASTROENTEROLOGY
ANTIDIARRHEALS &
ANTISPASMODICS
anaspaz 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
67
Drug Name Drug
Tier
Requirements
/ Limits
belladonna
alkaloids-opium
2
chlordiazepoxide-
clidinium
2
CUVPOSA 4
dicyclomine oral
capsule
2
dicyclomine oral
solution
2
dicyclomine oral
tablet
2
diphenoxylate-
atropine
2
DONNATAL
ORAL ELIXIR
16.2-0.1037 -0.0194
MG/5 ML
4
DONNATAL
ORAL TABLET
4
ed-spaz 2
GLYCATE 4
glycopyrrolate oral 2
hyoscyamine sulfate
oral
2
hyoscyamine sulfate
sublingual
2
hyosyne 2
LEVBID 4
LEVSIN ORAL 4
LEVSIN/SL 4
LOMOTIL 4
loperamide oral
capsule
2
methscopolamine 2
MOTOFEN 4
Drug Name Drug
Tier
Requirements
/ Limits
MYTESI 4
NULEV 4
opium tincture 2
oscimin oral tablet 2
oscimin sl 2
oscimin sr 2
phenobarb-hyoscy-
atropine-scop oral
elixir 16.2-0.1037 -
0.0194 mg/5 ml
2
phenobarb-hyoscy-
atropine-scop oral
tablet
2
phenohytro oral
elixir 16.2-0.1037 -
0.0194 mg/5 ml
2
phenohytro oral
tablet
2
propantheline 2
SYMAX DUOTAB 4
symax fastabs 2
symax-sl 2
symax-sr 2
MISCELLANEOUS
GASTROINTESTINAL AGENTS
ACTIGALL 4
alophen (bisacodyl) 2 ACA; OTC
alosetron 2
AMITIZA 4 QL
ANA-LEX KIT 4
ANALPRAM-HC
RECTAL CREAM
1-1 %
4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
68
Drug Name Drug
Tier
Requirements
/ Limits
ANALPRAM-HC
RECTAL CREAM
2.5-1 %
4 ST
ANALPRAM-HC
SINGLES RECTAL
CREAM 2.5-1 %
(4G)
4
anucort-hc 2
aprepitant 2 QL
APRISO 4
AURYXIA 4
AZULFIDINE 4 ST
AZULFIDINE EN-
TABS
4 ST
balsalazide 2
bisacodyl oral 2 ACA; OTC
bisa-lax (bisacodyl) 2 ACA; OTC
BONJESTA 4 QL
budesonide oral 2
calcium
acetate(phosphat
bind)
2
CANASA 4
CHENODAL 5 PA; LA
CHOLBAM ORAL
CAPSULE 250 MG
5 PA
CHOLBAM ORAL
CAPSULE 50 MG
5 PA; QL
citrate of magnesia 2 ACA; OTC
citroma 2 ACA; OTC
clearlax 2 ACA; OTC
CLENPIQ 3
COLAZAL 4 ST
COMPAZINE 4
Drug Name Drug
Tier
Requirements
/ Limits
compro 2
constulose 2
CORTENEMA 4
CREON 3
cromolyn oral 2
CYSTADANE 5
DICLEGIS 4 QL
DIPENTUM 4 ST
doxylamine-
pyridoxine (vit b6)
2 QL
dronabinol 2 PA
ducodyl (bisacodyl) 2 ACA; OTC
dulcolax
(magnesium
hydroxide)
2 ACA; OTC
ENTEREG 4
ENTOCORT EC 4
enulose 2
fleet laxative
(bisacodyl)
2 ACA; OTC
GASTROCROM 4
GATTEX 30-VIAL 5 $$$$$
gavilax oral powder 2 ACA; OTC
gavilyte-c 1 ACA
gavilyte-g 1 ACA
gavilyte-n 1 ACA
generlac 2
gentle laxative
(bisacodyl) oral
2 ACA; OTC
gentlelax 2 ACA; OTC
glycolax oral
powder
2 ACA; OTC
GOLYTELY 4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
69
Drug Name Drug
Tier
Requirements
/ Limits
granisetron hcl oral 2 QL
healthylax 2 ACA; OTC
hemmorex-hc rectal
suppository 25 mg
2
hydrocortisone
acetate rectal
2
hydrocortisone
rectal
2
hydrocortisone
topical cream with
perineal applicator
2
hydrocortisone-
pramoxine rectal
2
kionex (with
sorbitol)
2
KRISTALOSE 4
lactulose oral packet 2
lactulose oral
solution 10 gram/15
ml, 20 gram/30 ml
2
lanthanum 2
laxaclear 2 ACA; OTC
laxative (bisacodyl)
oral
2 ACA; OTC
laxative peg 3350
oral powder
2 ACA; OTC
LIALDA 4 ST
lidocaine hcl-
hydrocortison ac
rectal cream 3-0.5 %
2
LIDOCAINE HCL-
HYDROCORTISO
N AC RECTAL
GEL
4
lidocaine hcl-
hydrocortison ac
rectal kit
2
Drug Name Drug
Tier
Requirements
/ Limits
lidocaine-
hydrocortisone-aloe
rectal gel
2
lidocaine-
hydrocortisone-aloe
rectal kit 3-2.5 % (7
gram)
2
LINZESS 3 QL
LOKELMA 3 QL
LOTRONEX 4
magnesium citrate
oral solution
2 ACA; OTC
MARINOL 4 PA
meclizine oral tablet
12.5 mg, 25 mg
2
mesalamine oral
capsule (with del rel
tablets)
2
mesalamine oral
capsule,extended
release 24hr
2
mesalamine oral
tablet,delayed
release (dr/ec) 1.2
gram
2
mesalamine oral
tablet,delayed
release (dr/ec) 800
mg
1
mesalamine rectal
enema
2
mesalamine rectal
suppository
1
mesalamine with
cleansing wipe
2
metoclopramide hcl
oral
2
milk of magnesia 2 ACA; OTC
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
70
Drug Name Drug
Tier
Requirements
/ Limits
milk of magnesia
concentrated
2 ACA; OTC
miralax oral powder
in packet
2 ACA; OTC
MOTEGRITY 4 QL
MOVANTIK 3 QL
MOVIPREP 4
natura-lax 2 ACA; OTC
NULYTELY
LEMON-LIME
4
NULYTELY WITH
FLAVOR PACKS
4
OCALIVA 5 PA; $$$$$;
LA; QL
ondansetron 2 QL
ondansetron hcl oral
solution
2 QL
ondansetron hcl oral
tablet 4 mg, 8 mg
2 QL
oral saline laxative
oral liquid
2 ACA; OTC
ORTIKOS 4
peg 3350-
electrolytes oral
recon soln 236-
22.74-6.74 -5.86
gram
1 ACA
peg3350-sod sul-
nacl-kcl-asb-c
1 ACA
peg-electrolyte soln 1 ACA
peg-prep 1 ACA
PENTASA 3
PHOSLYRA 3
phosphate laxative
oral liquid
2 ACA; OTC
PLENVU 4
Drug Name Drug
Tier
Requirements
/ Limits
polyethylene glycol
3350
2 ACA; OTC
powderlax 2 ACA; OTC
prochlorperazine 2
prochlorperazine
maleate
2
PROCORT 4
PROCTOCORT
RECTAL
4 ST
PROCTOFOAM HC 4 ST
procto-med hc 2
procto-pak 2
proctosol hc topical 2
proctozone-hc 2
purelax 2 ACA; OTC
RECTIV 3
REGLAN ORAL 4
RELISTOR ORAL 3 ST
RELISTOR
SUBCUTANEOUS
SOLUTION
3 ST
RELISTOR
SUBCUTANEOUS
SYRINGE
3 ST
RENVELA 4
ROWASA RECTAL
ENEMA KIT
4
SANCUSO 4 QL
scopolamine base 2
sevelamer carbonate 2
sevelamer hcl 2
SFROWASA 4
smoothlax 2 ACA; OTC
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
71
Drug Name Drug
Tier
Requirements
/ Limits
sodium polystyrene
(sorb free)
2
sodium polystyrene
sulfonate oral
powder
2
SOLESTA 5
sps (with sorbitol) 2
SUCRAID 5
sulfasalazine 2
SUPREP BOWEL
PREP KIT
3
SYMPROIC 3
SYNDROS 4 PA
TIGAN ORAL
CAPSULE 300 MG
4
trilyte with flavor
packets
1 ACA
trimethobenzamide
oral
2
TRULANCE 3
UCERIS ORAL 4
UCERIS RECTAL 3
URSO 250 4
URSO FORTE 4
ursodiol 2
VARUBI ORAL 3 QL
VELPHORO 3
VIBERZI 3
VIOKACE 3
women's gentle
laxative(bisac)
2 ACA; OTC
women's laxative
(bisacodyl)
2 ACA; OTC
ZELNORM 4
Drug Name Drug
Tier
Requirements
/ Limits
ZENPEP ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
10,000-32,000 -
42,000 UNIT,
15,000-47,000 -
63,000 UNIT,
20,000-63,000-
84,000 UNIT,
25,000-79,000-
105,000 UNIT,
3,000-10,000 -
14,000-UNIT,
40,000-126,000-
168,000 UNIT,
5,000-17,000-
24,000 UNIT
3
ZOFRAN ORAL
TABLET
4 QL
ZUPLENZ 4 QL
ULCER THERAPY
amoxicil-
clarithromy-
lansopraz
2 QL
CARAFATE 4
cimetidine 2
cimetidine hcl oral 2
CYTOTEC 4
DEXILANT 4 ST; QL
esomeprazole
magnesium oral
capsule,delayed
release(dr/ec) 20 mg
2 QL
esomeprazole
magnesium oral
capsule,delayed
release(dr/ec) 40 mg
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
72
Drug Name Drug
Tier
Requirements
/ Limits
esomeprazole
magnesium oral
granules dr for susp
in packet 10 mg, 20
mg
2 ST; QL
esomeprazole
magnesium oral
granules dr for susp
in packet 40 mg
2 ST
famotidine oral
suspension
2
famotidine oral
tablet 20 mg, 40 mg
2
lansoprazole oral
capsule,delayed
release(dr/ec) 15 mg
2 QL
lansoprazole oral
capsule,delayed
release(dr/ec) 30 mg
2
lansoprazole oral
tablet,disintegrat,
delay rel 15 mg
2 QL
lansoprazole oral
tablet,disintegrat,
delay rel 30 mg
2
misoprostol 2
NEXIUM ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
20 MG
4 ST; QL
NEXIUM ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
40 MG
4 ST
Drug Name Drug
Tier
Requirements
/ Limits
NEXIUM PACKET
ORAL GRANULES
DR FOR SUSP IN
PACKET 10 MG, 20
MG
4 ST; QL
NEXIUM PACKET
ORAL GRANULES
DR FOR SUSP IN
PACKET 2.5 MG, 5
MG
3 ST; QL
NEXIUM PACKET
ORAL GRANULES
DR FOR SUSP IN
PACKET 40 MG
4 ST
nizatidine 2
OMECLAMOX-
PAK
4 QL
omeprazole oral
capsule,delayed
release(dr/ec) 10 mg
2 QL
omeprazole oral
capsule,delayed
release(dr/ec) 20
mg, 40 mg
2
omeprazole-sodium
bicarbonate oral
capsule 20-1.1 mg-
gram
2 ST; QL
omeprazole-sodium
bicarbonate oral
capsule 40-1.1 mg-
gram
2 ST
omeprazole-sodium
bicarbonate oral
packet 20-1,680 mg
2 ST; QL
omeprazole-sodium
bicarbonate oral
packet 40-1,680 mg
2 ST
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
73
Drug Name Drug
Tier
Requirements
/ Limits
pantoprazole oral
granules dr for susp
in packet
2
pantoprazole oral
tablet,delayed
release (dr/ec) 20
mg
2 QL
pantoprazole oral
tablet,delayed
release (dr/ec) 40
mg
2
PEPCID ORAL
TABLET
4
rabeprazole oral
tablet,delayed
release (dr/ec)
2
ranitidine hcl oral
syrup
2
ranitidine hcl oral
tablet 150 mg, 300
mg
2
sucralfate 2
TALICIA 3 QL
IMMUNOLOGY, VACCINES &
BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
FULPHILA 5 PA; $$$$$;
QL
LEUKINE
INJECTION
RECON SOLN
5 $$$$$
MACRILEN 5 QL
MOZOBIL 5 $$$$$
NEULASTA 5 PA; $$$$$;
QL
NIVESTYM 5 PA
PROCRIT 5 PA; $$$$$
Drug Name Drug
Tier
Requirements
/ Limits
RETACRIT 5 PA
UDENYCA 5 PA; QL
ZARXIO 5 PA; $$$$$
ZIEXTENZO 5 PA
GROWTH HORMONES
EGRIFTA SV 5 PA
GENOTROPIN 5 PA; $$$$$
GENOTROPIN
MINIQUICK
5 PA; $$$$$
NORDITROPIN
FLEXPRO
5 PA; $$$$$
SEROSTIM
SUBCUTANEOUS
RECON SOLN 4
MG, 5 MG, 6 MG
5 PA; $$$$$
ZORBTIVE 5 PA; $$$$$
INTERFERONS
AUBAGIO 5 PA; $$$$$
AVONEX
INTRAMUSCULA
R PEN INJECTOR
KIT
5 PA; $$$$$;
QL
AVONEX
INTRAMUSCULA
R SYRINGE KIT
5 PA; $$$$$;
QL
BETASERON
SUBCUTANEOUS
KIT
5 $$$$$; QL
COPAXONE
SUBCUTANEOUS
SYRINGE
5 $$$$$; QL
dimethyl fumarate 5 PA
GILENYA ORAL
CAPSULE 0.5 MG
5 PA; $$$$$
glatiramer 5 $$$$$; QL
glatopa 5 $$$$$; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
74
Drug Name Drug
Tier
Requirements
/ Limits
KESIMPTA PEN 5 PA
MAVENCLAD (10
TABLET PACK)
5 PA; QL
MAVENCLAD (4
TABLET PACK)
5 PA; QL
MAVENCLAD (5
TABLET PACK)
5 PA; QL
MAVENCLAD (6
TABLET PACK)
5 PA; QL
MAVENCLAD (7
TABLET PACK)
5 PA; QL
MAVENCLAD (8
TABLET PACK)
5 PA; QL
MAVENCLAD (9
TABLET PACK)
5 PA; QL
MAYZENT 5 PA; QL
PEGASYS 5 PA; $$$$$;
QL
PEGINTRON
SUBCUTANEOUS
KIT 50 MCG/0.5
ML
5 PA; $$$$$;
QL
PLEGRIDY 5 PA; $$$$$;
QL
POMALYST 5 PA; $$$$$
REBIF (WITH
ALBUMIN)
5 PA; $$$$$;
QL
REBIF REBIDOSE 5 PA; $$$$$;
QL
REBIF TITRATION
PACK
5 PA; $$$$$;
QL
REVLIMID 5 PA; $$$$$;
LA
ribavirin oral
capsule
5 PA; $$$
ribavirin oral tablet
200 mg
5 PA; $$$
Drug Name Drug
Tier
Requirements
/ Limits
SYLATRON
SUBCUTANEOUS
KIT 200 MCG, 300
MCG
5 PA; $$$$$
TECFIDERA 5 PA; $$$$$
VUMERITY 5 PA
ZEPOSIA 5
ZEPOSIA
STARTER KIT
5
ZEPOSIA
STARTER PACK
5
INTERLEUKINS
ACTIMMUNE 5 $$$$$
ALDARA 4
ALFERON N 3
ARCALYST 5 PA; $$$$$
imiquimod topical
cream in packet
2
INTRON A
INJECTION
5 $$$$$
PROLEUKIN 5 PA; $$$$$
VACCINES & MISCELLANEOUS
IMMUNOLOGICALS
ACTHIB (PF) 3 ACA
ADACEL(TDAP
ADOLESN/ADULT
)(PF)
3 ACA
AFLURIA QD
2020-21(3YR
UP)(PF)
3 ACA
AFLURIA QD
2020-21(6-
35MO)(PF)
3 ACA
AFLURIA QUAD
2020-2021(6MO
UP)
3 ACA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
75
Drug Name Drug
Tier
Requirements
/ Limits
BCG VACCINE,
LIVE (PF)
3 ACA
BEXSERO 3 ACA
BIOTHRAX 3 ACA
BOOSTRIX TDAP 3 ACA
BOTOX
INJECTION
RECON SOLN 100
UNIT
5 PA
DAPTACEL (DTAP
PEDIATRIC) (PF)
3 ACA
ENGERIX-B (PF) 3 ACA
ENGERIX-B
PEDIATRIC (PF)
INTRAMUSCULA
R SYRINGE
3 ACA
FLUAD 2020-2021
(65 YR UP)(PF)
3 ACA
FLUAD QUAD
2020-21(65Y
UP)(PF)
3 ACA
FLUARIX QUAD
2020-2021 (PF)
3 ACA
FLUBLOK QUAD
2020-2021 (PF)
3 ACA
FLUCELVAX
QUAD 2020-2021
3 ACA
FLUCELVAX
QUAD 2020-2021
(PF)
3 ACA
FLULAVAL QUAD
2020-2021 (PF)
3 ACA
FLUMIST QUAD
2020-2021
4 ACA
FLUZONE
HIGHDOSE QUAD
20-21 PF
3 ACA
Drug Name Drug
Tier
Requirements
/ Limits
FLUZONE QUAD
2020-2021
3 ACA
FLUZONE QUAD
2020-2021 (PF)
3 ACA
GARDASIL 9 (PF) 3 ACA
HAVRIX (PF)
INTRAMUSCULA
R SUSPENSION
1,440 ELISA
UNIT/ML
3 ACA
HAVRIX (PF)
INTRAMUSCULA
R SYRINGE
3 ACA
HEPLISAV-B (PF)
INTRAMUSCULA
R SYRINGE
4 ACA
HIBERIX (PF) 3 ACA
IMOVAX RABIES
VACCINE (PF)
3 ACA
INFANRIX (DTAP)
(PF)
3 ACA
IPOL 3 ACA
IXIARO (PF) 3 ACA
KINRIX (PF) 4 ACA
MENACTRA (PF)
INTRAMUSCULA
R SOLUTION
3 ACA
MENQUADFI (PF) 4 ACA
MENVEO A-C-Y-
W-135-DIP (PF)
4 ACA
M-M-R II (PF) 3 ACA
PEDIARIX (PF) 3 ACA
PEDVAX HIB (PF) 3 ACA
PENTACEL (PF) 3 ACA
PENTACEL
ACTHIB
COMPONENT (PF)
3 ACA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
76
Drug Name Drug
Tier
Requirements
/ Limits
PNEUMOVAX-23 3 ACA
PREVNAR 13 (PF) 3 ACA
PROQUAD (PF) 3 ACA
QUADRACEL (PF) 3 ACA
RABAVERT (PF) 3 ACA
RECOMBIVAX HB
(PF)
3 ACA
ROTARIX 4 ACA
ROTATEQ
VACCINE
3 ACA
SHINGRIX (PF) 3 ACA
STAMARIL (PF) 3 ACA
TDVAX 3 ACA
TENIVAC (PF) 4 ACA
TETANUS,DIPHTH
ERIA TOX
PED(PF)
3 ACA
TRUMENBA 3 ACA
TWINRIX (PF)
INTRAMUSCULA
R SYRINGE
3 ACA
TYPHIM VI 3 ACA
VAQTA (PF) 4 ACA
VARIVAX (PF) 3 ACA
VARIZIG
INTRAMUSCULA
R SOLUTION
3 ACA
VAXCHORA
VACCINE
3 ACA
VIVOTIF 3 ACA
YF-VAX (PF) 3 ACA
ZOSTAVAX (PF) 4 ACA
MUSCULOSKELETAL &
RHEUMATOLOGY
Drug Name Drug
Tier
Requirements
/ Limits
GOUT THERAPY
allopurinol 2
colchicine oral
tablet
2
COLCRYS 4 ST
febuxostat 2 ST
GLOPERBA 4
MITIGARE 3
probenecid 2
probenecid-
colchicine
2
ZYLOPRIM 4
OSTEOPOROSIS THERAPY
ACTONEL ORAL
TABLET 150 MG,
35 MG
4 ST; QL
alendronate oral
solution
1 QL
alendronate oral
tablet 10 mg, 35 mg,
5 mg, 70 mg
1 QL
ATELVIA 4 ST; QL
BINOSTO 4 ST; QL
BONIVA ORAL 4 ST; QL
EVISTA 4
FORTEO 5 PA; $$$$; QL
FOSAMAX ORAL
TABLET 70 MG
4 ST; QL
FOSAMAX PLUS
D
4 ST; QL
ibandronate oral 1 QL
raloxifene 1 ACA
risedronate oral
tablet 150 mg, 35
mg, 5 mg
1 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
77
Drug Name Drug
Tier
Requirements
/ Limits
risedronate oral
tablet,delayed
release (dr/ec)
1 QL
TERIPARATIDE 5 PA; QL
TYMLOS 5 PA; $$$$$;
QL
OTHER RHEUMATOLOGICALS
ACTEMRA
ACTPEN
5 PA; QL
ACTEMRA
SUBCUTANEOUS
5 PA; $$$$; QL
ARAVA 4 QL
BENLYSTA
SUBCUTANEOUS
5 PA; $$$$$;
QL
DEPEN
TITRATABS
4 PA
ENBREL MINI 5 PA; $$$$$;
QL
ENBREL
SUBCUTANEOUS
RECON SOLN
5 PA; $$$$; QL
ENBREL
SUBCUTANEOUS
SOLUTION
5 PA; QL
ENBREL
SUBCUTANEOUS
SYRINGE
5 PA; $$$$; QL
ENBREL
SURECLICK
5 PA; $$$$; QL
HUMIRA 5 PA; $$$$$;
QL
HUMIRA PEN 5 PA; $$$$$;
QL
HUMIRA PEN
CROHNS-UC-HS
START
5 PA; $$$$$;
QL
Drug Name Drug
Tier
Requirements
/ Limits
HUMIRA PEN
PSOR-UVEITS-
ADOL HS
5 PA; $$$$$;
QL
HUMIRA(CF) 5 PA; $$$$$;
QL
HUMIRA(CF) PEDI
CROHNS
STARTER
5 PA; $$$$$;
QL
HUMIRA(CF) PEN
CROHNS-UC-HS
5 PA; $$$$$;
QL
HUMIRA(CF) PEN
PSOR-UV-ADOL
HS
5 PA; $$$$$;
QL
HUMIRA(CF) PEN
SUBCUTANEOUS
PEN INJECTOR
KIT 40 MG/0.4 ML
5 PA; $$$$$;
QL
KEVZARA 5 PA; $$$$$;
QL
leflunomide 2 QL
OTEZLA 5 PA; $$$$; QL
OTEZLA
STARTER ORAL
TABLETS,DOSE
PACK 10 MG (4)-
20 MG (4)-30 MG
(47)
5 PA; $$$$; QL
OTREXUP (PF)
SUBCUTANEOUS
AUTO-INJECTOR
10 MG/0.4 ML, 12.5
MG/0.4 ML, 15
MG/0.4 ML, 17.5
MG/0.4 ML, 20
MG/0.4 ML, 22.5
MG/0.4 ML, 25
MG/0.4 ML
3 ST
penicillamine 2 PA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
78
Drug Name Drug
Tier
Requirements
/ Limits
RASUVO (PF)
SUBCUTANEOUS
AUTO-INJECTOR
10 MG/0.2 ML, 12.5
MG/0.25 ML, 15
MG/0.3 ML, 17.5
MG/0.35 ML, 20
MG/0.4 ML, 22.5
MG/0.45 ML, 25
MG/0.5 ML, 30
MG/0.6 ML, 7.5
MG/0.15 ML
3 ST
RIDAURA 3
RINVOQ 5 PA; QL
SAVELLA 3 ST; QL
SIMPONI ARIA 5 PA; $$$$$
SIMPONI
SUBCUTANEOUS
PEN INJECTOR
100 MG/ML
5 PA; $$$$$;
QL
SIMPONI
SUBCUTANEOUS
SYRINGE 100
MG/ML
5 PA; $$$$$;
QL
XELJANZ ORAL
TABLET 10 MG
5 PA; $$$$$;
QL
XELJANZ ORAL
TABLET 5 MG
5 PA; $$$$; QL
XELJANZ XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
11 MG
5 PA; $$$$; QL
XELJANZ XR
ORAL TABLET
EXTENDED
RELEASE 24 HR
22 MG
5 PA; QL
OBSTETRICS &
GYNECOLOGY
Drug Name Drug
Tier
Requirements
/ Limits
DIAPHRAGMS AND OTHER NON-
ORAL CONTRACEPTIVES
CAYA
CONTOURED
4 ACA
FC2 FEMALE
CONDOM
3 ACA; OTC
FEMCAP
VAGINAL DEVICE
22 MM
3 ACA
KYLEENA 5 ACA
LILETTA 5 $$$$$; ACA
MIRENA 5 ACA
PARAGARD T
380A
5 ACA
SKYLA 5 ACA
WIDE-SEAL
DIAPHRAGM
4 ACA
ESTROGENS & PROGESTINS
ACTIVELLA
ORAL TABLET 1-
0.5 MG
4
ALORA 4 QL
amabelz 2
ANGELIQ 4
AYGESTIN 4
BIJUVA 4
camila 2 ACA
CLIMARA 4 QL
COMBIPATCH 3
covaryx 2
covaryx h.s. 2
CRINONE
VAGINAL GEL 4
%
3
deblitane 2 ACA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
79
Drug Name Drug
Tier
Requirements
/ Limits
DELESTROGEN 4
DEPO-ESTRADIOL 3
DEPO-PROVERA
INTRAMUSCULA
R SUSPENSION
150 MG/ML
4 ACA; QL
DEPO-PROVERA
INTRAMUSCULA
R SYRINGE
4 ACA; QL
DEPO-SUBQ
PROVERA 104
4 ACA; QL
DIVIGEL
TRANSDERMAL
GEL IN PACKET
0.25 MG/0.25
GRAM (0.1 %), 0.5
MG/0.5 GRAM (0.1
%), 0.75 MG/0.75
GRAM (0.1%), 1
MG/GRAM (0.1 %)
3 QL
DIVIGEL
TRANSDERMAL
GEL IN PACKET
1.25 MG/1.25
GRAM (0.1 %)
3
dotti 2 QL
DUAVEE 3
eemt 2
eemt hs 2
ELESTRIN 4 QL
errin 2 ACA
ESTRACE 4
estradiol oral 2
estradiol
transdermal
2 QL
estradiol vaginal 2
Drug Name Drug
Tier
Requirements
/ Limits
estradiol valerate
intramuscular oil 20
mg/ml, 40 mg/ml
2
estradiol-
norethindrone acet
2
ESTRING 3
estrogens-
methyltestosterone
2
EVAMIST 4 QL
FEMHRT LOW
DOSE
4
fyavolv 2
heather 2 ACA
IMVEXXY
MAINTENANCE
PACK
4 QL
IMVEXXY
STARTER PACK
4 QL
incassia 2 ACA
jencycla 2 ACA
jinteli 2
lyza 2 ACA
medroxyprogesteron
e intramuscular
2 ACA; QL
medroxyprogesteron
e oral
2
MENEST 4
MENOSTAR 4 QL
mimvey 2
MINIVELLE 4 QL
nora-be 2 ACA
norethindrone
(contraceptive)
2 ACA
norethindrone
acetate
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
80
Drug Name Drug
Tier
Requirements
/ Limits
norethindrone ac-eth
estradiol oral tablet
0.5-2.5 mg-mcg, 1-5
mg-mcg
2
norlyda 2 ACA
PREFEST 4
PREMARIN ORAL 3
PREMARIN
VAGINAL
3
PREMPHASE 3
PREMPRO 3
progesterone 5
progesterone
micronized
2
PROMETRIUM 4
PROVERA 4
sharobel 2 ACA
tulana 2 ACA
yuvafem 2
MISCELLANEOUS OB/GYN
ANNOVERA 4 QL
CERVIDIL 4
CLEOCIN
VAGINAL
4
clindamycin
phosphate vaginal
2
CLINDESSE 4
eluryng 2 ACA
etonogestrel-ethinyl
estradiol
2 ACA
fem ph 2
GYNAZOLE-1 4 QL
gynol ii 2 ACA; OTC
INTRAROSA 4
Drug Name Drug
Tier
Requirements
/ Limits
isoxsuprine 2
LUPANETA PACK
(1 MONTH)
5 PA; $$$
LUPANETA PACK
(3 MONTH)
5 PA; $$$
LYSTEDA 4
METROGEL
VAGINAL
4
metronidazole
vaginal
2
miconazole-3
vaginal suppository
2
NEXPLANON 5 ACA
NUVARING 4 ACA
NUVESSA 4
ORIAHNN 3 PA
OSPHENA 4
PREPIDIL 4
PROSTIN E2 4
RELAGARD 4
terconazole 2
TODAY
CONTRACEPTIVE
SPONGE
3 ACA; OTC
tranexamic acid oral 2
TRIMO-SAN
JELLY
3
vaginal
contraceptive foam
2 ACA; OTC
vandazole 2
VCF
CONTRACEPTIVE
FILM
3 ACA; OTC
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
81
Drug Name Drug
Tier
Requirements
/ Limits
VCF
CONTRACEPTIVE
GEL
3 ACA; OTC
xulane 2 ACA
ORAL CONTRACEPTIVES &
RELATED AGENTS
afirmelle 2 ACA
AFTERA 4 ACA; OTC;
QL
altavera (28) 2 ACA
alyacen 1/35 (28) 2 ACA
alyacen 7/7/7 (28) 2 ACA
amethia 2 ACA
amethia lo 2 ACA
amethyst (28) 2 ACA
apri 2 ACA
aranelle (28) 2 ACA
ashlyna 2 ACA
aubra 2 ACA
aubra eq 2 ACA
aurovela 1.5/30 (21) 2 ACA
aurovela 1/20 (21) 2 ACA
aurovela 24 fe 2 ACA
aurovela fe 1.5/30
(28)
2 ACA
aurovela fe 1-20
(28)
2 ACA
aviane 2 ACA
ayuna 2 ACA
azurette (28) 2 ACA
BALCOLTRA 4
balziva (28) 2 ACA
bekyree (28) 2 ACA
Drug Name Drug
Tier
Requirements
/ Limits
BEYAZ 4 ACA
blisovi 24 fe 2 ACA
blisovi fe 1.5/30 (28) 2 ACA
blisovi fe 1/20 (28) 2 ACA
briellyn 2 ACA
camrese 2 ACA
camrese lo 2 ACA
caziant (28) 2 ACA
charlotte 24 fe 2 ACA
chateal (28) 2 ACA
chateal eq (28) 2 ACA
cryselle (28) 2 ACA
cyclafem 1/35 (28) 2 ACA
cyclafem 7/7/7 (28) 2 ACA
cyred 2 ACA
cyred eq 2 ACA
dasetta 1/35 (28) 2 ACA
dasetta 7/7/7 (28) 2 ACA
daysee 2 ACA
desog-
e.estradiol/e.estradio
l
2 ACA
drospirenone-
e.estradiol-lm.fa
2 ACA
drospirenone-ethinyl
estradiol
2 ACA
econtra ez 2 ACA; OTC;
QL
econtra one-step 2 ACA; OTC;
QL
elinest 2 ACA
ELLA 4 ACA; QL
emoquette 2 ACA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
82
Drug Name Drug
Tier
Requirements
/ Limits
enpresse 2 ACA
enskyce 2 ACA
estarylla 2 ACA
ESTROSTEP FE-28 4 ACA
ethynodiol diac-eth
estradiol
2 ACA
falmina (28) 2 ACA
fayosim 2 ACA
femynor 2 ACA
GENERESS FE 4 ACA
gianvi (28) 2 ACA
hailey 2 ACA
hailey 24 fe 2 ACA
hailey fe 1.5/30 (28) 2 ACA
hailey fe 1/20 (28) 2 ACA
introvale 2 ACA
isibloom 2 ACA
jaimiess 2 ACA
jasmiel (28) 2 ACA
jolessa 2 ACA
juleber 2 ACA
junel 1.5/30 (21) 2 ACA
junel 1/20 (21) 2 ACA
junel fe 1.5/30 (28) 2 ACA
junel fe 1/20 (28) 2 ACA
junel fe 24 2 ACA
kaitlib fe 2 ACA
kalliga 2 ACA
kariva (28) 2 ACA
kelnor 1/35 (28) 2 ACA
kelnor 1-50 2 ACA
kurvelo (28) 2 ACA
Drug Name Drug
Tier
Requirements
/ Limits
l norgest/e.estradiol-
e.estrad
2 ACA
larin 1.5/30 (21) 2 ACA
larin 1/20 (21) 2 ACA
larin 24 fe 2 ACA
larin fe 1.5/30 (28) 2 ACA
larin fe 1/20 (28) 2 ACA
larissia 2 ACA
layolis fe 2 ACA
leena 28 2 ACA
lessina 2 ACA
levonest (28) 2 ACA
levonorgestrel oral
tablet 1.5 mg
2 ACA; OTC
levonorgestrel-
ethinyl estrad
2 ACA
levonorg-eth estrad
triphasic
2 ACA
levora-28 2 ACA
lillow (28) 2 ACA
LO LOESTRIN FE 3 ACA
lojaimiess 2 ACA
loryna (28) 2 ACA
LOSEASONIQUE 4 ACA
low-ogestrel (28) 2 ACA
lo-zumandimine (28) 2 ACA
lutera (28) 2 ACA
marlissa (28) 2 ACA
melodetta 24 fe 2 ACA
mibelas 24 fe 2 ACA
microgestin 1.5/30
(21)
2 ACA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
83
Drug Name Drug
Tier
Requirements
/ Limits
microgestin 1/20
(21)
2 ACA
microgestin fe 1.5/30
(28)
2 ACA
microgestin fe 1/20
(28)
2 ACA
mili 2 ACA
MIRCETTE (28) 4 ACA
mono-linyah 2 ACA
my choice 2 ACA; OTC;
QL
my way 2 ACA; OTC;
QL
NATAZIA 4 ACA
necon 0.5/35 (28) 2 ACA
new day 2 ACA; OTC;
QL
nikki (28) 2 ACA
noreth-ethinyl
estradiol-iron
2 ACA
norethindrone ac-eth
estradiol oral tablet
1-20 mg-mcg, 1.5-30
mg-mcg
2 ACA
norethindrone-
e.estradiol-iron oral
tablet 1 mg-20 mcg
(21)/75 mg (7), 1.5
mg-30 mcg (21)/75
mg (7)
2 ACA
norethindrone-
e.estradiol-iron oral
tablet,chewable
2 ACA
norgestimate-ethinyl
estradiol
2 ACA
nortrel 0.5/35 (28) 2 ACA
nortrel 1/35 (21) 2 ACA
Drug Name Drug
Tier
Requirements
/ Limits
nortrel 1/35 (28) 2 ACA
nortrel 7/7/7 (28) 2 ACA
ocella 2 ACA
opcicon one-step 2 ACA; OTC;
QL
option-2 2 ACA; OTC;
QL
orsythia 2 ACA
philith 2 ACA
pimtrea (28) 2 ACA
pirmella 2 ACA
PLAN B ONE-STEP 3 ACA; OTC;
QL
portia 28 2 ACA
previfem 2 ACA
QUARTETTE 4 ACA
reclipsen (28) 2 ACA
rivelsa 2 ACA
SAFYRAL 4 ACA
SEASONIQUE 4 ACA
setlakin 2 ACA
simliya (28) 2 ACA
simpesse 2 ACA
SLYND 4
sprintec (28) 2 ACA
sronyx 2 ACA
syeda 2 ACA
TAKE ACTION 4 ACA; OTC;
QL
tarina 24 fe 2 ACA
tarina fe 1/20 (28) 2 ACA
TAYTULLA 3 ACA
tilia fe 2 ACA
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
84
Drug Name Drug
Tier
Requirements
/ Limits
tri femynor 2 ACA
tri-estarylla 2 ACA
tri-legest fe 2 ACA
tri-linyah 2 ACA
tri-lo-estarylla 2 ACA
tri-lo-marzia 2 ACA
tri-lo-mili 2 ACA
tri-lo-sprintec 2 ACA
tri-mili 2 ACA
tri-previfem (28) 2 ACA
tri-sprintec (28) 2 ACA
trivora (28) 2 ACA
tri-vylibra 2 ACA
tri-vylibra lo 2 ACA
tydemy 2 ACA
velivet triphasic
regimen (28)
2 ACA
vienva 2 ACA
viorele (28) 2 ACA
volnea (28) 2 ACA
vyfemla (28) 2 ACA
vylibra 2 ACA
wera (28) 2 ACA
wymzya fe 2 ACA
YAZ (28) 4 ACA
zarah 2 ACA
zovia 1/35e (28) 2 ACA
zumandimine (28) 2 ACA
OXYTOCICS
methergine 2 ST; QL
methylergonovine
oral
2 ST; QL
Drug Name Drug
Tier
Requirements
/ Limits
OPHTHALMOLOGY
ANTIBIOTICS
ak-poly-bac 2
AZASITE 3
BACIGUENT 4
bacitracin
ophthalmic (eye)
2
bacitracin-
polymyxin b
ophthalmic (eye)
2
BESIVANCE 4
BETADINE
OPHTHALMIC
PREP
4
CILOXAN 4
ciprofloxacin hcl
ophthalmic (eye)
2
erythromycin
ophthalmic (eye)
2
gatifloxacin 2
gentak ophthalmic
(eye) ointment
2
gentamicin
ophthalmic (eye)
drops
2
levofloxacin
ophthalmic (eye)
2
MOXEZA 4
MOXIFLOXACIN
(PF)-BSS
INTRAVITREAL
SOLUTION
4
moxifloxacin
ophthalmic (eye)
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
85
Drug Name Drug
Tier
Requirements
/ Limits
MOXIFLOXACIN-
SOD
CHLOR,ISO(PF)
4
NATACYN 3
neomycin-
bacitracin-
polymyxin
2
neomycin-
polymyxin-
gramicidin
2
neo-polycin 2
OCUFLOX 4
ofloxacin ophthalmic
(eye)
2
polycin 2
polymyxin b sulf-
trimethoprim
2
POLYTRIM 4
tobramycin
ophthalmic (eye)
2
TOBREX 4
VIGAMOX 4
ZYMAXID 4
ANTIVIRALS
trifluridine 2
ZIRGAN 4
BETA-BLOCKERS
betaxolol ophthalmic
(eye)
2
BETIMOL 4
BETOPTIC S 4
carteolol 2
levobunolol
ophthalmic (eye)
drops 0.5 %
2
Drug Name Drug
Tier
Requirements
/ Limits
timolol maleate
ophthalmic (eye)
2
TIMOPTIC 4
TIMOPTIC-XE 4
CHOLINESTERASE INHIBITOR
MIOTICS
PHOSPHOLINE
IODIDE
3
CYCLOPLEGIC MYDRIATICS
atropine ophthalmic
(eye) drops
2
ATROPINE
OPHTHALMIC
(EYE) DROPS,
EMULSION
4
atropine ophthalmic
(eye) ointment
2
CYCLOGYL 4
cyclopentolate 2
CYCLOPEN-
TROPIC-
PHENYLEPH-
WATR
4
CYCLOPENT-
TROPIC-PHEN-
KETR-WAT
4
CYCLOP-TROP-
PROPA-PHEN-
KET-WAT
4
homatropaire 2
ISOPTO
ATROPINE
4
MYDRIACYL 4
PAREMYD 4
PHENYLEPH-
TROPICAMIDE IN
WATER
4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
86
Drug Name Drug
Tier
Requirements
/ Limits
tropicamide 2
DIRECT ACTING MIOTICS
ISOPTO CARPINE 4
MIOCHOL-E 4
pilocarpine hcl
ophthalmic (eye)
drops 1 %, 2 %, 4 %
2
MISCELLANEOUS
OPHTHALMOLOGICS
AKTEN (PF) 4
ALCAINE 4
ALOCRIL 4 ST
ALOMIDE 4 ST
altacaine 2
ALTAFLUOR
BENOX
4
azelastine
ophthalmic (eye)
2
BEOVU 5 PA
BEPREVE 3 ST
BEVACIZUMAB
INTRAVITREAL
SYRINGE 2.5
MG/0.1 ML, 3.25
MG/0.13 ML, 3.75
MG/0.15 ML
4
CEQUA 4 PA
cromolyn
ophthalmic (eye)
2
CYCLOSPORINE
IN KLARITY
4
CYSTARAN 5
DEXAMET-
MOXIFL-
KETORO-
NACL(PF)
4
Drug Name Drug
Tier
Requirements
/ Limits
epinastine 2
EYLEA
INTRAVITREAL
SOLUTION
5 PA; $$$$
EYLEA
INTRAVITREAL
SYRINGE
5
fluorescein-
proparacaine
2
KLARITY-A
(AZITHRO-
CHONDR)(PF)
4
KLARITY-B
(BETAMETH-
CHOND)(PF)
4
KLARITY-L
(LOTEPRED-
CHOND)(PF)
4
LACRISERT 4
LASTACAFT 4 ST
LIDOCAINE-
PHENYLEPHRIN-
BSS(PF)
4
lidocaine-
phenylephrn in
water
2
LUCENTIS 5 PA; $$$$$
MYDRIATIC4(TRO
P-PROP-PE-
KTRLC)
4
olopatadine
ophthalmic (eye)
2
OMIDRIA 4
OXERVATE 5 PA
PAZEO 3 ST
PHOTREXA
CROSS-LINKING
KIT
4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
87
Drug Name Drug
Tier
Requirements
/ Limits
PHOTREXA
VISCOUS
4
PREDNISOL ACE-
GATIFLOX-
BROMFEN
4
PREDNISOLN SP-
GATIFLOX-
BROMFEN
4
PREDNISOLN SP-
MOXIFLOX-
BROMFEN
4
PREDNISOLONE
ACETATE-
NEPAFENAC
4
PREDNISOLONE
SOD PH-
BROMFENAC
4
PREDNISOLONE-
MOXIFLO-
NEPAFENAC
4
PREDNISOLONE-
MOXIFLOX-
BROMFEN
4
proparacaine 2
RACEPINEPH-
LIDOCAINE-BSS
7(PF)
4
RESTASIS 3 PA; QL
RESTASIS
MULTIDOSE
3 PA; QL
tetracaine hcl 2
TETRACAINE
HCL (PF)
OPHTHALMIC
(EYE)
4
XIIDRA 3 PA; QL
ZERVIATE 4 ST
Drug Name Drug
Tier
Requirements
/ Limits
NON-STEROIDAL ANTI-
INFLAMMATORY AGENTS
ACULAR 4
ACULAR LS 4
bromfenac 2
BROMSITE 4
diclofenac sodium
ophthalmic (eye)
2
flurbiprofen sodium 2
ILEVRO 3
ketorolac
ophthalmic (eye)
2
PROLENSA 3
ORAL DRUGS FOR GLAUCOMA
acetazolamide 2
methazolamide 2
OTHER GLAUCOMA DRUGS
AZOPT 4
bimatoprost
ophthalmic (eye)
2 PA
BRIMONIDINE-
DORZOLAMIDE
(PF)
4
COMBIGAN 3
COSOPT (PF) 4
dorzolamide 2
DORZOLAMIDE
(PF)
4
dorzolamide-timolol 2
dorzolamide-timolol
(pf) ophthalmic (eye)
dropperette
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
88
Drug Name Drug
Tier
Requirements
/ Limits
DORZOLAMIDE-
TIMOLOL (PF)
OPHTHALMIC
(EYE) DROPS
4
latanoprost 2 PA
LATANOPROST
(PF)
4
LUMIGAN
OPHTHALMIC
(EYE) DROPS 0.01
%
3 PA; ST
miostat 2
MITOSOL 4
RHOPRESSA 3
ROCKLATAN 4 ST
SIMBRINZA 4
TIMOL-BRIMON-
DORZO-
LATANOP(PF)
4
TIMOLOL-
BRIMONIDI-
DORZOLAM(PF)
4
TIMOLOL-
DORZOLAMID-
LATANOP(PF)
4
TIMOLOL-
LATANOPROST(P
F)
4
TRAVATAN Z 4 ST
travoprost 2 ST
TRUSOPT 4
VYZULTA 4 ST
ZIOPTAN (PF) 3 ST
STEROID-ANTIBIOTIC
COMBINATIONS
Drug Name Drug
Tier
Requirements
/ Limits
DEXAMETH-
MOXIFLOX(PF)-
NACL,ISO
4
MAXITROL 4
neomycin-
bacitracin-poly-hc
2
neomycin-polymyxin
b-dexameth
2
neomycin-
polymyxin-hc
ophthalmic (eye)
2
neo-polycin hc 2
PRED-G 4
PRED-G S.O.P. 4
PREDNISOLONE
ACET-
GATIFLOXACIN
4
PREDNISOLONE
SOD PH-
MOXIFLOX
4
PREDNISOLONE-
MOXIFLOXACIN
HCL
4
TOBRADEX
OPHTHALMIC
(EYE)
DROPS,SUSPENSI
ON
4
TOBRADEX
OPHTHALMIC
(EYE) OINTMENT
3
TOBRADEX ST 3
tobramycin-
dexamethasone
2
TRIAMCINOLON-
MOXIFLOX-
WATR(PF)
4
ZYLET 3
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
89
Drug Name Drug
Tier
Requirements
/ Limits
STEROIDS
ALREX 3 ST
dexamethasone
sodium phosphate
ophthalmic (eye)
2
DEXTENZA 4
DEXYCU (PF) 4
DUREZOL 4
FLAREX 4
fluorometholone 2
FML LIQUIFILM 4
ILUVIEN 5 $$$$$
INVELTYS 3
LOTEMAX
OPHTHALMIC
(EYE) DROPS,GEL
3
LOTEMAX
OPHTHALMIC
(EYE)
DROPS,SUSPENSI
ON
4
LOTEMAX
OPHTHALMIC
(EYE) OINTMENT
3
LOTEMAX SM 3
loteprednol
etabonate
2
OZURDEX 5 $$$$$
PRED FORTE 4
prednisolone acetate 2
PREDNISOLONE
ACETATE (PF)
4
prednisolone sodium
phosphate
ophthalmic (eye)
2
RETISERT 5 $$$$$
Drug Name Drug
Tier
Requirements
/ Limits
YUTIQ 5
STEROID-SULFONAMIDE
COMBINATIONS
BLEPHAMIDE 4
BLEPHAMIDE
S.O.P.
4
sulfacetamide-
prednisolone
2
SULFONAMIDES
BLEPH-10 4
sulfacetamide
sodium ophthalmic
(eye)
2
SYMPATHOMIMETICS
ALPHAGAN P
OPHTHALMIC
(EYE) DROPS 0.1
%
3
ALPHAGAN P
OPHTHALMIC
(EYE) DROPS 0.15
%
4
apraclonidine 2
brimonidine 2
IOPIDINE
OPHTHALMIC
(EYE)
DROPPERETTE
4
VASOCONSTRICTOR
DECONGESTANTS
CYCLOMYDRIL 4
phenylephrine hcl
ophthalmic (eye)
2
RESPIRATORY, ALLERGY,
COUGH & COLD
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
90
Drug Name Drug
Tier
Requirements
/ Limits
ANTIHISTAMINE &
ANTIALLERGENIC AGENTS
carbinoxamine
maleate oral liquid
2
carbinoxamine
maleate oral tablet 4
mg
2
carbinoxamine
maleate oral tablet 6
mg
2 ST
cetirizine oral
solution 1 mg/ml
2
CLARINEX ORAL
TABLET
4 QL
clemastine oral
tablet 2.68 mg
2
cyproheptadine 2
desloratadine 2 QL
dexchlorpheniramin
e maleate oral
solution
1
DIPHEN ORAL
ELIXIR
4
epinephrine
injection auto-
injector 0.15 mg/0.3
ml, 0.3 mg/0.3 ml
2 QL
EPIPEN 2-PAK 3 QL
EPIPEN JR 2-PAK 3 QL
hydroxyzine hcl oral
solution 10 mg/5 ml
2
hydroxyzine hcl oral
tablet
2
hydroxyzine
pamoate
2
KARBINAL ER 4 ST
Drug Name Drug
Tier
Requirements
/ Limits
levocetirizine oral
solution
2
levocetirizine oral
tablet
2 QL
phenadoz rectal
suppository 25 mg
2
promethazine oral 2
promethazine rectal
suppository 12.5 mg,
25 mg
2
promethegan 2
RYCLORA 4
RYVENT 4 ST
SYMJEPI 3 QL
VISTARIL 4
COUGH & COLD THERAPY
benzonatate 2
BROMFED DM 4
brompheniramine-
pseudoeph-dm oral
syrup
2
CAPCOF 4
CLARINEX-D 12
HOUR
4 QL
codeine-guaifenesin 2
CODITUSSIN AC 4
CODITUSSIN DAC 4
g tussin ac 2
guaiatussin ac 2
HISTEX-AC 4
hydrocodone-
chlorpheniramine
2
hydrocodone-
homatropine oral
syrup 5-1.5 mg/5 ml
2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
91
Drug Name Drug
Tier
Requirements
/ Limits
hydrocodone-
homatropine oral
tablet
2
hydromet 2
MAR-COF CG 4
maxi-tuss ac 2
MAXI-TUSS CD 4
m-clear wc 2
M-END PE 4
NINJACOF-XG 4
OBREDON 4 ST
POLY-TUSSIN AC
ORAL LIQUID 4-
10-10 MG/5 ML
4
promethazine-
codeine
2
promethazine-dm 2
promethazine-
phenyleph-codeine
2
promethazine-
phenylephrine
2
RESPA-AR 4
SEMPREX-D 4
TESSALON
PERLES
4
TUSSICAPS ORAL
CAPSULE,EXTEN
DED RELEASE 12
HR 10-8 MG
4 ST
TUXARIN ER 4
TUZISTRA XR 4 ST
virtussin ac 2
virtussin dac 2
Z-TUSS AC 4
PULMONARY AGENTS
Drug Name Drug
Tier
Requirements
/ Limits
ACCOLATE 4
acetylcysteine 1
ADEMPAS 5 PA; $$$$$;
LA
ADRENALIN
NASAL
4
ADVAIR DISKUS 4 ST; QL
ADVAIR HFA 3 ST; QL
AIRDUO
RESPICLICK
4 ST; QL
albuterol sulfate
inhalation hfa
aerosol inhaler
1 QL
albuterol sulfate
inhalation solution
for nebulization
1
albuterol sulfate oral 1
ALVESCO 4 QL
alyq 5 PA; QL
ambrisentan 5 PA
ANORO ELLIPTA 3 QL
ARCAPTA
NEOHALER
4 QL
ARNUITY
ELLIPTA
3 QL
ASMANEX HFA 3 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
92
Drug Name Drug
Tier
Requirements
/ Limits
ASMANEX
TWISTHALER
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED 110
MCG/
ACTUATION (30),
220 MCG/
ACTUATION (120),
220 MCG/
ACTUATION (14),
220 MCG/
ACTUATION (30),
220 MCG/
ACTUATION (60)
3 QL
ATROVENT HFA 4 QL
azelastine-
fluticasone
2 ST; QL
BEVESPI
AEROSPHERE
3 QL
bosentan 5 PA
BREO ELLIPTA 3 PA; QL
BREZTRI
AEROSPHERE
3 QL
BROVANA 4 QL
budesonide
inhalation
1 QL
COMBIVENT
RESPIMAT
3 QL
cromolyn inhalation 1
CUROSURF 4
DALIRESP ORAL
TABLET 250 MCG
3 PA; QL
DALIRESP ORAL
TABLET 500 MCG
3 PA
Drug Name Drug
Tier
Requirements
/ Limits
DULERA
INHALATION HFA
AEROSOL
INHALER 100-5
MCG/ACTUATION
, 200-5
MCG/ACTUATION
3 PA; QL
DULERA
INHALATION HFA
AEROSOL
INHALER 50-5
MCG/ACTUATION
3 ST; QL
DYMISTA 3 ST; QL
ELIXOPHYLLIN
ORAL ELIXIR 80
MG/15 ML
4
epinephrine hcl 2
ESBRIET ORAL
CAPSULE
5 PA; $$$$$;
QL
ESBRIET ORAL
TABLET 267 MG
5 PA; $$$$$;
QL
ESBRIET ORAL
TABLET 801 MG
5 PA; $$$$$
FASENRA PEN 5 PA
FLOVENT DISKUS 3 QL
FLOVENT HFA 3 QL
flunisolide nasal
spray,non-aerosol
25 mcg (0.025 %)
2 ST; QL
fluticasone
propionate nasal
2 QL
FLUTICASONE
PROPION-
SALMETEROL
INHALATION
AEROSOL POWDR
BREATH
ACTIVATED
3 ST; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
93
Drug Name Drug
Tier
Requirements
/ Limits
fluticasone propion-
salmeterol
inhalation blister
with device
1 ST; QL
HAEGARDA 5 PA; $$$$$;
LA
icatibant 5 PA
INCRUSE
ELLIPTA
3 QL
ipratropium bromide
inhalation
1
ipratropium-
albuterol
1 QL
KALYDECO ORAL
GRANULES IN
PACKET 25 MG
5 PA
KALYDECO ORAL
GRANULES IN
PACKET 50 MG, 75
MG
5 PA; $$$$$;
QL
KALYDECO ORAL
TABLET
5 PA; $$$$$;
QL
levalbuterol hcl 1
LONHALA
MAGNAIR REFILL
4 QL
LONHALA
MAGNAIR
STARTER
4 QL
metaproterenol oral
syrup
1
mometasone nasal 2 ST; QL
montelukast 1
nebusal inhalation
solution for
nebulization 3 %
2
Drug Name Drug
Tier
Requirements
/ Limits
NEBUSAL
INHALATION
SOLUTION FOR
NEBULIZATION 6
%
4
NUCALA
SUBCUTANEOUS
AUTO-INJECTOR
5 PA; LA; QL
NUCALA
SUBCUTANEOUS
SYRINGE
5 PA; LA; QL
OFEV 5 PA; $$$$$;
QL
OPSUMIT 5 PA; $$$$$;
LA
ORKAMBI 5 PA; $$$$$;
QL
PERFOROMIST 3 QL
PROAIR HFA 3 QL
PROAIR
RESPICLICK
3 QL
PULMICORT
FLEXHALER
3 QL
pulmosal 2
PULMOZYME 5 $$$$
QNASL 3 QL
QVAR
REDIHALER
3 QL
REVATIO ORAL 5 PA; ST;
$$$$$; QL
RUCONEST 5 PA; $$$$$
SEEBRI
NEOHALER
4 QL
SEREVENT
DISKUS
3 QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
94
Drug Name Drug
Tier
Requirements
/ Limits
sildenafil
(pulm.hypertension)
oral suspension for
reconstitution
5 PA; QL
sildenafil
(pulm.hypertension)
oral tablet
5 PA; $$$; QL
SINUVA 5
sodium chloride
inhalation
2
SPIRIVA
RESPIMAT
3 QL
SPIRIVA WITH
HANDIHALER
3 QL
STIOLTO
RESPIMAT
3 QL
SURFAXIN 4
SYMBICORT 3 PA; QL
SYMDEKO ORAL
TABLETS,
SEQUENTIAL 100-
150 MG (D)/ 150
MG (N)
5 PA; $$$$$;
QL
SYMDEKO ORAL
TABLETS,
SEQUENTIAL 50-
75 MG (D)/ 75 MG
(N)
5 PA; QL
tadalafil (pulm.
hypertension)
5 PA; $$$$$;
QL
TAKHZYRO 5 PA
terbutaline oral 1
THEO-24 4
theophylline oral
elixir
1
theophylline oral
solution
1
Drug Name Drug
Tier
Requirements
/ Limits
theophylline oral
tablet extended
release 12 hr 300
mg, 450 mg
1
theophylline oral
tablet extended
release 24 hr
1
TRACLEER 5 PA; $$$$$;
LA
TRELEGY
ELLIPTA
INHALATION
BLISTER WITH
DEVICE 100-62.5-
25 MCG
3 QL
TRELEGY
ELLIPTA
INHALATION
BLISTER WITH
DEVICE 200-62.5-
25 MCG
3
TRIKAFTA 5 PA
TYVASO 5 PA; $$$$$
TYVASO REFILL
KIT
5 PA; $$$$$
TYVASO
STARTER KIT
5 PA; $$$$$
UTIBRON
NEOHALER
4 QL
VENTAVIS 5 PA; ST; $$$$$
VENTOLIN HFA 3 QL
wixela inhub 1 ST; QL
XHANCE 4 ST; QL
XOLAIR
SUBCUTANEOUS
RECON SOLN
5 PA; $$$$; LA;
QL
XOLAIR
SUBCUTANEOUS
SYRINGE
5 PA; LA; QL
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
95
Drug Name Drug
Tier
Requirements
/ Limits
XOPENEX 4
XOPENEX
CONCENTRATE
4
YUPELRI 3 QL
zafirlukast 1
zileuton 1 ST
ZYFLO 4 ST
UROLOGICALS
ANTICHOLINERGICS &
ANTISPASMODICS
darifenacin 2
DITROPAN XL
ORAL TABLET
EXTENDED
RELEASE 24HR 10
MG, 5 MG
4 ST
flavoxate 2
GELNIQUE
TRANSDERMAL
GEL IN PACKET
3 QL
MYRBETRIQ 3
oxybutynin chloride 2
OXYTROL 4 ST; QL
solifenacin 2
tolterodine 2
TOVIAZ 3
trospium 2
BENIGN PROSTATIC
HYPERPLASIA (BPH) THERAPY
alfuzosin 2
dutasteride 2 PA
dutasteride-
tamsulosin
2 ST
Drug Name Drug
Tier
Requirements
/ Limits
finasteride oral
tablet 5 mg
2
FLOMAX 4 ST
JALYN 4 ST
PROSCAR 4 ST
silodosin 1
tadalafil oral tablet
2.5 mg, 5 mg
2 PA; QL
tamsulosin 2
CHOLINERGIC STIMULANTS
bethanechol chloride 2
MISCELLANEOUS UROLOGICALS
CAVERJECT 3 PA; QL
CAVERJECT
IMPULSE
3 PA; QL
CYSTAGON 5 LA
EDEX 4 PA; QL
ELMIRON 3
hyophen 2
IFE-BIMIX 30/1 4
IFE-PG20 4
K-PHOS NO 2 4
K-PHOS
ORIGINAL
3
LEVITRA ORAL
TABLET 10 MG, 20
MG
4 PA; QL
methen-sod phos-
meth blue-hyos
2
ORACIT 4
phosphasal 2
potassium citrate 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
96
Drug Name Drug
Tier
Requirements
/ Limits
RENACIDIN
IRRIGATION
SOLUTION 1980.6
MG-59.4 MG-
980.4MG/30ML
3
SHOHL'S
MODIFIED
4
sildenafil 2 PA; QL
STAXYN 4 PA; QL
STENDRA 4 PA; QL
tadalafil oral tablet
10 mg, 20 mg
2 PA; QL
TRI-MIX
(PAPAVRN-
PHNTLMN-PGE1)
4
URELLE 4
uretron d-s oral
tablet 81.6-10.8-40.8
mg
2
URIBEL 4
urimar-t 2
urin ds 2
uro-458 2
UROCIT-K 10 4
UROCIT-K 15 4
UROCIT-K 5 4
urogesic-blue 2
uro-mp 2
UROQID-ACID
NO.2
4
uryl 2
ustell 2
utira-c 2
vardenafil 1 PA; QL
URINARY ANESTHETICS
Drug Name Drug
Tier
Requirements
/ Limits
phenazopyridine
oral tablet 100 mg,
200 mg
2
PYRIDIUM 4
VITAMINS, HEMATINICS &
ELECTROLYTES
ELECTROLYTES
calcium 500 + d oral
tablet,chewable
1 ACA; OTC
calcium 600 + d(3)
oral tablet 600
mg(1,500mg) -200
unit, 600
mg(1,500mg) -400
unit
1 ACA; OTC
calcium citrate-
vitamin d3 oral
tablet 315 mg-5 mcg
(200 unit)
1 ACA; OTC
calcium citrate-
vitamin d3 oral
tablet 315 mg-6.25
mcg (250 unit)
1 OTC
EFFER-K ORAL
TABLET,
EFFERVESCENT
10 MEQ, 20 MEQ
4
effer-k oral tablet,
effervescent 25 meq
2
GALZIN 4
klor-con 2
klor-con 10 2
klor-con 8 2
klor-con m10 2
klor-con m15 2
klor-con m20 2
klor-con/ef 2
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
97
Drug Name Drug
Tier
Requirements
/ Limits
K-TAB ORAL
TABLET
EXTENDED
RELEASE 10 MEQ,
20 MEQ
4
k-tab oral tablet
extended release 8
meq
2
lugols oral 2
oyster shell + d3 1 ACA; OTC
oyster shell calcium-
vit d3 oral tablet 500
mg(1,250mg) -400
unit
1 ACA; OTC
POTABA ORAL
CAPSULE
4
potassium chloride
oral
2
strong iodine oral 2
MISCELLANEOUS VITAMINS,
HEMATINICS, & ELECTROLYTES
DOJOLVI 5 PA; LA
VITAMINS & HEMATINICS
b complex 1 (with
folic acid)
2 ACA; OTC
b complex-vitamin
b12
2 ACA; OTC
b complex-vitamin c-
folic acid oral tablet
2 ACA; OTC
balanced b-100
complex oral tablet
extended release 100
mg
2 ACA; OTC
balanced b-100 oral
tablet 0.4 mg
2 ACA; OTC
balanced b-50 oral
tablet
2 ACA; OTC
Drug Name Drug
Tier
Requirements
/ Limits
bal-care dha 1
BAL-CARE DHA
ESSENTIAL
4
b-complex with
vitamin c oral tablet
2 ACA; OTC
cholecalciferol
(vitamin d3) oral
capsule 25 mcg
(1,000 unit)
1 ACA; OTC
cholecalciferol
(vitamin d3) oral
tablet 25 mcg (1,000
unit)
2 OTC
CITRANATAL
(DUAL-IRON)
4
CITRANATAL 90
DHA (ALGAL OIL)
4
CITRANATAL
ASSURE ORAL
COMBO PACK 35
MG IRON-1 MG -
50 MG-300 MG
4
CITRANATAL B-
CALM (FE GLUC)
4
CITRANATAL
BLOOM
4
CITRANATAL
DHA (ALGAL OIL)
4
CITRANATAL
HARMONY (IRON
FUM)
4
classic prenatal 1 ACA; OTC
c-nate dha 1
complete natal dha 1
complex b-100 oral
tablet extended
release
2 ACA; OTC
CONCEPT DHA 4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
98
Drug Name Drug
Tier
Requirements
/ Limits
CONCEPT OB 4
cyanocobalamin
(vitamin b-12)
injection
2
dialyvite 800 oral
tablet
2 ACA; OTC
DRISDOL ORAL
CAPSULE
4
DUET DHA
BALANCED ORAL
COMBO PACK 25
MG IRON-1 MG -
267 MG-233 MG
4
DUET DHA WITH
OMEGA-3 ORAL
COMBO PACK 25
MG IRON-1 MG -
400 MG
4
elite-ob 1
ENBRACE HR 4
ergocalciferol
(vitamin d2) oral
capsule 1,250 mcg
(50,000 unit)
2
FLORIVA
(FLUORIDE-
VITAMIN D3)
4 OTC
fluoride (sodium)
oral drops
1 ACA; OTC
fluoride (sodium)
oral tablet,chewable
1 ACA; OTC
fluoritab oral
tablet,chewable
1 ACA; OTC
FLURA-DROPS 4 OTC
FOLET ONE 4
folic acid oral tablet
1 mg
1
Drug Name Drug
Tier
Requirements
/ Limits
folic acid oral tablet
400 mcg, 800 mcg
1 ACA; OTC
folivane-ob 1
foltabs 800 2 ACA; OTC
full spectrum b-
vitamin c
2 ACA; OTC
hydroxocobalamin 2
kobee 2 ACA; OTC
KOSHER
PRENATAL PLUS
IRON
4
kpn oral tablet 1 ACA; OTC
ludent fluoride 1 ACA; OTC
MARNATAL-F 4
MECOBALAMIN
(VITAMIN B12)
INJECTION
4
m-natal plus 1
multi-vitamin with
fluoride
1 ACA; OTC
multivitamins with
fluoride
1 ACA; OTC
mvc-fluoride 1 ACA; OTC
mynatal 1
mynatal advance 1
mynatal plus 1
mynatal-z 1
mynate 90 plus 1
NASCOBAL 3
NATACHEW (FE
BIS-GLYCINATE)
4
natural b-100
complex
2 ACA; OTC
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
99
Drug Name Drug
Tier
Requirements
/ Limits
NEEVODHA
(WITH ALGAL
OIL)
4
NESTABS 4
NESTABS ABC 4
NESTABS DHA 4
NESTABS ONE 4
newgen 1
OB COMPLETE
ONE
4
OB COMPLETE
ORAL TABLET
4
OB COMPLETE
PETITE
4
OB COMPLETE
PREMIER
4
OB COMPLETE
WITH DHA
4
obstetrix dha 1
OBSTETRIX EC 4
OBSTETRIX ONE 4
OBTREX DHA 4
one daily prenatal
oral combo pack 28-
800-440 mg-mcg-mg
1 ACA; OTC
perry prenatal 1 ACA; OTC
pnv 29-1 1
pnv-dha 1
pnv-dha + docusate 1
pnv-omega 1
pnv-select 1
pr natal 400 1
pr natal 400 ec 1
pr natal 430 1
Drug Name Drug
Tier
Requirements
/ Limits
pr natal 430 ec 1
PREGENNA 4
prena1 chew 1
prena1 pearl 1
prena1 true 1
prenaissance 1
prenaissance plus 1
PRENATA 4
prenatabs fa 1
prenatabs rx 1
prenatal complete 1 ACA; OTC
prenatal formula
oral tablet 28 mg
iron- 800 mcg
1 ACA; OTC
prenatal multi-dha
(algal oil)
1 ACA; OTC
prenatal one daily 1 ACA; OTC
prenatal oral tablet
28 mg iron- 800 mcg
1 ACA; OTC
prenatal plus 1
prenatal plus
(calcium carb)
1
PRENATAL PLUS
DHA ORAL
COMBO PACK
4
prenatal vitamin
oral tablet 27 mg
iron- 0.8 mg
1 ACA; OTC
prenatal vitamin
plus low iron
1
prenatal vitamin
with minerals
1 ACA; OTC
prenatal vits96-iron
fum-folic
1 ACA; OTC
prenatal-u 1
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
100
Drug Name Drug
Tier
Requirements
/ Limits
PRENATE AM 4
PRENATE
CHEWABLE
4
PRENATE DHA
(FERR ASP
GLYCIN)
4
PRENATE ELITE
(IRON ASP GLYC)
4
PRENATE
ENHANCE
4
PRENATE
ESSENTIAL(IRON-
ASP-GL)
4
PRENATE MINI
(FERR ASP
GLYCIN)
4
PRENATE PIXIE 4
PRENATE
RESTORE
4
PRENATE STAR 4
preplus 1
pretab 1
PRIMACARE 4
PROVIDA OB 4
PUREFE OB PLUS 4
rena-vite 2 ACA; OTC
R-NATAL OB 4
SELECT-OB 4
SELECT-OB
(FOLIC ACID)
4
SELECT-OB +
DHA
4
se-natal 19 chewable 1
se-natal-19 1
stress formula 2 ACA; OTC
Drug Name Drug
Tier
Requirements
/ Limits
stress formula with
iron
2 ACA; OTC
stress formula with
iron(sulf)
2 ACA; OTC
super b complex-
vitamin c
2 ACA; OTC
super b maxi
complex
2 ACA; OTC
super quints 2 ACA; OTC
super quints b-50 2 ACA; OTC
taron-c dha 1
taron-prex prenatal-
dha
1
THRIVITE RX 4
TRICARE 4
TRIFERIC 4
trinatal rx 1 1
trinate 1
TRINAZ 4
TRISTART DHA 4
triveen-duo dha 1
tri-vitamin with
fluoride
1 ACA; OTC
VINATE DHA RF 4
virt-c dha 1
virt-nate dha 1
virt-pn dha 1
virt-pn plus 1
VITAFOL FE PLUS 4
VITAFOL FE+
(WITH
DOCUSATE)
4
VITAFOL
GUMMIES
4
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
101
Drug Name Drug
Tier
Requirements
/ Limits
VITAFOL NANO 4
VITAFOL ULTRA 4
VITAFOL-OB 4
VITAFOL-
OB+DHA
4
VITAFOL-ONE 4
VITAMED MD
ONE RX
4
VITAMEDMD
REDICHEW RX
4
vitamin b complex
oral tablet
2 ACA; OTC
vitamin b complex-
folic acid oral tablet
2 ACA; OTC
vitamin d3 oral
capsule 10 mcg (400
unit)
1 ACA; OTC
Drug Name Drug
Tier
Requirements
/ Limits
vitamin d3 oral
tablet 10 mcg (400
unit)
1 ACA; OTC
vitamin d3 oral
tablet,chewable 25
mcg (1,000 unit)
1 ACA; OTC
vitamins a,c,d and
fluoride
1 ACA; OTC
VITAPEARL 4
VITATRUE 4
vp-ch-pnv 1
VP-PNV-DHA 4
zatean-pn dha 1
zatean-pn plus 1
zingiber 1
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
102
Index
A abacavir .................................. 9
abacavir-lamivudine ............... 9
abacavir-lamivudine-
zidovudine .......................... 9
ABILIFY MYCITE .............. 30
abiraterone ............................ 16
ABSORICA .......................... 45
ABSORICA LD ................... 45
acamprosate .......................... 53
acarbose ................................ 65
ACCOLATE......................... 91
ACCU-CHEK GUIDE L1-L2
CTRL SOL ....................... 58
ACCU-CHEK SMARTVIEW
CONTRL SOL ................. 58
ACCUPRIL .......................... 35
ACCURETIC ....................... 35
ACCUTREND GLUCOSE
CONTROL ....................... 58
acebutolol ............................. 35
acetaminophen-caff-
dihydrocod ........................ 25
acetaminophen-codeine ........ 25
acetazolamide ....................... 87
acetic acid ....................... 53, 56
acetylcysteine ....................... 91
acitretin ................................. 43
ACTEMRA .......................... 77
ACTEMRA ACTPEN .......... 77
ACTHAR ............................. 56
ACTHIB (PF) ....................... 74
ACTICLATE ........................ 15
ACTIGALL .......................... 67
ACTIMMUNE ..................... 74
ACTIQ .................................. 25
ACTIVELLA ....................... 78
ACTONEL ........................... 76
ACTOPLUS MET ................ 65
ACTOS ................................. 65
ACULAR ............................. 87
ACULAR LS ........................ 87
acyclovir ........................... 9, 50
ACZONE .............................. 45
ADACEL(TDAP
ADOLESN/ADULT)(PF) 74
ADALAT CC ....................... 36
adapalene .............................. 45
ADAPALENE ...................... 45
adapalene-benzoyl peroxide . 45
ADASUVE ........................... 30
ADDERALL XR .................. 30
ADDYI ................................. 30
adefovir ................................... 9
ADEMPAS ........................... 91
ADHANSIA XR................... 30
ADRENALIN ....................... 91
adult aspirin regimen ............ 28
ADVAIR DISKUS ............... 91
ADVAIR HFA ..................... 91
ADVATE.............................. 39
ADVOCATE LOW
CONTROL ....................... 58
ADVOCATE REDI-CODE+
CTRL LOW ...................... 58
ADYNOVATE ..................... 39
ADZENYS ER ..................... 30
ADZENYS XR-ODT ........... 30
AEMCOLO .......................... 13
AFINITOR ........................... 16
AFINITOR DISPERZ .......... 16
afirmelle................................ 81
AFLURIA QD 2020-21(3YR
UP)(PF) ............................ 74
AFLURIA QD 2020-21(6-
35MO)(PF) ....................... 74
AFLURIA QUAD 2020-
2021(6MO UP) ................. 74
AFREZZA ............................ 62
AFSTYLA ............................ 39
AFTERA .............................. 81
AGAMATRIX CONTROL
HIGH ................................ 58
AGRYLIN ............................ 53
AIMOVIG AUTOINJECTOR
.......................................... 23
AIRDUO RESPICLICK....... 91
AJOVY AUTOINJECTOR .. 23
AJOVY SYRINGE............... 23
AKLIEF ................................ 46
ak-poly-bac ........................... 84
AKTEN (PF) ........................ 86
ala-cort .................................. 50
ALA-SCALP ........................ 50
albendazole ........................... 13
ALBENZA ........................... 13
albuterol sulfate .................... 91
ALCAINE ............................. 86
alclometasone ....................... 50
ALDACTAZIDE .................. 36
ALDACTONE ...................... 36
ALDARA ............................. 74
ALECENSA ......................... 17
alendronate ........................... 76
ALFERON N ........................ 74
alfuzosin ............................... 95
ALINIA ................................ 13
aliskiren ................................ 36
ALKERAN ........................... 17
allopurinol ............................. 76
ALLZITAL ........................... 25
almotriptan malate ................ 23
ALOCRIL ............................. 86
ALOMIDE ............................ 86
alophen (bisacodyl) .............. 67
ALORA ................................ 78
alosetron ............................... 67
ALPHAGAN P ..................... 89
alprazolam ............................ 30
alprazolam intensol ............... 30
ALPROLIX .......................... 39
ALREX ................................. 89
ALTABAX ........................... 48
altacaine ................................ 86
ALTACE .............................. 36
ALTAFLUOR BENOX ........ 86
altavera (28) .......................... 81
ALTRENO ........................... 46
ALUNBRIG ......................... 17
ALVESCO ............................ 91
alyacen 1/35 (28) .................. 81
alyacen 7/7/7 (28) ................. 81
alyq ....................................... 91
amabelz ................................. 78
amantadine hcl ........................ 9
AMARYL ............................. 65
ambrisentan ........................... 91
amcinonide ........................... 50
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
103
AMELUZ ............................. 44
AMERGE ............................. 23
amethia ................................. 81
amethia lo ............................. 81
amethyst (28) ........................ 81
AMICAR .............................. 39
amiloride............................... 36
amiloride-hydrochlorothiazide
.......................................... 36
aminocaproic acid ................ 39
amiodarone ........................... 35
AMITIZA ............................. 67
amitriptyline ......................... 30
amitriptyline-chlordiazepoxide
.......................................... 30
amlodipine ............................ 36
amlodipine-atorvastatin ........ 41
amlodipine-benazepril .......... 36
amlodipine-olmesartan ......... 36
amlodipine-valsartan ............ 36
amlodipine-valsartan-hcthiazid
.......................................... 36
ammonium lactate ................ 44
amnesteem ............................ 46
amoxapine ............................ 30
amoxicil-clarithromy-lansopraz
.......................................... 71
amoxicillin ............................ 14
amoxicillin-pot clavulanate .. 14
amphetamine sulfate ............. 30
ampicillin .............................. 14
AMZEEQ ............................. 46
ANADROL-50 ..................... 63
ANAFRANIL ....................... 30
anagrelide ............................. 53
ANA-LEX KIT .................... 67
ANALPRAM-HC..... 43, 67, 68
ANALPRAM-HC SINGLES68
ANAPROX DS .................... 28
anaspaz ................................. 66
anastrozole ............................ 17
ANCOBON ............................ 9
ANDRODERM .................... 63
ANDROGEL ........................ 63
ANDROID ........................... 63
ANGELIQ ............................ 78
ANNOVERA ....................... 80
ANORO ELLIPTA .............. 91
ANTARA ............................. 41
anucort-hc ............................. 68
apexicon e ............................. 50
APLENZIN .......................... 30
APOKYN ............................. 22
apraclonidine ........................ 89
aprepitant .............................. 68
apri ........................................ 81
APRISO ................................ 68
APTENSIO XR .................... 30
APTIOM ............................... 20
APTIVUS ............................... 9
APTIVUS (WITH VITAMIN
E) ........................................ 9
aqua care sodium chloride .... 53
aqua care sterile water .......... 53
ARAKODA .......................... 13
aranelle (28) .......................... 81
ARAVA ................................ 77
ARAZLO .............................. 46
ARCALYST ......................... 74
ARCAPTA NEOHALER ..... 91
ARESTIN ............................. 55
ARICEPT ............................. 24
ARIKAYCE ......................... 13
aripiprazole ........................... 30
ARIXTRA ............................ 39
armodafinil ........................... 30
ARMOUR THYROID ......... 66
ARNUITY ELLIPTA ........... 91
AROMASIN ......................... 17
ARTHROTEC 50 ................. 28
ARTHROTEC 75 ................. 28
ARYMO ER ......................... 25
ascomp with codeine ............ 25
ashlyna .................................. 81
ASMANEX HFA ................. 91
ASMANEX TWISTHALER 92
aspirin ................................... 28
aspirin low dose .................... 28
aspirin-dipyridamole ............ 39
ASPIRIN-OMEPRAZOLE .. 39
aspir-trin ............................... 28
ASSURE 4 CONTROL
SOLUTION ...................... 58
ASSURE DOSE NORMAL
CONTROL ....................... 58
ASSURE PRISM CONTROL
1-2 SOLN ......................... 58
ASTAGRAF XL ................... 17
AT HOME A1C ................... 58
atazanavir ................................ 9
ATELVIA ............................. 76
atenolol ................................. 36
atenolol-chlorthalidone ......... 36
ATIVAN ............................... 31
atomoxetine .......................... 31
atorvastatin ........................... 41
atovaquone ............................ 13
atovaquone-proguanil ........... 13
atropine ................................. 85
ATROPINE .......................... 85
ATROVENT HFA ................ 92
AUBAGIO ............................ 73
aubra ..................................... 81
aubra eq ................................ 81
AUGMENTIN ...................... 14
AUGMENTIN XR ............... 14
aurovela 1.5/30 (21) .............. 81
aurovela 1/20 (21) ................. 81
aurovela 24 fe ....................... 81
aurovela fe 1.5/30 (28) ......... 81
aurovela fe 1-20 (28) ............ 81
AURYXIA ............................ 68
AUSTEDO ........................... 24
AUTOJECT 2 INJECTION
DEVICE ........................... 58
AUTOPEN 1 TO 21 UNITS 58
AUTOSOFT 30 .................... 58
AUTOSOFT 90 .................... 58
AUTOSOFT XC INFUSION
SET 23 .............................. 58
AVANDIA ........................... 65
avar ....................................... 46
AVAR ................................... 46
AVAR LS ............................. 46
AVAR-E GREEN ................. 46
AVAR-E LS ......................... 46
aviane .................................... 81
avidoxy ................................. 15
AVIDOXY DK ..................... 15
avita ...................................... 46
AVITA .................................. 46
AVONEX ............................. 73
AYGESTIN .......................... 78
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
104
ayuna .................................... 81
AYVAKIT ............................ 17
AZASAN .............................. 17
AZASITE ............................. 84
azathioprine .......................... 17
azelaic acid ........................... 46
azelastine ........................ 55, 86
azelastine-fluticasone ........... 92
AZELEX .............................. 46
AZILECT ............................. 22
azithromycin ......................... 12
AZOPT ................................. 87
AZULFIDINE ...................... 68
AZULFIDINE EN-TABS .... 68
azurette (28).......................... 81
B b complex 1 (with folic acid) 97
b complex-vitamin b12......... 97
b complex-vitamin c-folic acid
.......................................... 97
BACIGUENT ....................... 84
bacitracin .............................. 84
bacitracin-polymyxin b ........ 84
baclofen ................................ 24
BACTRIM ............................ 15
BACTRIM DS...................... 15
balanced b-100 ..................... 97
balanced b-100 complex....... 97
balanced b-50 ....................... 97
bal-care dha .......................... 97
BAL-CARE DHA
ESSENTIAL..................... 97
BALCOLTRA ...................... 81
balsalazide ............................ 68
BALVERSA ......................... 17
balziva (28) ........................... 81
BANZEL .............................. 20
BAQSIMI ............................. 57
BARACLUDE ....................... 9
BASAGLAR KWIKPEN U-
100 INSULIN ................... 62
BAXDELA ........................... 15
bayer aspirin ......................... 28
BCG VACCINE, LIVE (PF) 75
b-complex with vitamin c ..... 97
BD INTEGRA NEEDLE ..... 58
BD MICROTAINER
LANCET .......................... 58
BD SPECIALTY USE
NEEDLES ........................ 58
BD ULTRA FINE LANCETS
.......................................... 58
BD ULTRA-FINE NANO
PEN NEEDLE .................. 58
bekyree (28) .......................... 81
BELBUCA ........................... 25
belladonna alkaloids-opium . 67
BELSOMRA ........................ 31
benazepril ............................. 36
benazepril-hydrochlorothiazide
.......................................... 36
BENEFIX ............................. 39
BENLYSTA ......................... 77
BENZACLIN ....................... 46
BENZACLIN PUMP ........... 46
BENZAMYCIN ................... 46
benzepro ............................... 46
BENZEPRO
(MICROSPHERES) ......... 46
BENZNIDAZOLE ............... 13
benzonatate ........................... 90
benzoyl peroxide .................. 46
benztropine ........................... 22
BEOVU ................................ 86
BEPREVE ............................ 86
beser...................................... 50
BESIVANCE........................ 84
BETADINE OPHTHALMIC
PREP ................................ 84
betamethasone dipropionate . 50
betamethasone valerate......... 50
betamethasone, augmented ... 50
BETAPACE ......................... 35
BETAPACE AF ................... 35
BETASERON ...................... 73
betaxolol ......................... 36, 85
bethanechol chloride............. 95
BETHKIS ............................. 13
BETIMOL ............................ 85
BETOPTIC S ........................ 85
BEVACIZUMAB ................. 86
BEVESPI AEROSPHERE ... 92
bexarotene ............................ 17
BEXSERO ............................ 75
BEYAZ ................................. 81
bicalutamide ......................... 17
BIDIL ................................... 36
BIJUVA ................................ 78
BIKTARVY ......................... 10
BILTRICIDE ........................ 13
bimatoprost ........................... 87
BINOSTO ............................. 76
BIOTHRAX ......................... 75
bisacodyl ............................... 68
bisa-lax (bisacodyl) .............. 68
bisoprolol fumarate ............... 36
bisoprolol-hydrochlorothiazide
.......................................... 36
BLEPH-10 ............................ 89
BLEPHAMIDE .................... 89
BLEPHAMIDE S.O.P. ......... 89
blisovi 24 fe .......................... 81
blisovi fe 1.5/30 (28) ............ 81
blisovi fe 1/20 (28) ............... 81
BLOOD GLUCOSE
CONTROL, NORMAL .... 58
BONIVA ............................... 76
BONJESTA .......................... 68
BOOSTRIX TDAP ............... 75
bosentan ................................ 92
BOSULIF ............................. 17
BOTOX ................................ 75
bp 10-1 .................................. 46
BRAFTOVI .......................... 17
BREEZE 2 CONTROL
SOLUTION,HIGH ........... 58
BREO ELLIPTA .................. 92
BREZTRI AEROSPHERE ... 92
briellyn .................................. 81
BRILINTA ........................... 39
brimonidine ........................... 89
BRIMONIDINE-
DORZOLAMIDE (PF) ..... 87
BRIVIACT ........................... 20
BROMFED DM ................... 90
bromfenac ............................. 87
bromocriptine ....................... 22
brompheniramine-pseudoeph-
dm ..................................... 90
BROMSITE .......................... 87
BROVANA .......................... 92
BRUKINSA .......................... 17
BRYHALI ............................ 50
budesonide ...................... 68, 92
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
105
bumetanide ........................... 36
BUPHENYL......................... 53
buprenorphine....................... 25
buprenorphine hcl ................. 26
buprenorphine-naloxone....... 28
bupropion hcl........................ 31
BUPROPION HCL .............. 31
bupropion hcl (smoking deter)
.......................................... 54
buspirone .............................. 31
butalbital compound w/codeine
.......................................... 26
butalbital-acetaminop-caf-cod
.......................................... 26
butalbital-acetaminophen ..... 26
butalbital-acetaminophen-caff
.......................................... 26
butalbital-aspirin-caffeine .... 26
butorphanol........................... 28
BYDUREON ........................ 65
BYDUREON BCISE ........... 65
BYETTA .............................. 65
BYNFEZIA .......................... 17
BYSTOLIC .......................... 36
C cabergoline ........................... 63
CABLIVI .............................. 39
CABOMETYX..................... 17
CADUET .............................. 42
CAFERGOT ......................... 23
caffeine citrate ...................... 53
CALAN SR .......................... 36
calcipotriene ......................... 43
calcipotriene-betamethasone 44
calcitonin (salmon) ............... 63
calcitriol .......................... 44, 63
calcium 500 + d .................... 96
calcium 600 + d(3) ............... 96
calcium acetate(phosphat bind)
.......................................... 68
calcium citrate-vitamin d3 .... 96
CALQUENCE ...................... 17
CAMBIA .............................. 28
camila ................................... 78
camrese ................................. 81
camrese lo ............................. 81
CANASA ............................. 68
candesartan ........................... 36
candesartan-hydrochlorothiazid
.......................................... 36
CANTHARIDIN IN
ACETONE ....................... 44
CAPCOF .............................. 90
capecitabine .......................... 17
CAPEX ................................. 50
CAPRELSA.......................... 17
captopril ................................ 36
captopril-hydrochlorothiazide
.......................................... 36
CARAFATE ......................... 71
CARBAGLU ........................ 53
carbamazepine ...................... 20
CARBATROL ...................... 20
carbidopa .............................. 22
carbidopa-levodopa .............. 22
carbidopa-levodopa-
entacapone ........................ 22
carbinoxamine maleate ......... 90
CARDIZEM ......................... 36
CARDIZEM CD................... 36
CARDIZEM LA ................... 36
CARDURA .......................... 36
CARDURA XL .................... 36
CARESENS CONTROL A
NORMAL ......................... 58
carisoprodol .......................... 25
carisoprodol-aspirin .............. 25
carisoprodol-aspirin-codeine 25
CARNITOR.......................... 53
CARNITOR (SUGAR-FREE)
.......................................... 53
CAROSPIR .......................... 36
carteolol ................................ 85
cartia xt ................................. 36
carvedilol .............................. 36
carvedilol phosphate ............. 36
CASODEX ........................... 17
CATAPRES.......................... 36
CATAPRES-TTS-1 .............. 36
CATAPRES-TTS-2 .............. 36
CATAPRES-TTS-3 .............. 36
CAVERJECT ....................... 95
CAVERJECT IMPULSE ..... 95
CAYA CONTOURED ......... 78
CAYSTON ........................... 13
caziant (28) ........................... 81
cefaclor ................................. 12
cefadroxil .............................. 12
cefdinir .................................. 12
cefditoren pivoxil .................. 12
cefixime ................................ 12
cefpodoxime ......................... 12
cefprozil ................................ 12
cefuroxime axetil .................. 12
celecoxib ............................... 28
CELLCEPT .......................... 17
CELONTIN .......................... 21
CENTANY ........................... 48
CENTANY AT ..................... 48
cephalexin ............................. 12
CEPROTIN (BLUE BAR) ... 39
CEPROTIN (GREEN BAR) 39
CEQUA ................................ 86
CEQUR SIMPLICITY ......... 58
CERDELGA ......................... 63
CERVIDIL ........................... 80
cetirizine ............................... 90
cevimeline ............................. 53
CHANTIX ............................ 54
CHANTIX CONTINUING
MONTH BOX .................. 54
CHANTIX STARTING
MONTH BOX .................. 54
charlotte 24 fe ....................... 81
chateal (28) ........................... 81
chateal eq (28) ...................... 81
CHEMET .............................. 53
CHENODAL ........................ 68
children's aspirin ................... 28
chlordiazepoxide hcl ............. 31
chlordiazepoxide-clidinium .. 67
chlorhexidine gluconate ........ 55
chloroquine phosphate .......... 13
chlorpromazine ..................... 31
chlorthalidone ....................... 36
chlorzoxazone ....................... 25
CHOLBAM .......................... 68
cholecalciferol (vitamin d3) . 97
cholestyramine (with sugar) . 42
cholestyramine light ............. 42
choline,magnesium salicylate
.......................................... 28
ciclodan ................................. 49
CICLODAN KIT .................. 49
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
106
ciclopirox .............................. 49
ciclopirox-ure-camph-menth-
euc .................................... 49
cilostazol............................... 39
CILOXAN ............................ 84
CIMDUO .............................. 10
cimetidine ............................. 71
cimetidine hcl ....................... 71
cinacalcet .............................. 63
CIPRO .................................. 15
CIPRO HC............................ 56
CIPRODEX .......................... 56
ciprofloxacin......................... 15
ciprofloxacin hcl ....... 15, 56, 84
ciprofloxacin-dexamethasone
.......................................... 56
citalopram ............................. 31
CITRANATAL (DUAL-
IRON) ............................... 97
CITRANATAL 90 DHA
(ALGAL OIL) .................. 97
CITRANATAL ASSURE .... 97
CITRANATAL B-CALM (FE
GLUC) .............................. 97
CITRANATAL BLOOM ..... 97
CITRANATAL DHA
(ALGAL OIL) .................. 97
CITRANATAL HARMONY
(IRON FUM) .................... 97
citrate of magnesia ............... 68
citroma .................................. 68
claravis ................................. 46
CLARINEX .......................... 90
CLARINEX-D 12 HOUR .... 90
clarithromycin ...................... 12
classic prenatal ..................... 97
clearlax ................................. 68
clemastine ............................. 90
CLENPIQ ............................. 68
CLEO 90 INFUSION SET 24
.......................................... 58
CLEOCIN............................. 80
CLEOCIN HCL.................... 13
CLEOCIN PEDIATRIC ....... 13
CLEOCIN T ......................... 46
CLEVER CHOICE LEVEL 2
CONTROL ....................... 58
CLIMARA ........................... 78
CLINDACIN ETZ ................ 46
clindacin p ............................ 46
CLINDACIN PAC ............... 46
clindamycin hcl .................... 13
clindamycin pediatric ........... 13
clindamycin phosphate ... 46, 80
clindamycin-benzoyl peroxide
.......................................... 46
clindamycin-tretinoin ........... 46
CLINDESSE ........................ 80
CLINPRO 5000 .................... 55
clobazam ............................... 21
clobetasol .............................. 50
clobetasol-emollient ............. 50
CLOBEX .............................. 50
clodan ................................... 50
CLODAN KIT ...................... 50
CLODERM .......................... 50
clomipramine ........................ 31
clonazepam ........................... 21
clonidine ............................... 36
clonidine hcl ................... 31, 36
clopidogrel ............................ 39
clorazepate dipotassium ....... 31
clotrimazole ...................... 9, 49
clotrimazole-betamethasone . 49
clovique ................................ 53
clozapine ............................... 31
CLOZARIL .......................... 31
c-nate dha ............................. 97
COAGADEX........................ 39
COARTEM .......................... 13
COCAINE ............................ 48
codeine sulfate ...................... 26
codeine-butalbital-asa-caff ... 26
codeine-guaifenesin .............. 90
CODITUSSIN AC ................ 90
CODITUSSIN DAC ............. 90
COLAZAL ........................... 68
colchicine.............................. 76
COLCRYS............................ 76
colesevelam .......................... 42
COLESTID ........................... 42
COLESTID FLAVORED .... 42
colestipol .............................. 42
COMBIGAN ........................ 87
COMBIPATCH .................... 78
COMBIVENT RESPIMAT . 92
COMBIVIR .......................... 10
COMETRIQ ......................... 17
COMFORT INFUSION SET
43 ...................................... 58
COMFORT SHORT INSULIN
PUMP 23 .......................... 58
COMPAZINE ....................... 68
complete natal dha ................ 97
complex b-100 ...................... 97
compro .................................. 68
COMTAN ............................. 22
CONCEPT DHA .................. 97
CONCEPT OB ..................... 98
CONCERTA ......................... 31
CONDYLOX ........................ 45
CONSENSI ........................... 36
constulose ............................. 68
CONTACT DETACH INFUS
SET 23 .............................. 59
CONTOUR CONTROL
SOLUTION, NML ........... 59
CONTOUR NEXT LEV 2
CONTROL SOL ............... 59
CONZIP ................................ 28
COOL CONTROL A
SOLUTION ...................... 59
COPAXONE ........................ 73
COPIKTRA .......................... 17
CORDRAN ........................... 51
CORDRAN TAPE LARGE
ROLL ................................ 50
COREG CR .......................... 36
coremino ............................... 15
CORGARD ........................... 36
CORLANOR ........................ 43
CORTANE-B ....................... 45
CORTEF ............................... 56
CORTENEMA ..................... 68
cortisone ............................... 56
CORTISPORIN .................... 48
CORTISPORIN-TC ............. 56
COSENTYX ......................... 44
COSENTYX (2 SYRINGES)
.......................................... 44
COSENTYX PEN ................ 44
COSENTYX PEN (2 PENS) 44
COSOPT (PF) ....................... 87
COTELLIC ........................... 17
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
107
COTEMPLA XR-ODT ........ 31
covaryx ................................. 78
covaryx h.s. .......................... 78
CREON ................................ 68
CRESEMBA .......................... 9
CRINONE ............................ 78
CRIXIVAN .......................... 10
cromolyn................... 68, 86, 92
crotan .................................... 53
cryselle (28) .......................... 81
CUROSURF ......................... 92
CUTIVATE .......................... 51
CUVPOSA ........................... 67
cyanocobalamin (vitamin b-12)
.......................................... 98
cyclafem 1/35 (28) ............... 81
cyclafem 7/7/7 (28) .............. 81
cyclobenzaprine .................... 25
CYCLOGYL ........................ 85
CYCLOMYDRIL................. 89
cyclopentolate....................... 85
CYCLOPEN-TROPIC-
PHENYLEPH-WATR ..... 85
CYCLOPENT-TROPIC-
PHEN-KETR-WAT ......... 85
cyclophosphamide ................ 17
CYCLOP-TROP-PROPA-
PHEN-KET-WAT ............ 85
CYCLOSERINE .................. 13
CYCLOSET ......................... 65
cyclosporine ......................... 17
CYCLOSPORINE IN
KLARITY ........................ 86
cyclosporine modified .......... 17
cyproheptadine ..................... 90
cyred ..................................... 81
cyred eq ................................ 81
CYSTADANE ...................... 68
CYSTAGON ........................ 95
CYSTARAN ........................ 86
CYTOTEC ........................... 71
D D.H.E.45 ............................... 23
dalfampridine ....................... 24
DALIRESP ........................... 92
danazol ................................. 63
DANTRIUM ........................ 25
dantrolene ............................. 25
dapsone ........................... 13, 46
DAPSONE............................ 46
DAPTACEL (DTAP
PEDIATRIC) (PF) ............ 75
DARAPRIM ......................... 13
darifenacin ............................ 95
dasetta 1/35 (28) ................... 81
dasetta 7/7/7 (28) .................. 81
DAURISMO ......................... 17
DAYPRO.............................. 28
daysee ................................... 81
DAYTRANA........................ 31
DAYVIGO ........................... 31
DDAVP ................................ 63
deblitane ............................... 78
decadron ............................... 56
deferasirox ............................ 53
deferiprone............................ 53
DELESTROGEN ................. 79
demeclocycline ..................... 15
DEMSER .............................. 36
DENAVIR ............................ 50
denta 5000 plus ..................... 55
dentagel ................................ 55
DEPAKOTE ......................... 21
DEPAKOTE ER ................... 21
DEPAKOTE SPRINKLES .. 21
DEPEN TITRATABS .......... 77
DEPO-ESTRADIOL ............ 79
DEPO-PROVERA................ 79
DEPO-SUBQ PROVERA 104
.......................................... 79
DEPO-TESTOSTERONE .... 63
DERMA-SMOOTHE/FS
BODY OIL ....................... 51
DERMA-SMOOTHE/FS
SCALP OIL ...................... 51
DERMOTIC OIL ................. 56
DESCOVY ........................... 10
desipramine .......................... 31
desloratadine ......................... 90
desmopressin ........................ 63
desog-e.estradiol/e.estradiol . 81
DESONATE ......................... 51
desonide ................................ 51
DESOWEN .......................... 51
desoximetasone .................... 51
DESOXYN ........................... 31
DESVENLAFAXINE .......... 31
desvenlafaxine succinate ...... 31
dexabliss ............................... 56
dexamethasone ..................... 56
dexamethasone intensol ........ 56
dexamethasone sodium
phosphate .......................... 89
DEXAMETH-
MOXIFLOX(PF)-
NACL,ISO ........................ 88
DEXAMET-MOXIFL-
KETORO-NACL(PF) ....... 86
dexchlorpheniramine maleate
.......................................... 90
DEXCOM G4 RECEIVER .. 59
DEXCOM G5 RECEIVER .. 59
DEXCOM G6 RECEIVER .. 59
DEXCOM RECEIVER ........ 59
DEXEDRINE SPANSULE .. 31
DEXILANT .......................... 71
dexmethylphenidate .............. 31
DEXTENZA ......................... 89
dextroamphetamine .............. 31
dextroamphetamine-
amphetamine ..................... 31
DEXYCU (PF) ..................... 89
DIACOMIT .......................... 21
dialyvite 800 ......................... 98
DIASTAT ............................. 21
DIASTAT ACUDIAL .......... 21
DIATRUE CONTROL SOLN
NORMAL ......................... 59
diazepam ......................... 21, 31
diazepam intensol ................. 31
diazoxide ............................... 57
DIBENZYLINE ................... 36
DICLEGIS ............................ 68
diclofenac potassium ............ 28
diclofenac sodium ..... 28, 45, 87
diclofenac-misoprostol ......... 28
dicloxacillin .......................... 15
dicyclomine .......................... 67
didanosine ............................. 10
DIFFERIN ............................ 46
DIFICID ............................... 12
diflorasone ............................ 51
DIFLUCAN ............................ 9
diflunisal ............................... 28
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
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digitek ................................... 39
digox ..................................... 39
digoxin .................................. 39
dihydroergotamine ............... 23
DILANTIN ........................... 21
DILANTIN EXTENDED .... 21
DILANTIN INFATABS ...... 21
DILANTIN-125 ................... 21
DILATRATE-SR ................. 43
DILAUDID .......................... 26
diltiazem ......................... 36, 37
dilt-xr .................................... 37
dimethyl fumarate ................ 73
DIPENTUM ......................... 68
DIPHEN ............................... 90
diphenoxylate-atropine ......... 67
DIPROLENE
(AUGMENTED) .............. 51
dipyridamole......................... 40
DISALCID ........................... 28
diskets ................................... 26
disopyramide phosphate ....... 35
disulfiram ............................. 53
DITROPAN XL ................... 95
DIURIL ................................ 37
divalproex ............................. 21
DIVIGEL .............................. 79
dofetilide............................... 35
DOJOLVI ............................. 97
DOLOPHINE ....................... 26
donepezil .............................. 24
DONNATAL ........................ 67
DOPTELET (15 TAB PACK)
.......................................... 40
DORYX ................................ 15
DORYX MPC ...................... 15
dorzolamide .......................... 87
DORZOLAMIDE (PF) ........ 87
dorzolamide-timolol ............. 87
dorzolamide-timolol (pf) ...... 87
DORZOLAMIDE-TIMOLOL
(PF) ................................... 88
dotti....................................... 79
DOVATO ............................. 10
DOVONEX .......................... 44
doxazosin .............................. 37
doxepin ........................... 31, 45
doxercalciferol ...................... 63
doxycycline hyclate .............. 15
doxycycline monohydrate .... 15
doxylamine-pyridoxine (vit b6)
.......................................... 68
DRISDOL ............................. 98
dronabinol ............................. 68
drospirenone-e.estradiol-lm.fa
.......................................... 81
drospirenone-ethinyl estradiol
.......................................... 81
DROXIA .............................. 17
DSUVIA ............................... 26
DUAVEE.............................. 79
ducodyl (bisacodyl) .............. 68
DUET DHA BALANCED ... 98
DUET DHA WITH OMEGA-3
.......................................... 98
DUETACT ........................... 65
DUEXIS ............................... 28
dulcolax (magnesium
hydroxide) ........................ 68
DULERA .............................. 92
duloxetine ....................... 31, 32
DUOBRII ............................. 51
DUOPA ................................ 22
DUPIXENT PEN ................. 45
DUPIXENT SYRINGE ........ 45
DURAGESIC ....................... 26
DUREZOL ........................... 89
dutasteride ............................ 95
dutasteride-tamsulosin .......... 95
dvorah ................................... 26
DXEVO ................................ 56
DYANAVEL XR ................. 32
DYAZIDE ............................ 37
DYMISTA ............................ 92
DYRENIUM ........................ 37
E e.c. prin ................................. 28
e.e.s. 400 ............................... 12
E.E.S. GRANULES.............. 12
EASY PLUS II HIGH
CONTROL ....................... 59
EASY STEP HIGH
CONTROL SOLN ............ 59
EASY TALK HIGH
CONTROL ....................... 59
EASY TRAK II CTRL SOLN-
NORMAL ......................... 59
EASY TRAK LOW
CONTROL ....................... 59
EASYGLUCO PLUS
NORMAL CONTROL ..... 59
EASYMAX LOW CONTROL
.......................................... 59
EASYMAX NORMAL
CONTROL ....................... 59
ECLIPSE NEEDLE .............. 59
EC-NAPROSYN .................. 28
econazole .............................. 49
econtra ez .............................. 81
econtra one-step .................... 81
ecotrin ................................... 29
ecotrin low strength .............. 29
ECOZA ................................. 49
EDARBI ............................... 37
EDARBYCLOR ................... 37
EDECRIN ............................. 37
EDEX ................................... 95
EDLUAR .............................. 32
ed-spaz .................................. 67
EDURANT ........................... 10
eemt ...................................... 79
eemt hs .................................. 79
efavirenz ............................... 10
efavirenz-emtricitabin-tenofov
.......................................... 10
efavirenz-lamivu-tenofov disop
.......................................... 10
effer-k ................................... 96
EFFER-K .............................. 96
EFFIENT .............................. 40
EFUDEX .............................. 45
EGRIFTA SV ....................... 73
ELEMENT COMPACT
NORMAL CONTROL ..... 59
ELEMENT NORMAL
CONTROL ....................... 59
ELESTRIN ........................... 79
eletriptan ............................... 23
ELIGARD ............................. 17
ELIGARD (3 MONTH) ....... 17
ELIGARD (4 MONTH) ....... 17
ELIGARD (6 MONTH) ....... 17
ELIMITE .............................. 53
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
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elinest ................................... 81
ELIQUIS .............................. 40
ELIQUIS DVT-PE TREAT
30D START ..................... 40
elite-ob .................................. 98
ELIXOPHYLLIN ................. 92
ELLA .................................... 81
ELMIRON ............................ 95
ELOCTATE ......................... 40
eluryng .................................. 80
EMBRACE EVO LEVEL 1 . 59
EMBRACE GLUCOSE
CONTROL LOW ............. 59
EMBRACE TALK
CONTROL-LOW (L1) .... 59
EMCYT ................................ 17
EMGALITY PEN ................ 23
EMGALITY SYRINGE ....... 23
emoquette ............................. 81
EMSAM ............................... 32
emtricitabine ......................... 10
emtricitabine-tenofovir (tdf) . 10
EMTRIVA ............................ 10
EMVERM ............................ 13
enalapril maleate .................. 37
enalapril-hydrochlorothiazide
.......................................... 37
ENBRACE HR ..................... 98
ENBREL .............................. 77
ENBREL MINI .................... 77
ENBREL SURECLICK ....... 77
endocet ................................. 26
ENGERIX-B (PF) ................ 75
ENGERIX-B PEDIATRIC
(PF) ................................... 75
ENLITE SYSTEM ............... 59
enoxaparin ............................ 40
enpresse ................................ 82
enskyce ................................. 82
ENSPRYNG ......................... 17
ENSTILAR........................... 44
entacapone ............................ 22
entecavir ............................... 10
ENTEREG ............................ 68
ENTOCORT EC .................. 68
ENTRESTO ......................... 43
enulose .................................. 68
ENVARSUS XR .................. 17
ENZOCLEAR ...................... 46
EPCLUSA ............................ 10
EPIDIOLEX ......................... 21
EPIFOAM ............................ 44
epinastine .............................. 86
epinephrine ........................... 90
epinephrine hcl ..................... 92
EPIPEN 2-PAK .................... 90
EPIPEN JR 2-PAK ............... 90
EPISIL .................................. 55
epitol ..................................... 21
EPIVIR ................................. 10
EPIVIR HBV ........................ 10
eplerenone ............................ 37
eprosartan ............................. 37
EPZICOM ............................ 10
EQUETRO ........................... 21
ergocalciferol (vitamin d2) ... 98
ergoloid ................................. 32
ERGOMAR .......................... 23
ergotamine-caffeine .............. 23
ERIVEDGE .......................... 17
ERLEADA ........................... 17
erlotinib ................................ 17
errin ...................................... 79
ERTACZO............................ 49
ery pads................................. 46
erygel .................................... 46
ERYPED 200 ....................... 12
ERYPED 400 ....................... 12
ery-tab ................................... 12
ERY-TAB ............................. 12
erythrocin (as stearate) ......... 12
erythromycin .................. 13, 84
erythromycin ethylsuccinate. 13
erythromycin with ethanol.... 47
erythromycin-benzoyl peroxide
.......................................... 47
ESBRIET .............................. 92
escitalopram oxalate ............. 32
ESGIC .................................. 26
ESKATA .............................. 45
esomeprazole magnesium.... 71,
72
ESPEROCT .......................... 40
estarylla ................................ 82
estazolam .............................. 32
ESTRACE ............................ 79
estradiol ................................ 79
estradiol valerate ................... 79
estradiol-norethindrone acet . 79
ESTRING ............................. 79
estrogens-methyltestosterone 79
ESTROSTEP FE-28 ............. 82
eszopiclone ........................... 32
ethacrynic acid ...................... 37
ethambutol ............................ 13
ethosuximide ......................... 21
ethynodiol diac-eth estradiol 82
etodolac ................................. 29
etonogestrel-ethinyl estradiol80
etoposide ............................... 17
EUCRISA ............................. 45
EURAX ................................ 53
euthyrox ................................ 66
EVAMIST ............................ 79
EVEKEO .............................. 32
EVEKEO ODT ..................... 32
everolimus (antineoplastic) .. 17
everolimus
(immunosuppressive) ....... 17
EVERSENSE SENSOR-
HOLDER .......................... 59
EVISTA ................................ 76
EVOCLIN ............................. 47
EVOLUTION NORMAL
CONTROL ....................... 59
EVOTAZ .............................. 10
EVOXAC ............................. 53
EVRYSDI ............................. 24
EXELDERM ........................ 49
EXELON .............................. 24
exemestane ........................... 17
EXTINA ............................... 49
EYLEA ................................. 86
ezetimibe ............................... 42
ezetimibe-simvastatin ........... 42
F FABIOR ............................... 47
FACTIVE ............................. 15
falmina (28) .......................... 82
famciclovir ............................ 10
famotidine ............................. 72
FANAPT ............................... 32
FARESTON ......................... 17
FARXIGA ............................ 65
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
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FARYDAK........................... 17
FASENRA PEN ................... 92
fayosim ................................. 82
FC2 FEMALE CONDOM ... 78
febuxostat ............................. 76
felbamate .............................. 21
FELBATOL ......................... 21
FELDENE ............................ 29
felodipine .............................. 37
fem ph ................................... 80
FEMARA ............................. 17
FEMCAP .............................. 78
FEMHRT LOW DOSE ........ 79
femynor ................................ 82
fenofibrate ............................ 42
FENOFIBRATE ................... 42
fenofibrate micronized ......... 42
fenofibrate nanocrystallized . 42
fenofibric acid ...................... 42
fenofibric acid (choline) ....... 42
FENOGLIDE ....................... 42
fenoprofen ............................ 29
fentanyl ................................. 26
fentanyl citrate ...................... 26
FERRIPROX ........................ 53
FETZIMA............................. 32
FEXMID............................... 25
FIBRICOR ........................... 42
FINACEA............................. 47
finasteride ............................. 95
FIORICET ............................ 26
FIORICET WITH CODEINE
.......................................... 26
FIORINAL ........................... 26
FIORINAL-CODEINE #3 ... 26
FIRDAPSE ........................... 24
FIRVANQ ............................ 16
flac otic oil ............................ 56
FLAGYL .............................. 13
FLAREX .............................. 89
flavoxate ............................... 95
flecainide .............................. 35
FLECTOR ............................ 29
fleet laxative (bisacodyl) ...... 68
FLOLIPID ............................ 42
FLOMAX ............................. 95
FLORIVA (FLUORIDE-
VITAMIN D3) ................. 98
FLOVENT DISKUS ............ 92
FLOVENT HFA ................... 92
FLUAD 2020-2021 (65 YR
UP)(PF) ............................ 75
FLUAD QUAD 2020-21(65Y
UP)(PF) ............................ 75
FLUARIX QUAD 2020-2021
(PF) ................................... 75
FLUBLOK QUAD 2020-2021
(PF) ................................... 75
FLUCELVAX QUAD 2020-
2021 .................................. 75
FLUCELVAX QUAD 2020-
2021 (PF) .......................... 75
fluconazole ............................. 9
flucytosine .............................. 9
fludrocortisone...................... 56
FLULAVAL QUAD 2020-
2021 (PF) .......................... 75
FLUMADINE ...................... 10
FLUMIST QUAD 2020-2021
.......................................... 75
flunisolide ............................. 92
fluocinolone .......................... 51
fluocinolone acetonide oil .... 56
fluocinolone and shower cap 51
fluocinonide .......................... 51
fluocinonide-e ....................... 51
fluorescein-proparacaine ...... 86
fluoride (sodium) ............ 55, 98
FLUORIDEX DAILY
DEFENSE ........................ 55
FLUORIDEX SENSITIVITY
RELIEF ............................ 55
fluoritab ................................ 98
fluorometholone ................... 89
FLUOROPLEX .................... 45
fluorouracil ........................... 45
fluoxetine .............................. 32
fluphenazine hcl ................... 32
FLURA-DROPS ................... 98
flurandrenolide ..................... 51
flurazepam ............................ 32
flurbiprofen ........................... 29
flurbiprofen sodium .............. 87
flutamide ............................... 17
fluticasone propionate .... 51, 92
fluticasone propion-salmeterol
.......................................... 93
FLUTICASONE PROPION-
SALMETEROL ................ 92
fluvastatin ............................. 42
fluvoxamine .......................... 32
FLUZONE HIGHDOSE
QUAD 20-21 PF ............... 75
FLUZONE QUAD 2020-2021
.......................................... 75
FLUZONE QUAD 2020-2021
(PF) ................................... 75
FML LIQUIFILM ................ 89
FOLET ONE ........................ 98
folic acid ............................... 98
folivane-ob ............................ 98
foltabs 800 ............................ 98
fondaparinux ......................... 40
FORA GTEL MULTI-
FUNCTN MONITOR ...... 59
FORA NORMAL CONTROL
.......................................... 59
FORACARE GDH LOW
CONTROL ....................... 59
FORFIVO XL ....................... 32
FORTAMET ......................... 65
FORTEO ............................... 76
FORTESTA .......................... 63
FORTISCARE NORMAL ... 59
FOSAMAX ........................... 76
FOSAMAX PLUS D ............ 76
fosamprenavir ....................... 10
fosfomycin tromethamine ..... 16
fosinopril ............................... 37
fosinopril-hydrochlorothiazide
.......................................... 37
FRAGMIN ............................ 40
FREESTYLE CONTROL .... 59
FREESTYLE FREEDOM .... 60
FREESTYLE FREEDOM
LITE ................................. 60
FREESTYLE INSULINX ... 57,
60
FREESTYLE INSULINX
TEST STRIPS .................. 57
FREESTYLE LIBRE 14 DAY
READER .......................... 60
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FREESTYLE LIBRE 14 DAY
SENSOR........................... 60
FREESTYLE LITE METER 60
FREESTYLE LITE STRIPS 57
FREESTYLE TEST ............. 57
FROVA ................................ 23
frovatriptan ........................... 23
full spectrum b-vitamin c ..... 98
FULPHILA........................... 73
FURADANTIN .................... 16
furosemide ............................ 37
FUZEON .............................. 10
fyavolv .................................. 79
FYCOMPA .......................... 21
G g tussin ac ............................. 90
gabapentin ............................ 21
GABITRIL ........................... 21
GALAFOLD ........................ 63
galantamine .......................... 24
GALZIN ............................... 96
GARDASIL 9 (PF)............... 75
GASTROCROM .................. 68
gatifloxacin ........................... 84
GATTEX 30-VIAL .............. 68
gavilax .................................. 68
gavilyte-c .............................. 68
gavilyte-g .............................. 68
gavilyte-n .............................. 68
GE100 CONTROL
SOLUTION NORMAL.... 60
GELCLAIR .......................... 55
GELNIQUE .......................... 95
GELX ................................... 55
gemfibrozil ........................... 42
GENERESS FE .................... 82
generlac ................................ 68
gengraf ............................ 17, 18
GENOTROPIN .................... 73
GENOTROPIN MINIQUICK
.......................................... 73
gentak ................................... 84
gentamicin ...................... 48, 84
GENTEEL VACUUM
LANCING DEVICE ........ 60
gentle laxative (bisacodyl) ... 68
gentlelax ............................... 68
GENVOYA .......................... 10
GEODON ............................. 32
gianvi (28) ............................ 82
GILENYA ............................ 73
GILOTRIF ............................ 18
GLASSIA ............................. 53
glatiramer.............................. 73
glatopa .................................. 73
GLEOLAN ........................... 53
GLEOSTINE ........................ 18
GLIADEL WAFER .............. 18
glimepiride............................ 65
glipizide ................................ 65
glipizide-metformin .............. 65
GLOPERBA ......................... 76
GLUCAGEN DIAGNOSTIC
KIT ................................... 57
GLUCAGEN HYPOKIT ..... 57
GLUCAGON (HCL)
EMERGENCY KIT ......... 57
GLUCAGON EMERGENCY
KIT (HUMAN)................. 57
GLUCAGON HCL............... 57
GLUCOCARD 01 NORMAL
CONTROL ....................... 60
GLUCOCOM CONTROL
NORMAL ......................... 60
GLUCOSE CONTROL ........ 60
GLUCOTROL ...................... 65
GLUCOTROL XL ............... 65
glyburide ............................... 65
glyburide micronized ............ 65
glyburide-metformin ............ 65
GLYCATE ........................... 67
glycolax ................................ 68
glycopyrrolate ....................... 67
glydo ..................................... 48
GLYNASE ........................... 65
GLYSET ............................... 65
GLYXAMBI ........................ 65
GOJJI GLUCOSE CNTRL
SOL-NORMAL ................ 60
GOJJI KETONE CONTROL
SOLN-L1 .......................... 60
GOJJI MULTI-FUNCTIONAL
METER ............................ 60
GOLYTELY ......................... 68
GONITRO ............................ 43
GOPRELTO ......................... 48
GRALISE ............................. 21
granisetron hcl ...................... 69
griseofulvin microsize ............ 9
griseofulvin ultramicrosize ..... 9
guaiatussin ac ........................ 90
guanfacine ....................... 32, 37
guanidine .............................. 32
GUARDIAN REAL-TIME
GLU MONITOR .............. 60
GVOKE HYPOPEN 2-PACK
.......................................... 57
GVOKE PFS 2-PACK
SYRINGE ......................... 58
GYNAZOLE-1 ..................... 80
gynol ii .................................. 80
H HAEGARDA ........................ 93
hailey .................................... 82
hailey 24 fe ........................... 82
hailey fe 1.5/30 (28) ............. 82
hailey fe 1/20 (28) ................ 82
halcinonide ........................... 51
HALCION ............................ 32
halobetasol propionate .......... 51
HALOBETASOL
PROPIONATE ................. 51
HALOG ................................ 51
haloperidol ............................ 32
haloperidol lactate ................ 32
HARVONI ............................ 10
HAVRIX (PF) ...................... 75
HEALTHPRO HIGH-LOW
CONTROL ....................... 60
healthylax ............................. 69
heather .................................. 79
HEMANGEOL ..................... 37
HEMLIBRA ......................... 40
hemmorex-hc ........................ 69
hep flush-10 (pf) ................... 40
heparin (porcine) .................. 40
HEPARIN (PORCINE) IN
0.9% NACL ...................... 40
heparin (porcine) in 5 % dex 40
heparin (porcine) in nacl (pf) 40
heparin flush(porcine)-0.9nacl
.......................................... 40
heparin lock flush ................. 40
heparin lock flush (porcine) .. 40
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
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heparin lockflush(porcine)(pf)
.......................................... 40
heparin(porcine) in 0.45% nacl
.......................................... 40
HEPARIN(PORCINE) IN
0.45% NACL .................... 40
heparin, porcine (pf) ............. 41
HEPARIN, PORCINE (PF) . 41
HEPLISAV-B (PF) .............. 75
HEPSERA ............................ 10
HETLIOZ ............................. 32
HIBERIX (PF)...................... 75
hidex ..................................... 56
HIPREX ............................... 16
HISTEX-AC ......................... 90
homatropaire......................... 85
HORIZANT ......................... 24
HUMALOG JUNIOR
KWIKPEN U-100 ............ 62
HUMALOG KWIKPEN
INSULIN .......................... 62
HUMALOG MIX 50-50
INSULN U-100 ................ 62
HUMALOG MIX 50-50
KWIKPEN ....................... 62
HUMALOG MIX 75-25
KWIKPEN ....................... 62
HUMALOG MIX 75-25(U-
100)INSULN .................... 62
HUMALOG U-100 INSULIN
.......................................... 62
HUMIRA .............................. 77
HUMIRA PEN ..................... 77
HUMIRA PEN CROHNS-UC-
HS START ....................... 77
HUMIRA PEN PSOR-
UVEITS-ADOL HS ......... 77
HUMIRA(CF) ...................... 77
HUMIRA(CF) PEDI
CROHNS STARTER ....... 77
HUMIRA(CF) PEN.............. 77
HUMIRA(CF) PEN
CROHNS-UC-HS ............ 77
HUMIRA(CF) PEN PSOR-
UV-ADOL HS.................. 77
HUMULIN 70/30 U-100
INSULIN .......................... 62
HUMULIN 70/30 U-100
KWIKPEN........................ 62
HUMULIN N NPH INSULIN
KWIKPEN........................ 62
HUMULIN N NPH U-100
INSULIN .......................... 62
HUMULIN R REGULAR U-
100 INSULN .................... 62
HUMULIN R U-500 (CONC)
INSULIN .......................... 62
HUMULIN R U-500 (CONC)
KWIKPEN........................ 62
HYCAMTIN ........................ 18
hydralazine ........................... 37
HYDREA ............................. 18
hydrochlorothiazide .............. 37
hydrocodone bitartrate .......... 26
hydrocodone-acetaminophen 26
hydrocodone-chlorpheniramine
.......................................... 90
hydrocodone-homatropine ... 90,
91
hydrocodone-ibuprofen ........ 26
hydrocortisone .......... 52, 56, 69
hydrocortisone acetate .......... 69
hydrocortisone butyrate .. 51, 52
hydrocortisone butyr-emollient
.......................................... 52
hydrocortisone valerate ........ 52
hydrocortisone-acetic acid .... 56
hydrocortisone-pramoxine ... 44,
69
hydromet ............................... 91
hydromorphone .............. 26, 27
hydroxocobalamin ................ 98
hydroxychloroquine.............. 13
hydroxyurea .......................... 18
hydroxyzine hcl .................... 90
hydroxyzine pamoate ........... 90
hyophen ................................ 95
hyoscyamine sulfate ............. 67
hyosyne ................................. 67
HYSINGLA ER ................... 27
I ibandronate ........................... 76
IBRANCE ............................ 18
ibu ......................................... 29
ibuprofen .............................. 29
ibuprofen-oxycodone ............ 27
icatibant ................................ 93
ICLUSIG .............................. 18
IDELVION ........................... 41
IDHIFA ................................. 18
IFE-BIMIX 30/1 ................... 95
IFE-PG20 .............................. 95
ILEVRO ............................... 87
ILUVIEN .............................. 89
imatinib ................................. 18
IMBRUVICA ....................... 18
imipramine hcl ...................... 32
imipramine pamoate ............. 32
imiquimod ............................. 74
IMOVAX RABIES VACCINE
(PF) ................................... 75
IMPAVIDO .......................... 13
IMPOYZ ............................... 52
IMURAN .............................. 18
IMVEXXY MAINTENANCE
PACK ............................... 79
IMVEXXY STARTER PACK
.......................................... 79
INBRIJA ............................... 22
incassia ................................. 79
INCRELEX .......................... 54
INCRUSE ELLIPTA ............ 93
indapamide ........................... 37
INDERAL XL ...................... 37
INDOCIN ............................. 29
indomethacin ........................ 29
INFANRIX (DTAP) (PF) ..... 75
INFASURF ........................... 54
INFINITY CONTROL
SOLUTION NORM ......... 60
INFINITY VOICE CTRL
SOLN-LVL 2 .................... 60
INLYTA ............................... 18
INNOPRAN XL ................... 37
INOVA ................................. 47
INOVA 4-1 ........................... 44
INOVA 8-2 ........................... 44
INPEN (FOR HUMALOG) . 60
INPEN (FOR NOVOLOG OR
FIASP) .............................. 60
INSPRA ................................ 37
INSULIN SYRINGE-
NEEDLE U-100 ............... 57
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
113
INTELENCE ........................ 10
INTERMEZZO .................... 32
INTRAROSA ....................... 80
INTRON A ........................... 74
introvale ................................ 82
INVEGA............................... 32
INVELTYS .......................... 89
INVIRASE ........................... 10
INVOKAMET ...................... 65
INVOKAMET XR ............... 65
INVOKANA ........................ 65
iodine-sodium iodide ............ 45
IODOFLEX .......................... 45
IODOSORB ......................... 45
IOPIDINE............................. 89
IPOL ..................................... 75
ipratropium bromide ....... 55, 93
ipratropium-albuterol ........... 93
irbesartan .............................. 37
irbesartan-hydrochlorothiazide
.......................................... 37
IRESSA ................................ 18
ISENTRESS ......................... 10
ISENTRESS HD .................. 10
isibloom ................................ 82
isoniazid ............................... 13
ISOPTO ATROPINE ........... 85
ISOPTO CARPINE .............. 86
ISORDIL .............................. 43
ISORDIL TITRADOSE ....... 43
isosorbide dinitrate ............... 43
isosorbide mononitrate ......... 43
isotretinoin ............................ 47
isoxsuprine ........................... 80
isradipine .............................. 37
itraconazole ............................ 9
ivermectin ............................. 13
IXIARO (PF) ........................ 75
IXINITY ............................... 41
J jaimiess ................................. 82
JAKAFI ................................ 18
JALYN ................................. 95
jantoven ................................ 41
JANUMET ........................... 65
JANUMET XR ..................... 65
JANUVIA............................. 65
JARDIANCE ........................ 65
jasmiel (28) ........................... 82
JELMYTO ............................ 18
jencycla ................................. 79
JENTADUETO .................... 65
JENTADUETO XR .............. 65
jinteli ..................................... 79
JIVI ....................................... 41
jolessa ................................... 82
JORNAY PM ....................... 32
JUBLIA ................................ 49
juleber ................................... 82
JULUCA ............................... 10
junel 1.5/30 (21) ................... 82
junel 1/20 (21) ...................... 82
junel fe 1.5/30 (28) ............... 82
junel fe 1/20 (28) .................. 82
junel fe 24 ............................. 82
JUXTAPID ........................... 42
JYNARQUE ................... 63, 64
K KADIAN .............................. 27
kaitlib fe ................................ 82
KALETRA ........................... 10
kalliga ................................... 82
KALYDECO ........................ 93
KAPVAY ............................. 32
KARBINAL ER ................... 90
kariva (28) ............................ 82
KEFLEX ............................... 12
kelnor 1/35 (28) .................... 82
kelnor 1-50 ........................... 82
KENALOG ........................... 52
KERYDIN ............................ 49
KESIMPTA PEN ................. 74
KETAMINE ......................... 32
ketoconazole ..................... 9, 49
ketodan ................................. 49
ketodan kit ............................ 49
ketoprofen ............................. 29
ketorolac ......................... 29, 87
KEVEYIS ............................. 24
KEVZARA ........................... 77
KINRIX (PF) ........................ 75
kionex (with sorbitol) ........... 69
KITABIS PAK ..................... 13
KLARITY-A (AZITHRO-
CHONDR)(PF) ................. 86
KLARITY-B (BETAMETH-
CHOND)(PF) ................... 86
KLARITY-L (LOTEPRED-
CHOND)(PF) ................... 86
KLARON ............................. 49
KLONOPIN .......................... 21
klor-con ................................. 96
klor-con 10 ............................ 96
klor-con 8 .............................. 96
klor-con m10 ........................ 96
klor-con m15 ........................ 96
klor-con m20 ........................ 96
klor-con/ef ............................ 96
kobee ..................................... 98
KOGENATE FS ................... 41
KOSELUGO ......................... 18
KOSHER PRENATAL PLUS
IRON ................................ 98
KOVALTRY ........................ 41
K-PHOS NO 2 ...................... 95
K-PHOS ORIGINAL ........... 95
kpn ........................................ 98
KRINTAFEL ........................ 13
KRISTALOSE ...................... 69
k-tab ...................................... 97
K-TAB .................................. 97
kurvelo (28) .......................... 82
KUVAN ................................ 64
KYLEENA ........................... 78
KYNMOBI ........................... 23
L l norgest/e.estradiol-e.estrad . 82
labetalol ................................ 37
LACRISERT ........................ 86
lactated ringers ...................... 53
lactulose ................................ 69
LAMICTAL XR STARTER
(BLUE) ............................. 21
LAMICTAL XR STARTER
(GREEN) .......................... 21
LAMICTAL XR STARTER
(ORANGE) ....................... 21
lamivudine ............................ 10
lamivudine-zidovudine ......... 10
lamotrigine ............................ 21
LANCETS ............................ 60
LANCING DEVICE ............ 60
LANOXIN ............................ 39
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
114
lansoprazole .......................... 72
lanthanum ............................. 69
LANTUS SOLOSTAR U-100
INSULIN .......................... 62
LANTUS U-100 INSULIN .. 62
lapatinib ................................ 18
larin 1.5/30 (21) .................... 82
larin 1/20 (21) ....................... 82
larin 24 fe ............................. 82
larin fe 1.5/30 (28) ................ 82
larin fe 1/20 (28) ................... 82
larissia................................... 82
LASIX .................................. 37
LASTACAFT ....................... 86
latanoprost ............................ 88
LATANOPROST (PF) ......... 88
LATUDA ............................. 32
laxaclear ............................... 69
laxative (bisacodyl) .............. 69
laxative peg 3350 ................. 69
layolis fe ............................... 82
leena 28 ................................ 82
leflunomide........................... 77
LENVIMA ........................... 18
LESCOL XL ........................ 42
lessina ................................... 82
letrozole ................................ 18
leucovorin calcium ............... 16
LEUKERAN ........................ 18
LEUKINE............................. 73
leuprolide .............................. 18
levalbuterol hcl ..................... 93
LEVBID ............................... 67
LEVEMIR FLEXTOUCH U-
100 INSULN .................... 62
LEVEMIR U-100 INSULIN 63
levetiracetam ........................ 21
LEVITRA ............................. 95
levobunolol ........................... 85
levocarnitine ......................... 54
levocarnitine (with sugar)..... 54
levocetirizine ........................ 90
levofloxacin .................... 15, 84
levonest (28) ......................... 82
levonorgestrel ....................... 82
levonorgestrel-ethinyl estrad 82
levonorg-eth estrad triphasic 82
levora-28............................... 82
levorphanol tartrate............... 27
LEVORPHANOL
TARTRATE ..................... 27
levo-t ..................................... 66
levothyroxine ........................ 66
levoxyl .................................. 66
LEVSIN ................................ 67
LEVSIN/SL .......................... 67
LEVULAN ........................... 45
LEXETTE ............................ 52
LEXIVA ......................... 10, 11
LIALDA ............................... 69
LICART................................ 29
lidocaine ............................... 48
lidocaine hcl ......................... 48
lidocaine hcl-hydrocortison ac
.................................... 48, 69
LIDOCAINE HCL-
HYDROCORTISON AC . 69
lidocaine viscous .................. 48
lidocaine-hydrocortisone-aloe
.......................................... 69
LIDOCAINE-
PHENYLEPHRIN-BSS(PF)
.......................................... 86
lidocaine-phenylephrn in water
.......................................... 86
lidocaine-prilocaine .............. 48
LILETTA.............................. 78
lillow (28) ............................. 82
lindane .................................. 53
linezolid ................................ 13
LINZESS .............................. 69
liothyronine .......................... 66
LIPOFEN.............................. 42
lisinopril................................ 37
lisinopril-hydrochlorothiazide
.......................................... 37
lite coat aspirin ..................... 29
lithium carbonate .................. 32
lithium citrate ....................... 32
LITHOBID ........................... 32
LITHOSTAT ........................ 54
LIVALO ............................... 42
LO LOESTRIN FE ............... 82
LODINE ............................... 29
LODOSYN ........................... 23
lojaimiess .............................. 82
LOKELMA ........................... 69
LOMOTIL ............................ 67
LONHALA MAGNAIR
REFILL ............................. 93
LONHALA MAGNAIR
STARTER ........................ 93
LONSURF ............................ 18
loperamide ............................ 67
LOPID .................................. 42
lopinavir-ritonavir ................. 11
LOPRESSOR ....................... 37
LOPROX .............................. 49
LOPROX (AS OLAMINE) .. 49
LOPROX KIT ...................... 49
lorazepam ............................. 32
lorazepam intensol ................ 32
LORBRENA ......................... 18
lorcet hd ................................ 27
LORTAB ELIXIR ................ 27
loryna (28) ............................ 82
LORZONE ........................... 25
losartan ................................. 37
losartan-hydrochlorothiazide 37
LOSEASONIQUE ................ 82
LOTEMAX ........................... 89
LOTEMAX SM .................... 89
LOTENSIN ........................... 37
LOTENSIN HCT .................. 37
loteprednol etabonate ............ 89
LOTRONEX ......................... 69
lovastatin ............................... 42
LOVAZA .............................. 42
low-ogestrel (28) .................. 82
loxapine succinate ................ 33
lo-zumandimine (28) ............ 82
lta pre-attached ..................... 48
LUCENTIS ........................... 86
ludent fluoride ...................... 98
lugols .............................. 49, 97
LUMIGAN ........................... 88
LUPANETA PACK (1
MONTH) .......................... 80
LUPANETA PACK (3
MONTH) .......................... 80
LUPRON DEPOT ................ 18
LUPRON DEPOT (3
MONTH) .......................... 18
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
115
LUPRON DEPOT (4
MONTH) .......................... 18
LUPRON DEPOT (6
MONTH) .......................... 18
LUPRON DEPOT-PED ....... 18
LUPRON DEPOT-PED (3
MONTH) .......................... 18
lutera (28) ............................. 82
LUXIQ ................................. 52
LUZU ................................... 49
LYNPARZA......................... 18
LYSODREN......................... 18
LYSTEDA ............................ 80
LYUMJEV KWIKPEN U-100
INSULIN .......................... 63
LYUMJEV KWIKPEN U-200
INSULIN .......................... 63
LYUMJEV U-100 INSULIN
.......................................... 63
lyza ....................................... 79
M MACRILEN ......................... 73
MACROBID ........................ 16
MACRODANTIN ................ 16
mafenide acetate ................... 49
magnesium citrate ................ 69
MALARONE ....................... 13
MALARONE PEDIATRIC . 13
malathion .............................. 53
maprotiline ........................... 33
MAR-COF CG ..................... 91
MARINOL ........................... 69
marlissa (28) ......................... 82
MARNATAL-F .................... 98
MARPLAN .......................... 33
MATULANE ....................... 18
matzim la .............................. 37
MAVENCLAD (10 TABLET
PACK) .............................. 74
MAVENCLAD (4 TABLET
PACK) .............................. 74
MAVENCLAD (5 TABLET
PACK) .............................. 74
MAVENCLAD (6 TABLET
PACK) .............................. 74
MAVENCLAD (7 TABLET
PACK) .............................. 74
MAVENCLAD (8 TABLET
PACK) .............................. 74
MAVENCLAD (9 TABLET
PACK) .............................. 74
MAXITROL ......................... 88
maxi-tuss ac .......................... 91
MAXI-TUSS CD .................. 91
MAXZIDE............................ 37
MAXZIDE-25MG ................ 37
MAYZENT .......................... 74
m-clear wc ............................ 91
meclizine .............................. 69
meclofenamate...................... 29
MECOBALAMIN (VITAMIN
B12) .................................. 98
MEDISENSE........................ 60
MEDISENSE GLUCOSE
KETONE .......................... 60
MEDROL ............................. 56
MEDROL (PAK) ................. 56
medroxyprogesterone ........... 79
mefenamic acid..................... 29
mefloquine ............................ 13
megestrol .............................. 18
MEKINIST ........................... 18
MEKTOVI............................ 18
melodetta 24 fe ..................... 82
meloxicam ............................ 29
melphalan ............................. 18
memantine ............................ 24
MEMANTINE...................... 24
MENACTRA (PF) ............... 75
M-END PE ........................... 91
MENEST .............................. 79
MENOSTAR ........................ 79
MENQUADFI (PF) .............. 75
MENTAX ............................. 49
MENVEO A-C-Y-W-135-DIP
(PF) ................................... 75
meperidine ............................ 27
MEPHYTON ........................ 41
meprobamate ........................ 25
MEPRON ............................. 13
mercaptopurine ..................... 18
mesalamine ........................... 69
mesalamine with cleansing
wipe .................................. 69
MESNEX.............................. 16
MESTINON ......................... 25
MESTINON TIMESPAN .... 25
metaproterenol ...................... 93
metaxall ................................ 25
metaxalone ............................ 25
metformin ....................... 65, 66
methadone ............................. 27
methadose ............................. 27
methamphetamine ................. 33
methazolamide ...................... 87
methenamine hippurate ........ 16
methenamine mandelate ....... 16
methen-sod phos-meth blue-
hyos ................................... 95
methergine ............................ 84
methimazole ......................... 57
METHITEST ........................ 64
methocarbamol ..................... 25
methotrexate sodium ............ 18
methotrexate sodium (pf) ..... 18
methoxsalen .......................... 45
methscopolamine .................. 67
methyl salicylate ................... 45
methyldopa ........................... 37
methyldopa-
hydrochlorothiazide .......... 38
methylergonovine ................. 84
METHYLIN ......................... 33
methylphenidate hcl .............. 33
METHYLPHENIDATE HCL
.......................................... 33
methylprednisolone .............. 56
methyltestosterone ................ 64
metoclopramide hcl .............. 69
metolazone ............................ 38
METOPIRONE .................... 54
metoprolol succinate ............. 38
metoprolol ta-hydrochlorothiaz
.......................................... 38
metoprolol tartrate ................ 38
METROCREAM .................. 47
METROGEL ........................ 47
METROGEL VAGINAL ..... 80
metronidazole ........... 13, 47, 80
metyrosine ............................ 38
mexiletine ............................. 35
MIACALCIN ....................... 64
mibelas 24 fe ......................... 82
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
116
MICONAZOLE NITRATE-
ZINC OX-PET ................. 49
miconazole-3 ........................ 80
microgestin 1.5/30 (21) ........ 82
microgestin 1/20 (21) ........... 83
microgestin fe 1.5/30 (28) .... 83
microgestin fe 1/20 (28) ....... 83
midazolam ............................ 33
midodrine ............................. 54
migergot ............................... 23
miglitol ................................. 66
miglustat ............................... 64
MIGRANAL ........................ 23
mili ....................................... 83
milk of magnesia .................. 69
milk of magnesia concentrated
.......................................... 70
millipred ............................... 56
millipred dp .......................... 56
mimvey ................................. 79
MINIMED INFUSION SET-
MMT 390 ......................... 60
MINIMED MIO 32 .............. 60
MINIMED MIO ADVANCE
INF SET23 ....................... 60
MINIMED QUICK SET 43 . 60
MINIMED SILHOUETTE 23
.......................................... 60
MINIMED SURE T 32 ........ 60
MINIPRESS ......................... 38
MINITRAN .......................... 43
MINIVELLE ........................ 79
minocycline .......................... 15
MINOLIRA ER .................... 15
minoxidil .............................. 38
MIO INFUSION SET .......... 60
MIOCHOL-E ....................... 86
miostat .................................. 88
miralax .................................. 70
MIRAPEX ER ...................... 23
MIRCETTE (28) .................. 83
MIRENA .............................. 78
mirtazapine ........................... 33
MIRVASO ........................... 47
misoprostol ........................... 72
MITIGARE .......................... 76
MITOSOL ............................ 88
MKO (MIDAZOLAM-
KETAMINE-ONDAN) .... 33
M-M-R II (PF) ...................... 75
m-natal plus .......................... 98
MOBIC ................................. 29
modafinil .............................. 33
moexipril .............................. 38
molindone ............................. 33
mometasone .................... 52, 93
mondoxyne nl ....................... 15
MONODOX ......................... 15
mono-linyah.......................... 83
montelukast .......................... 93
MONUROL .......................... 16
morgidox .............................. 16
MORGIDOX 1X 50 ............. 15
MORGIDOX 2X100 ............ 15
morphine ............................... 27
morphine concentrate ........... 27
morphine in 0.9 % sodium
chlor .................................. 27
MOTEGRITY ...................... 70
MOTOFEN ........................... 67
MOVANTIK ........................ 70
MOVIPREP .......................... 70
MOXATAG.......................... 15
MOXEZA ............................. 84
moxifloxacin ................... 15, 84
MOXIFLOXACIN (PF)-BSS
.......................................... 84
MOXIFLOXACIN-SOD
CHLOR,ISO(PF) .............. 85
MOZOBIL ............................ 73
MS CONTIN ........................ 27
MUGARD ............................ 55
MULTAQ ............................. 35
multi-vitamin with fluoride .. 98
multivitamins with fluoride .. 98
mupirocin.............................. 49
mupirocin calcium ................ 49
mvc-fluoride ......................... 98
my choice ............................. 83
my way ................................. 83
MYALEPT ........................... 64
MYAMBUTOL .................... 14
MYCOBUTIN ...................... 14
mycophenolate mofetil ......... 18
mycophenolate sodium ......... 18
MYDAYIS ........................... 33
MYDRIACYL ...................... 85
MYDRIATIC4(TROP-PROP-
PE-KTRLC) ...................... 86
MYFORTIC ......................... 18
MYGLUCOHEALTH
CONTROL SOLUTION .. 61
MYLERAN .......................... 19
mynatal ................................. 98
mynatal advance ................... 98
mynatal plus .......................... 98
mynatal-z .............................. 98
mynate 90 plus ...................... 98
myorisan ............................... 47
MYRBETRIQ ....................... 95
MYSOLINE ......................... 21
MYTESI ............................... 67
N nabumetone ........................... 29
nadolol .................................. 38
nadolol-bendroflumethiazide 38
naftifine ................................. 49
NAFTIN ............................... 49
NALFON .............................. 29
NALOCET ........................... 27
naloxone ............................... 29
naltrexone ............................. 29
NAMENDA .......................... 24
NAMENDA TITRATION
PAK .................................. 24
NAMENDA XR ................... 24
NAMZARIC ......................... 24
NAPRELAN CR .................. 29
NAPROSYN ......................... 29
naproxen ............................... 29
naproxen sodium .................. 29
naproxen-esomeprazole ........ 29
naratriptan ............................. 23
NARCAN ............................. 29
NARDIL ............................... 33
NASCOBAL ......................... 98
NATACHEW (FE BIS-
GLYCINATE) .................. 98
NATACYN ........................... 85
NATAZIA ............................ 83
nateglinide ............................ 66
NATESTO ............................ 64
NATPARA ........................... 64
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
117
NATROBA........................... 53
natural b-100 complex .......... 98
natura-lax .............................. 70
NAYZILAM......................... 21
NEBUPENT ......................... 14
nebusal .................................. 93
NEBUSAL ........................... 93
necon 0.5/35 (28).................. 83
NEEVODHA (WITH ALGAL
OIL) .................................. 99
nefazodone ........................... 33
neomycin .............................. 14
neomycin-bacitracin-poly-hc 88
neomycin-bacitracin-
polymyxin......................... 85
neomycin-polymyxin b gu ... 53
neomycin-polymyxin b-
dexameth .......................... 88
neomycin-polymyxin-
gramicidin......................... 85
neomycin-polymyxin-hc 56, 88
neo-polycin ........................... 85
neo-polycin hc ...................... 88
NEORAL .............................. 19
NEO-SYNALAR ................. 49
NEO-SYNALAR KIT .......... 49
NERLYNX ........................... 19
NESTABS ............................ 99
NESTABS ABC ................... 99
NESTABS DHA .................. 99
NESTABS ONE ................... 99
neuac..................................... 47
NEUAC KIT ........................ 47
NEULASTA ......................... 73
NEUPRO .............................. 23
nevirapine ............................. 11
new day ................................ 83
newgen ................................. 99
NEXAVAR .......................... 19
NEXIUM .............................. 72
NEXIUM PACKET ............. 72
NEXLETOL ......................... 42
NEXLIZET........................... 42
NEXPLANON ..................... 80
niacin .................................... 42
NIASPAN EXTENDED-
RELEASE ........................ 42
nicardipine ............................ 38
nicorette ................................ 54
nicotine ................................. 55
nicotine (polacrilex) ............. 54
NICOTROL .......................... 55
NICOTROL NS .................... 55
nifedipine .............................. 38
nikki (28) .............................. 83
NILANDRON ...................... 19
nilutamide ............................. 19
nimodipine ............................ 38
NINJACOF-XG.................... 91
NINLARO ............................ 19
nisoldipine ............................ 38
nitisinone .............................. 54
nitro-bid ................................ 43
NITRO-DUR ........................ 43
nitrofurantoin ........................ 16
nitrofurantoin macrocrystal .. 16
nitrofurantoin monohyd/m-
cryst .................................. 16
nitroglycerin ......................... 43
NITROLINGUAL ................ 43
NITROMIST ........................ 43
NITROSTAT ........................ 43
nitro-time .............................. 43
NITYR .................................. 54
NIVESTYM ......................... 73
nizatidine .............................. 72
NOCDURNA (MEN) ........... 64
NOCDURNA (WOMEN) .... 64
nolix ...................................... 52
nora-be .................................. 79
NORDITROPIN FLEXPRO 73
noreth-ethinyl estradiol-iron . 83
norethindrone (contraceptive)
.......................................... 79
norethindrone acetate ........... 79
norethindrone ac-eth estradiol
.................................... 80, 83
norethindrone-e.estradiol-iron
.......................................... 83
NORGESIC FORTE ............ 25
norgestimate-ethinyl estradiol
.......................................... 83
NORITATE .......................... 47
norlyda .................................. 80
NORPACE ........................... 35
NORPACE CR ..................... 35
NORPRAMIN ...................... 33
NORTHERA ........................ 54
nortrel 0.5/35 (28) ................. 83
nortrel 1/35 (21) .................... 83
nortrel 1/35 (28) .................... 83
nortrel 7/7/7 (28) ................... 83
nortriptyline .......................... 33
NORVIR ............................... 11
NOURIANZ ......................... 23
NOVA MAX GLUCOSE
CONTROL ....................... 61
NOVAMAX PLUS GLU-KET
.......................................... 61
NOVOEIGHT ....................... 41
NOVOPEN ECHO ............... 61
NOVOSEVEN RT ................ 41
NOXAFIL ............................... 9
np thyroid .............................. 66
NUBEQA ............................. 19
NUCALA ............................. 93
NUCORT .............................. 52
NUCYNTA ........................... 30
NUCYNTA ER .................... 30
NUEDEXTA ........................ 24
NULEV ................................. 67
NULYTELY LEMON-LIME
.......................................... 70
NULYTELY WITH FLAVOR
PACKS ............................. 70
NUMBRINO ........................ 48
NUPLAZID .......................... 33
NURTEC ODT ..................... 23
NUVARING ......................... 80
NUVESSA ............................ 80
NUZYRA ............................. 16
nyamyc ................................. 49
NYMALIZE ......................... 38
nystatin ............................. 9, 49
nystatin-triamcinolone .......... 50
nystop ................................... 50
O OB COMPLETE .................. 99
OB COMPLETE ONE ......... 99
OB COMPLETE PETITE .... 99
OB COMPLETE PREMIER 99
OB COMPLETE WITH DHA
.......................................... 99
OBREDON ........................... 91
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
118
obstetrix dha ......................... 99
OBSTETRIX EC .................. 99
OBSTETRIX ONE ............... 99
OBTREX DHA .................... 99
OCALIVA ............................ 70
ocella .................................... 83
octreotide acetate .................. 19
OCUFLOX ........................... 85
ODEFSEY ............................ 11
ODOMZO ............................ 19
OFEV ................................... 93
ofloxacin ................... 15, 56, 85
olanzapine............................. 33
olanzapine-fluoxetine ........... 33
olmesartan ............................ 38
olmesartan-amlodipin-
hcthiazid ........................... 38
olmesartan-
hydrochlorothiazide .......... 38
olopatadine ..................... 55, 86
OLUX ................................... 52
OLUX-E ............................... 52
OMECLAMOX-PAK .......... 72
omega-3 acid ethyl esters ..... 42
omeprazole ........................... 72
omeprazole-sodium
bicarbonate ....................... 72
OMIDRIA ............................ 86
OMNIPOD DASH 5 PACK
POD .................................. 61
ON CALL EXPRESS
CONTROL ....................... 61
ON CALL PLUS CONTROL
.......................................... 61
ON CALL VIVID CONTROL
.......................................... 61
ondansetron .......................... 70
ondansetron hcl .................... 70
one daily prenatal ................. 99
ONETOUCH ULTRA BLUE
TEST STRIP .................... 57
ONETOUCH ULTRA
CONTROL ....................... 61
ONETOUCH ULTRA2
METER ............................ 61
ONETOUCH ULTRAMINI 61
ONETOUCH VERIO FLEX
METER ............................ 61
ONETOUCH VERIO IQ
METER ............................ 61
ONETOUCH VERIO METER
.......................................... 61
ONETOUCH VERIO
REFLECT METER .......... 61
ONETOUCH VERIO TEST
STRIPS ............................. 57
ONEXTON ........................... 47
ONFI ..................................... 21
ONZETRA XSAIL............... 23
opcicon one-step ................... 83
opium tincture....................... 67
OPSUMIT ............................ 93
option-2 ................................ 83
ORACEA.............................. 16
ORACIT ............................... 95
oral saline laxative ................ 70
oralone .................................. 55
ORAMAGICRX ................... 55
ORAPRED ODT .................. 56
ORAVIG ................................ 9
ORENITRAM ...................... 38
ORFADIN ............................ 54
ORIAHNN............................ 80
ORILISSA ............................ 64
ORKAMBI ........................... 93
orphenadrine citrate .............. 25
orphenadrine-asa-caffeine .... 25
orphengesic forte .................. 25
orsythia ................................. 83
ORTIKOS ............................. 70
oscimin ................................. 67
oscimin sl .............................. 67
oscimin sr ............................. 67
oseltamivir ............................ 11
OSENI .................................. 66
OSMOLEX ER..................... 23
OSPHENA............................ 80
OTEZLA .............................. 77
OTEZLA STARTER ............ 77
OTIPRIO .............................. 56
OTOVEL .............................. 56
OTREXUP (PF) ................... 77
OVACE ................................ 44
OVACE PLUS ..................... 44
OVACE PLUS SHAMPOO . 44
OVACE PLUS WASH ......... 44
OVIDE .................................. 53
oxandrolone .......................... 64
oxaprozin .............................. 30
OXAYDO ............................. 27
oxazepam .............................. 33
oxcarbazepine ....................... 21
OXERVATE ......................... 86
oxiconazole ........................... 50
OXISTAT ............................. 50
OXSORALEN ULTRA ........ 45
OXTELLAR XR .................. 21
oxybutynin chloride .............. 95
oxycodone ............................. 27
oxycodone-acetaminophen ... 27
oxycodone-aspirin ................ 28
OXYCONTIN ...................... 28
oxymorphone ........................ 28
OXYTROL ........................... 95
oyster shell + d3.................... 97
oyster shell calcium-vit d3 .... 97
OZEMPIC ............................. 66
OZURDEX ........................... 89
P pacerone ................................ 35
PACNEX .............................. 47
paliperidone .......................... 33
PALYNZIQ .......................... 64
PAMELOR ........................... 33
PANDEL .............................. 52
PANRETIN .......................... 45
pantoprazole ......................... 73
PARAGARD T 380A ........... 78
PAREMYD ........................... 85
paricalcitol ............................ 64
PARLODEL ......................... 23
PARNATE ............................ 33
paroex oral rinse ................... 55
paromomycin ........................ 14
paroxetine hcl ....................... 33
paroxetine
mesylate(menop.sym) ....... 33
PASER .................................. 14
PATANASE ......................... 55
PAXIL ............................ 33, 34
PAXIL CR ............................ 33
PAZEO ................................. 86
PEDIARIX (PF) ................... 75
PEDVAX HIB (PF) .............. 75
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
119
peg 3350-electrolytes ........... 70
peg3350-sod sul-nacl-kcl-asb-c
.......................................... 70
PEGANONE ........................ 21
PEGASYS ............................ 74
peg-electrolyte soln .............. 70
PEGINTRON ....................... 74
peg-prep ................................ 70
PEMAZYRE ........................ 19
PEN NEEDLE, DIABETIC . 61
penicillamine ........................ 77
penicillin v potassium........... 15
PENTACEL (PF) ................. 75
PENTACEL ACTHIB
COMPONENT (PF) ......... 75
pentamidine .......................... 14
PENTASA ............................ 70
pentazocine-naloxone ........... 30
pentoxifylline ....................... 41
PEPCID ................................ 73
PERFOROMIST .................. 93
PERIDEX ............................. 55
perindopril erbumine ............ 38
periogard............................... 55
permethrin ............................ 53
perphenazine......................... 34
perphenazine-amitriptyline... 34
perry prenatal........................ 99
PEXEVA .............................. 34
phenadoz............................... 90
phenazopyridine ................... 96
phenelzine............................. 34
phenobarb-hyoscy-atropine-
scop................................... 67
phenobarbital ........................ 21
phenohytro ............................ 67
phenoxybenzamine ............... 38
phenylephrine hcl ................. 89
PHENYLEPH-
TROPICAMIDE IN
WATER ............................ 85
PHENYTEK ......................... 21
phenytoin .............................. 21
phenytoin sodium extended .. 22
philith ................................... 83
PHOSLYRA ......................... 70
phosphasal ............................ 95
phosphate laxative ................ 70
PHOSPHOLINE IODIDE .... 85
PHOTREXA CROSS-
LINKING KIT .................. 86
PHOTREXA VISCOUS....... 87
PHYSIOLYTE ..................... 53
PHYSIOSOL IRRIGATION 53
phytonadione (vitamin k1) ... 41
PHYTONADIONE
(VITAMIN K1) ................ 41
PICATO................................ 45
pilocarpine hcl .......... 54, 55, 86
pimecrolimus ........................ 45
pimozide ............................... 34
pimtrea (28) .......................... 83
pindolol ................................. 38
pioglitazone .......................... 66
pioglitazone-glimepiride ...... 66
pioglitazone-metformin ........ 66
pirmella ................................. 83
piroxicam .............................. 30
PLAN B ONE-STEP ............ 83
PLEGRIDY .......................... 74
PLENVU .............................. 70
PLEXION ............................. 47
PLEXION CLEANSING
CLOTHS .......................... 47
PLIAGLIS ............................ 48
PNEUMOVAX-23 ............... 76
pnv 29-1 ................................ 99
pnv-dha ................................. 99
pnv-dha + docusate ............... 99
pnv-omega ............................ 99
pnv-select.............................. 99
podofilox .............................. 45
POLIVY ............................... 19
polycin .................................. 85
polyethylene glycol 3350 ..... 70
polymyxin b sulf-trimethoprim
.......................................... 85
POLYTRIM.......................... 85
POLY-TUSSIN AC .............. 91
POMALYST ........................ 74
portia 28 ................................ 83
posaconazole .......................... 9
POTABA .............................. 97
potassium chloride ................ 97
potassium citrate ................... 95
powderlax ............................. 70
PR BENZOYL PEROXIDE . 47
pr natal 400 ........................... 99
pr natal 400 ec ...................... 99
pr natal 430 ........................... 99
pr natal 430 ec ...................... 99
PRALUENT PEN ................. 42
pramipexole .......................... 23
PRAMOSONE ..................... 44
PRANDIN ............................ 66
prasugrel ............................... 41
pravastatin ............................. 42
praziquantel .......................... 14
prazosin ................................. 38
PRECISION XTRA
KETONE-GLUCOSE ...... 61
PRECISION XTRA
MONITOR ....................... 61
PRECISION XTRA TEST ... 57
PRECOSE ............................. 66
PRED FORTE ...................... 89
PRED-G ................................ 88
PRED-G S.O.P. .................... 88
prednicarbate ........................ 52
PREDNISOL ACE-
GATIFLOX-BROMFEN . 87
PREDNISOLN SP-
GATIFLOX-BROMFEN . 87
PREDNISOLN SP-
MOXIFLOX-BROMFEN 87
prednisolone ......................... 56
prednisolone acetate ............. 89
PREDNISOLONE ACETATE
(PF) ................................... 89
PREDNISOLONE ACETATE-
NEPAFENAC ................... 87
PREDNISOLONE ACET-
GATIFLOXACIN ............ 88
PREDNISOLONE SOD PH-
BROMFENAC ................. 87
PREDNISOLONE SOD PH-
MOXIFLOX ..................... 88
prednisolone sodium phosphate
.................................... 57, 89
PREDNISOLONE-
MOXIFLO-NEPAFENAC
.......................................... 87
PREDNISOLONE-
MOXIFLOXACIN HCL .. 88
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
120
PREDNISOLONE-
MOXIFLOX-BROMFEN 87
prednisone ............................ 57
prednisone intensol ............... 57
PREFEST ............................. 80
pregabalin ............................. 22
PREGENNA......................... 99
PREMARIN ......................... 80
PREMPHASE ...................... 80
PREMPRO ........................... 80
prena1 chew.......................... 99
prena1 pearl .......................... 99
prena1 true ............................ 99
prenaissance ......................... 99
prenaissance plus .................. 99
PRENATA ........................... 99
prenatabs fa .......................... 99
prenatabs rx .......................... 99
prenatal ................................. 99
prenatal complete ................. 99
prenatal formula ................... 99
prenatal multi-dha (algal oil) 99
prenatal one daily ................. 99
prenatal plus ......................... 99
prenatal plus (calcium carb) . 99
PRENATAL PLUS DHA..... 99
prenatal vitamin .................... 99
prenatal vitamin plus low iron
.......................................... 99
prenatal vitamin with minerals
.......................................... 99
prenatal vits96-iron fum-folic
.......................................... 99
prenatal-u .............................. 99
PRENATE AM .................. 100
PRENATE CHEWABLE ... 100
PRENATE DHA (FERR ASP
GLYCIN) ....................... 100
PRENATE ELITE (IRON ASP
GLYC) ............................ 100
PRENATE ENHANCE ...... 100
PRENATE
ESSENTIAL(IRON-ASP-
GL) ................................. 100
PRENATE MINI (FERR ASP
GLYCIN) ....................... 100
PRENATE PIXIE ............... 100
PRENATE RESTORE ....... 100
PRENATE STAR ............... 100
PREPIDIL ............................ 80
preplus ................................ 100
PRESTALIA ........................ 38
pretab .................................. 100
PRETOMANID .................... 14
prevalite ................................ 42
PREVIDENT ........................ 55
PREVIDENT 5000 BOOSTER
PLUS ................................ 55
PREVIDENT 5000 DRY
MOUTH ........................... 55
PREVIDENT 5000 ENAMEL
PROTECT ........................ 55
PREVIDENT 5000 ORTHO
DEFENSE ........................ 55
PREVIDENT 5000 PLUS .... 55
PREVIDENT 5000
SENSITIVE ...................... 55
previfem................................ 83
PREVNAR 13 (PF) .............. 76
PREVYMIS .......................... 11
PREZISTA ........................... 11
PRIFTIN ............................... 14
PRIMACARE ..................... 100
primaquine ............................ 14
primidone.............................. 22
PRIMSOL ............................. 16
PRINIVIL ............................. 38
PROAIR HFA ...................... 93
PROAIR RESPICLICK ....... 93
probenecid ............................ 76
probenecid-colchicine .......... 76
PROCARDIA ....................... 38
PROCARDIA XL................. 38
procentra ............................... 34
prochlorperazine ................... 70
prochlorperazine maleate ..... 70
PROCORT............................ 70
PROCRIT ............................. 73
PROCTOCORT.............. 52, 70
PROCTOFOAM HC ............ 70
procto-med hc ....................... 70
procto-pak ............................. 70
proctosol hc .......................... 70
proctozone-hc ....................... 70
PRODIGY CONTROL
SOLUTION, LOW ........... 61
PRODIGY CONTROL
SOLUTION,HIGH ........... 61
progesterone ......................... 80
progesterone micronized ...... 80
PROGLYCEM ..................... 58
PROGRAF ............................ 19
prolate ................................... 28
PROLENSA ......................... 87
PROLEUKIN ....................... 74
PROMACTA ........................ 41
promethazine ........................ 90
promethazine-codeine ........... 91
promethazine-dm .................. 91
promethazine-phenyleph-
codeine .............................. 91
promethazine-phenylephrine 91
promethegan ......................... 90
PROMETRIUM ................... 80
propafenone .......................... 35
propantheline ........................ 67
proparacaine ......................... 87
propranolol ........................... 38
propranolol-hydrochlorothiazid
.......................................... 38
propylthiouracil .................... 57
PROQUAD (PF) ................... 76
PROSCAR ............................ 95
PROSTIN E2 ........................ 80
PROTHELIAL ..................... 55
PROTOPIC ........................... 45
protriptyline .......................... 34
PROVERA ........................... 80
PROVIDA OB .................... 100
prudoxin ................................ 45
PSORCON ............................ 52
PULMICORT FLEXHALER
.......................................... 93
pulmosal ............................... 93
PULMOZYME ..................... 93
PUREFE OB PLUS ............ 100
purelax .................................. 70
PURIXAN ............................ 19
pyrazinamide ........................ 14
PYRIDIUM .......................... 96
pyridostigmine bromide ........ 25
PYRIDOSTIGMINE
BROMIDE ........................ 25
pyrimethamine ...................... 14
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
121
Q QBREXZA ........................... 45
QNASL................................. 93
QTERN................................. 66
QUADRACEL (PF) ............. 76
QUALAQUIN ...................... 14
QUARTETTE ...................... 83
QUAZEPAM ........................ 34
QUDEXY XR ...................... 22
QUESTRAN......................... 42
QUESTRAN LIGHT............ 42
quetiapine ............................. 34
QUICK-SET PARADIGM .. 61
QUILLICHEW ER ............... 34
QUILLIVANT XR ............... 34
quinapril ............................... 38
quinapril-hydrochlorothiazide
.......................................... 38
quinidine gluconate .............. 35
quinidine sulfate ................... 35
quinine sulfate ...................... 14
quit 2 ..................................... 55
quit 4 ..................................... 55
QVAR REDIHALER ........... 93
R RABAVERT (PF) ................ 76
rabeprazole ........................... 73
RACEPINEPH-LIDOCAINE-
BSS 7(PF) ......................... 87
RADIOGARDASE .............. 54
raloxifene .............................. 76
ramelteon .............................. 34
ramipril ................................. 38
ranitidine hcl ......................... 73
ranolazine ............................. 43
RAPAMUNE ....................... 19
rasagiline .............................. 23
RASUVO (PF) ..................... 78
RAVICTI .............................. 54
RAYALDEE ........................ 64
RAYOS ................................ 57
RAZADYNE ER .................. 24
REBIF (WITH ALBUMIN) . 74
REBIF REBIDOSE .............. 74
REBIF TITRATION PACK 74
REBINYN ............................ 41
reclipsen (28) ........................ 83
RECOMBIVAX HB (PF) .... 76
RECTIV................................ 70
REFUAH PLUS GLUCOSE
CONTROL ....................... 61
REGLAN .............................. 70
REGRANEX ........................ 45
RELAFEN ............................ 30
RELAGARD ........................ 80
RELENZA DISKHALER .... 11
RELEXXII............................ 34
RELISTOR ........................... 70
RELPAX .............................. 23
REMERON .......................... 34
REMERON SOLTAB .......... 34
RENACIDIN ........................ 96
rena-vite .............................. 100
RENVELA ........................... 70
repaglinide ............................ 66
repaglinide-metformin .......... 66
REPATHA PUSHTRONEX 42
REPATHA SURECLICK .... 42
REPATHA SYRINGE ......... 43
REQUIP XL ......................... 23
RESPA-AR ........................... 91
RESTASIS............................ 87
RESTASIS MULTIDOSE ... 87
RESTORIL ........................... 34
RETACRIT .......................... 73
RETEVMO ........................... 19
RETIN-A .............................. 47
RETIN-A MICRO ................ 47
RETIN-A MICRO PUMP .... 47
RETISERT ........................... 89
RETROVIR .......................... 11
REVATIO ............................ 93
REVLIMID .......................... 74
REXULTI ............................. 34
REYATAZ ........................... 11
REYVOW ............................ 23
RHOFADE ........................... 47
RHOPRESSA ....................... 88
ribavirin .......................... 11, 74
RIDAURA ............................ 78
rifabutin ................................ 14
RIFADIN .............................. 14
RIFAMATE.......................... 14
rifampin ................................ 14
RIFATER ............................. 14
RIGHTEST CONTROL
SOLUTION HIGH ........... 61
RILUTEK ............................. 54
riluzole .................................. 54
rimantadine ........................... 11
ringer's .................................. 53
RINVOQ ............................... 78
RIOMET ............................... 66
RIOMET ER ......................... 66
risedronate ................ 54, 76, 77
RISPERDAL ........................ 34
risperidone ............................ 34
RITALIN .............................. 34
RITALIN LA ........................ 34
ritonavir ................................ 11
rivastigmine .......................... 24
rivastigmine tartrate .............. 24
rivelsa ................................... 83
RIXUBIS .............................. 41
rizatriptan .............................. 23
R-NATAL OB .................... 100
ROBAXIN-750 ..................... 25
ROCALTROL ...................... 64
ROCKLATAN ..................... 88
ropinirole .............................. 23
rosadan .................................. 47
ROSADAN ........................... 47
ROSANIL ............................. 47
ROSULA .............................. 47
rosula cleansing cloths .......... 47
rosuvastatin ........................... 43
ROTARIX ............................ 76
ROTATEQ VACCINE ......... 76
ROWASA ............................. 70
roweepra ............................... 22
ROXICODONE .................... 28
ROZLYTREK ...................... 19
RUBRACA ........................... 19
RUCONEST ......................... 93
RUZURGI ............................ 24
RYBELSUS .......................... 66
RYCLORA ........................... 90
RYDAPT .............................. 19
RYTARY .............................. 23
RYTHMOL SR .................... 35
RYVENT .............................. 90
S SABRIL ................................ 22
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
122
SAFE-CLIP BY MAIL ........ 61
SAFYRAL ............................ 83
SALAGEN (PILOCARPINE)
.................................... 54, 56
salsalate ................................ 30
SAMSCA ............................. 64
SANCUSO ........................... 70
SANDIMMUNE .................. 19
SANDOSTATIN .................. 19
SANTYL .............................. 53
SAPHRIS ............................. 34
sapropterin ............................ 64
SARAFEM ........................... 34
SAVELLA ............................ 78
scalacort ................................ 52
SCALACORT DK ............... 52
scopolamine base.................. 70
SEASONIQUE ..................... 83
seconal sodium ..................... 34
SECUADO ........................... 34
SEEBRI NEOHALER.......... 93
SEGLUROMET ................... 66
SELECT-OB ...................... 100
SELECT-OB (FOLIC ACID)
........................................ 100
SELECT-OB + DHA ......... 100
selegiline hcl ......................... 23
selenium sulfide.................... 44
SELRX ................................. 44
SELZENTRY ....................... 11
SEMPREX-D ....................... 91
se-natal 19 chewable .......... 100
se-natal-19 .......................... 100
SEREVENT DISKUS .......... 93
SERNIVO............................. 52
SEROSTIM .......................... 73
sertraline ............................... 34
setlakin ................................. 83
sevelamer carbonate ............. 70
sevelamer hcl ........................ 70
SEYSARA ............................ 16
sf 56
sf 5000 plus .......................... 56
SFROWASA ........................ 70
sharobel ................................ 80
SHINGRIX (PF) ................... 76
SHOHL'S MODIFIED ......... 96
SIGNIFOR ........................... 19
sildenafil ............................... 96
sildenafil (pulm.hypertension)
.......................................... 94
SILENOR ............................. 34
SILHOUETTE...................... 61
silodosin................................ 95
SILVADENE........................ 44
silver sulfadiazine ................. 44
SIMBRINZA ........................ 88
simliya (28)........................... 83
simpesse................................ 83
SIMPONI.............................. 78
SIMPONI ARIA ................... 78
simvastatin ............................ 43
SINEMET ............................. 23
SINUVA ............................... 94
sirolimus ............................... 19
SIRTURO ............................. 14
SIVEXTRO .......................... 14
SKELAXIN .......................... 25
SKLICE ................................ 53
SKYLA ................................. 78
SKYRIZI .............................. 44
SLYND ................................. 83
SMARTEST CONTROL ..... 61
smoothlax ............................. 70
sodium chloride .............. 54, 94
sodium chloride 0.9 % .......... 54
sodium chloride 0.9 % (flush)
.......................................... 54
sodium fluoride 5000 plus .... 56
sodium fluoride-pot nitrate ... 56
sodium phenylbutyrate ......... 54
sodium polystyrene (sorb free)
.......................................... 71
sodium polystyrene sulfonate
.......................................... 71
SOLESTA ............................ 71
solifenacin ............................ 95
SOLIQUA 100/33 ................ 63
SOLODYN ........................... 16
SOLOSEC ............................ 14
SOLTAMOX ........................ 19
SOLUS V2 CONTROL
SOLUTION,HIGH ........... 61
SOMA .................................. 25
SOMATULINE DEPOT ...... 19
SOMAVERT ........................ 64
SOOLANTRA ...................... 47
SORBITOL ........................... 53
SORBITOL-MANNITOL .... 53
SORIATANE ....................... 44
SORILUX ............................. 44
sotalol ................................... 35
sotalol af ............................... 35
SOTYLIZE ........................... 35
SPECTRACEF ..................... 12
spinosad ................................ 53
SPIRIVA RESPIMAT .......... 94
SPIRIVA WITH
HANDIHALER ................ 94
spironolactone ....................... 38
spironolacton-hydrochlorothiaz
.......................................... 38
SPORANOX ........................... 9
SPORANOX PULSEPAK ..... 9
sprintec (28) .......................... 83
SPRITAM ............................. 22
SPRIX ................................... 30
SPRYCEL ............................. 19
sps (with sorbitol) ................. 71
sronyx ................................... 83
ssd ......................................... 44
SSKI ..................................... 57
sss 10-5 ................................. 47
st joseph aspirin .................... 30
st. joseph aspirin ................... 30
STALEVO 100 ..................... 23
STALEVO 125 ..................... 23
STALEVO 150 ..................... 23
STALEVO 200 ..................... 23
STALEVO 50 ....................... 23
STALEVO 75 ....................... 23
STAMARIL (PF) .................. 76
STARLIX ............................. 66
stavudine ............................... 11
STAXYN .............................. 96
STEGLATRO ....................... 66
STEGLUJAN ....................... 66
STELARA ............................ 44
STENDRA ............................ 96
STIOLTO RESPIMAT ......... 94
STIVARGA .......................... 19
stop smoking aid ................... 55
STRENSIQ ........................... 64
stress formula ...................... 100
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
123
stress formula with iron ...... 100
stress formula with iron(sulf)
........................................ 100
STROMECTOL ................... 14
strong iodine ................... 49, 97
subvenite............................... 22
subvenite starter (blue) kit .... 22
subvenite starter (green) kit .. 22
subvenite starter (orange) kit 22
SUCRAID ............................ 71
sucralfate .............................. 73
SULAR ................................. 38
sulfacetamide sodium ..... 44, 89
sulfacetamide sodium (acne) 49
sulfacetamide sodium-sulfur 47,
48
sulfacetamide-prednisolone .. 89
sulfacetamide-sulfur-cleansr23
.......................................... 48
sulfacleanse 8-4 .................... 48
sulfadiazine........................... 15
sulfamethoxazole-trimethoprim
.......................................... 15
SULFAMYLON................... 49
sulfasalazine ......................... 71
sulfatrim ............................... 15
sulindac................................. 30
SUMADAN .......................... 48
SUMADAN XLT ................. 48
sumatriptan ........................... 23
sumatriptan succinate ..... 23, 24
sumatriptan-naproxen ........... 24
SUMAXIN ........................... 48
SUMAXIN CP ..................... 48
SUMAXIN TS...................... 48
SUNOSI ............................... 34
super b complex-vitamin c . 100
super b maxi complex ........ 100
super quints ........................ 100
super quints b-50 ................ 100
SUPPRELIN LA .................. 19
SUPRAX .............................. 12
SUPREP BOWEL PREP KIT
.......................................... 71
SURE-T PARADIGM.......... 61
SURFAXIN .......................... 94
SURVANTA ........................ 54
SUSTIVA ............................. 11
SUTENT ............................... 19
syeda ..................................... 83
SYLATRON ......................... 74
SYMAX DUOTAB .............. 67
symax fastabs ....................... 67
symax-sl................................ 67
symax-sr ............................... 67
SYMBICORT ....................... 94
SYMBYAX .......................... 34
SYMDEKO .......................... 94
SYMFI .................................. 11
SYMFI LO ........................... 11
SYMJEPI .............................. 90
SYMLINPEN 120 ................ 66
SYMLINPEN 60 .................. 66
SYMPAZAN ........................ 22
SYMPROIC.......................... 71
SYMTUZA ........................... 11
SYNALAR ........................... 52
SYNALAR CREAM KIT .... 52
SYNALAR OINTMENT KIT
.......................................... 52
SYNALAR TS ..................... 52
SYNAREL............................ 64
SYNDROS ........................... 71
SYNERA .............................. 48
SYNJARDY ......................... 66
SYNJARDY XR................... 66
SYNRIBO ............................ 19
SYNTHROID ....................... 66
SYPRINE ............................. 54
T T
30 INFUSION SET .......... 61
90 INFUSION SET 23 ..... 61
SLIM ................................ 61
SLIM G4........................... 61
TABLOID ............................ 19
TABRECTA ......................... 19
TACLONEX ........................ 44
tacrolimus ....................... 19, 45
tadalafil ........................... 95, 96
tadalafil (pulm. hypertension)
.......................................... 94
TAFINLAR .......................... 19
TAGRISSO .......................... 19
TAKE ACTION ................... 83
TAKHZYRO ........................ 94
TALICIA .............................. 73
TALZENNA ......................... 19
TAMIFLU ............................ 11
tamoxifen .............................. 19
tamsulosin ............................. 95
TAPAZOLE ......................... 57
TAPERDEX ......................... 57
TARCEVA ........................... 19
TARGADOX ........................ 16
TARGRETIN ....................... 19
tarina 24 fe ............................ 83
tarina fe 1/20 (28) ................. 83
TARKA ................................ 38
taron-c dha .......................... 100
taron-prex prenatal-dha ...... 100
TASIGNA ............................. 19
TASMAR ............................. 23
tavaborole ............................. 50
TAYTULLA ......................... 83
tazarotene .............................. 48
TAZORAC ........................... 48
taztia xt ................................. 38
TAZVERIK .......................... 19
TDVAX ................................ 76
TECFIDERA ........................ 74
TEGRETOL ......................... 22
TEGRETOL XR ................... 22
TEGSEDI ............................. 24
TEKTURNA ......................... 38
TEKTURNA HCT ................ 38
TELCARE CONTROL ........ 61
telmisartan ............................ 38
telmisartan-amlodipine ......... 38
telmisartan-hydrochlorothiazid
.......................................... 38
temazepam ............................ 34
TEMIXYS ............................ 11
TEMODAR .......................... 19
TEMOVATE ........................ 52
temozolomide ....................... 20
tencon ................................... 28
TENIVAC (PF) .................... 76
tenofovir disoproxil fumarate
.......................................... 11
TENORETIC 100 ................. 38
TENORETIC 50 ................... 38
TENORMIN ......................... 39
terazosin ................................ 39
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
124
terbinafine hcl ......................... 9
terbutaline ............................. 94
terconazole ........................... 80
TERIPARATIDE ................. 77
TERSI FOAM ...................... 44
TESSALON PERLES .......... 91
TESTOPEL .......................... 64
testosterone ..................... 64, 65
TESTOSTERONE ............... 64
testosterone cypionate .......... 64
testosterone enanthate .......... 64
TESTRED ............................ 65
TETANUS,DIPHTHERIA
TOX PED(PF) .................. 76
tetrabenazine......................... 24
tetracaine hcl ........................ 87
TETRACAINE HCL (PF) .... 87
tetracycline ........................... 16
TEXACORT......................... 52
THALOMID......................... 20
THEO-24 .............................. 94
theophylline .......................... 94
THIOLA ............................... 54
THIOLA EC ......................... 54
thioridazine ........................... 34
thiothixene ............................ 34
THRIVITE RX ................... 100
THYROLAR-1 ..................... 66
THYROLAR-1/2 .................. 66
THYROLAR-1/4 .................. 66
THYROLAR-2 ..................... 66
THYROLAR-3 ..................... 66
tiadylt er................................ 39
tiagabine ............................... 22
TIAZAC ............................... 39
TIBSOVO............................. 20
TIGAN ................................. 71
TIGLUTIK ........................... 54
tilia fe.................................... 83
TIMOL-BRIMON-DORZO-
LATANOP(PF) ................ 88
timolol maleate ............... 39, 85
TIMOLOL-BRIMONIDI-
DORZOLAM(PF) ............ 88
TIMOLOL-DORZOLAMID-
LATANOP(PF) ................ 88
TIMOLOL-
LATANOPROST(PF) ...... 88
TIMOPTIC ........................... 85
TIMOPTIC-XE .................... 85
tinidazole .............................. 14
TIROSINT ............................ 66
TIROSINT-SOL ................... 66
tis-u-sol pentalyte ................. 53
TIVICAY.............................. 11
TIVICAY PD ....................... 11
tizanidine .............................. 25
TOBI PODHALER .............. 14
TOBRADEX ........................ 88
TOBRADEX ST................... 88
tobramycin ...................... 14, 85
tobramycin in 0.225 % nacl .. 14
TOBRAMYCIN WITH
NEBULIZER .................... 14
tobramycin-dexamethasone .. 88
TOBREX .............................. 85
TODAY CONTRACEPTIVE
SPONGE .......................... 80
TOLAK ................................ 45
tolcapone .............................. 23
tolmetin ................................. 30
tolterodine ............................. 95
tolvaptan ............................... 65
TOPICORT .......................... 52
topiramate ............................. 22
toremifene ............................. 20
torsemide .............................. 39
TOSYMRA .......................... 24
TOUJEO MAX U-300
SOLOSTAR ..................... 63
TOUJEO SOLOSTAR U-300
INSULIN .......................... 63
tovet emollient ...................... 52
TOVIAZ ............................... 95
TRACLEER ......................... 94
TRADJENTA ....................... 66
tramadol ................................ 30
TRAMADOL ....................... 30
tramadol-acetaminophen ...... 30
trandolapril ........................... 39
trandolapril-verapamil .......... 39
tranexamic acid..................... 80
TRANXENE T-TAB ............ 34
tranylcypromine.................... 34
TRAVATAN Z..................... 88
travoprost .............................. 88
trazodone .............................. 34
TRECATOR ......................... 14
TRELEGY ELLIPTA ........... 94
TREMFYA ........................... 44
TRESIBA FLEXTOUCH U-
100 .................................... 63
TRESIBA FLEXTOUCH U-
200 .................................... 63
TRESIBA U-100 INSULIN . 63
tretinoin ................................. 48
tretinoin (antineoplastic) ....... 20
tretinoin microspheres .......... 48
TRETIN-X ............................ 48
TRETIN-X CREAM KIT ..... 48
TREXALL ............................ 20
TREZIX ................................ 28
tri femynor ............................ 84
triamcinolone acetonide .. 52, 56
TRIAMCINOLON-
MOXIFLOX-WATR(PF) . 88
triamterene ............................ 39
triamterene-hydrochlorothiazid
.......................................... 39
trianex ................................... 52
triazolam ............................... 34
TRICARE ........................... 100
triderm .................................. 53
TRIDESILON ....................... 53
trientine ................................. 54
TRIESENCE (PF) ................ 57
tri-estarylla ............................ 84
TRIFERIC .......................... 100
trifluoperazine ....................... 34
trifluridine ............................. 85
trihexyphenidyl ..................... 23
TRIJARDY XR .................... 66
TRIKAFTA .......................... 94
tri-legest fe ............................ 84
tri-linyah ............................... 84
TRILIPIX ............................. 43
tri-lo-estarylla ....................... 84
tri-lo-marzia .......................... 84
tri-lo-mili .............................. 84
tri-lo-sprintec ........................ 84
trilyte with flavor packets ..... 71
trimethobenzamide ............... 71
trimethoprim ......................... 16
tri-mili ................................... 84
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
125
trimipramine ......................... 34
TRI-MIX (PAPAVRN-
PHNTLMN-PGE1) .......... 96
TRIMO-SAN JELLY ........... 80
trinatal rx 1 ......................... 100
trinate .................................. 100
TRINAZ ............................. 100
TRINTELLIX....................... 34
tri-previfem (28) ................... 84
tri-sprintec (28) ..................... 84
TRISTART DHA ............... 100
TRIUMEQ ............................ 11
triveen-duo dha ................... 100
tri-vitamin with fluoride ..... 100
trivora (28)............................ 84
tri-vylibra .............................. 84
tri-vylibra lo.......................... 84
TRIZIVIR ............................. 11
TROKENDI XR ................... 22
tropicamide ........................... 86
trospium ................................ 95
TRUE METRIX LEVEL 1 .. 62
TRUECONTROL LEVEL 0 62
TRULANCE......................... 71
TRULICITY ......................... 66
TRUMENBA ....................... 76
TRUSOPT ............................ 88
TRUSTEEL INFUSION SET
32 ...................................... 62
TRUVADA .......................... 11
TUKYSA .............................. 20
tulana .................................... 80
TURALIO ............................ 20
TUSSICAPS ......................... 91
TUXARIN ER ...................... 91
TUZISTRA XR .................... 91
TWINRIX (PF) .................... 76
TYBOST .............................. 11
tydemy .................................. 84
TYKERB .............................. 20
TYMLOS ............................. 77
TYPHIM VI ......................... 76
TYVASO .............................. 94
TYVASO REFILL KIT ....... 94
TYVASO STARTER KIT ... 94
U UBRELVY ........................... 24
UCERIS ................................ 71
UDENYCA .......................... 73
ULESFIA.............................. 53
ULTOMIRIS ........................ 54
ULTRACET ......................... 30
ULTRAM ............................. 30
ULTRAVATE ...................... 53
UNISTRIP LOW CONTROL
.......................................... 62
unithroid ............................... 66
UPTRAVI ............................. 39
URELLE ............................... 96
uretron d-s............................. 96
URIBEL................................ 96
urimar-t ................................. 96
urin ds ................................... 96
uro-458 ................................. 96
UROCIT-K 10 ...................... 96
UROCIT-K 15 ...................... 96
UROCIT-K 5 ........................ 96
urogesic-blue ........................ 96
uro-mp .................................. 96
UROQID-ACID NO.2.......... 96
URSO 250 ............................ 71
URSO FORTE ...................... 71
ursodiol ................................. 71
uryl........................................ 96
ustell ..................................... 96
UTIBRON NEOHALER ...... 94
utira-c.................................... 96
V vaginal contraceptive foam .. 80
valacyclovir .......................... 11
VALCHLOR ........................ 45
VALCYTE ........................... 11
valganciclovir ....................... 11
valproic acid ......................... 22
valproic acid (as sodium salt)
.......................................... 22
valsartan................................ 39
valsartan-hydrochlorothiazide
.......................................... 39
VALTOCO ........................... 22
vanadom ............................... 25
VANATOL LQ .................... 28
VANATOL S ....................... 28
VANCOCIN ......................... 16
vancomycin .......................... 16
vandazole .............................. 80
VANOXIDE-HC .................. 48
VANTAS .............................. 20
VAQTA (PF) ........................ 76
vardenafil .............................. 96
VARISOFT INFUSION SET
43 ...................................... 62
VARIVAX (PF) .................... 76
VARIZIG .............................. 76
VARUBI ............................... 71
VASCEPA ............................ 43
VASERETIC ........................ 39
VASOTEC ............................ 39
VAXCHORA VACCINE ..... 76
VCF CONTRACEPTIVE
FILM ................................. 80
VCF CONTRACEPTIVE GEL
.......................................... 81
VECAMYL .......................... 43
VECTICAL .......................... 44
velivet triphasic regimen (28)
.......................................... 84
VELPHORO ......................... 71
VEMLIDY ............................ 11
VENCLEXTA ...................... 20
VENCLEXTA STARTING
PACK ............................... 20
venlafaxine ........................... 35
VENTAVIS .......................... 94
VENTOLIN HFA ................. 94
verapamil .............................. 39
VERASENS CONTROL
SOLN-LEVEL 1 ............... 62
VEREGEN ........................... 45
VERELAN ........................... 39
VERELAN PM ..................... 39
VERSACLOZ ....................... 35
VERZENIO .......................... 20
VFEND ................................... 9
V-GO 20 ............................... 62
V-GO 30 ............................... 62
V-GO 40 ............................... 62
VIBERZI .............................. 71
VIBRAMYCIN .................... 16
VIEKIRA PAK ..................... 11
vienva ................................... 84
vigabatrin .............................. 22
vigadrone .............................. 22
VIGAMOX ........................... 85
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
126
VIIBRYD ............................. 35
VIMOVO ............................. 30
VIMPAT............................... 22
VINATE DHA RF ............. 100
VIOKACE ............................ 71
viorele (28) ........................... 84
VIRACEPT .......................... 11
VIRAMUNE ........................ 11
VIRAMUNE XR .................. 11
VIRAZOLE .......................... 11
VIREAD ......................... 11, 12
virt-c dha ............................ 100
virt-nate dha........................ 100
virt-pn dha .......................... 100
virt-pn plus ......................... 100
virtussin ac............................ 91
virtussin dac.......................... 91
VISTARIL ............................ 90
VISTOGARD ....................... 16
VITAFOL FE PLUS .......... 100
VITAFOL FE+ (WITH
DOCUSATE) ................. 100
VITAFOL GUMMIES ....... 100
VITAFOL NANO .............. 101
VITAFOL ULTRA ............ 101
VITAFOL-OB .................... 101
VITAFOL-OB+DHA ......... 101
VITAFOL-ONE ................. 101
VITAMED MD ONE RX .. 101
VITAMEDMD REDICHEW
RX .................................. 101
vitamin b complex .............. 101
vitamin b complex-folic acid
........................................ 101
vitamin d3 ........................... 101
vitamin k ............................... 41
vitamin k1 ............................. 41
vitamins a,c,d and fluoride . 101
VITAPEARL ...................... 101
VITATRUE ........................ 101
VITRAKVI........................... 20
VIVAGUARD INO CTRL
SOLN-L1,2,3 .................... 62
VIVOTIF .............................. 76
VIZIMPRO........................... 20
VOGELXO........................... 65
volnea (28)............................ 84
VOLTAREN ........................ 30
voriconazole ........................... 9
VOSEVI ............................... 12
VOTRIENT .......................... 20
vp-ch-pnv............................ 101
VP-PNV-DHA.................... 101
VRAYLAR ........................... 35
vtol lq .................................... 28
VUMERITY ......................... 74
VUSION ............................... 50
vyfemla (28) ......................... 84
VYLEESI ............................. 35
vylibra ................................... 84
VYNDAMAX ...................... 43
VYNDAQEL ........................ 43
VYVANSE ........................... 35
VYZULTA ........................... 88
W WAKIX ................................ 35
warfarin ................................ 41
water for irrigation, sterile .... 54
WAVESENSE CONTROL
SOLUTION ...................... 62
WELCHOL .......................... 43
WELLBUTRIN XL .............. 35
wera (28)............................... 84
westhroid .............................. 66
WIDE-SEAL DIAPHRAGM
.......................................... 78
WILATE ............................... 41
wintergreen oil ...................... 45
wixela inhub ......................... 94
women's gentle laxative(bisac)
.......................................... 71
women's laxative (bisacodyl)71
wymzya fe ............................ 84
X XALKORI ............................ 20
XARELTO ........................... 41
XARELTO DVT-PE TREAT
30D START ..................... 41
XCOPRI ............................... 22
XCOPRI MAINTENANCE
PACK ............................... 22
XCOPRI TITRATION PACK
.......................................... 22
XELJANZ ............................ 78
XELJANZ XR ...................... 78
XELODA.............................. 20
XENLETA ............................ 14
XEPI ..................................... 49
XERAVA ............................. 16
XERESE ............................... 50
XERMELO ........................... 20
XGEVA ................................ 16
XHANCE ............................. 94
XIFAXAN ............................ 14
XIGDUO XR ........................ 66
XIIDRA ................................ 87
XOFLUZA ........................... 12
XOLAIR ............................... 94
XOLEGEL ............................ 50
XOPENEX ........................... 95
XOPENEX CONCENTRATE
.......................................... 95
XOSPATA ............................ 20
XTANDI ............................... 20
xulane ................................... 81
XULTOPHY 100/3.6 ........... 63
XURIDEN ............................ 54
XYOSTED ........................... 65
XYREM ................................ 35
XYWAV ............................... 35
Y YAZ (28) .............................. 84
YF-VAX (PF) ....................... 76
YONSA ................................ 20
YOSPRALA ......................... 41
YUPELRI ............................. 95
YUTIQ .................................. 89
yuvafem ................................ 80
Z zafirlukast ............................. 95
zaleplon ................................. 35
ZANAFLEX ......................... 25
zarah ..................................... 84
ZARONTIN .......................... 22
ZARXIO ............................... 73
zatean-pn dha ...................... 101
zatean-pn plus ..................... 101
ZCORT ................................. 57
zebutal ................................... 28
ZEJULA ............................... 20
ZELBORAF ......................... 20
ZELNORM ........................... 71
ZEMBRACE SYMTOUCH . 24
ZEMPLAR ........................... 65
QL: Quantity Limit ST: Step Therapy PA:Prior Authorization LA:Limited Availability OTC:Over the
Counter ACA: Affordable Care Act
127
zenatane ................................ 48
ZENPEP ............................... 71
zenzedi .................................. 35
ZENZEDI ............................. 35
ZEPATIER ........................... 12
ZEPOSIA ............................. 74
ZEPOSIA STARTER KIT ... 74
ZEPOSIA STARTER PACK
.......................................... 74
ZERVIATE .......................... 87
ZESTORETIC ...................... 39
ZESTRIL .............................. 39
ZIAC..................................... 39
ZIAGEN ............................... 12
ZIANA ................................. 48
zidovudine ............................ 12
ZIEXTENZO ........................ 73
zileuton ................................. 95
ZILXI ................................... 48
zingiber ............................... 101
ZIOPTAN (PF) ..................... 88
ziprasidone hcl ...................... 35
ZIRGAN ............................... 85
ZITHROMAX ...................... 13
ZITHROMAX TRI-PAK ..... 13
ZITHROMAX Z-PAK ......... 13
ZOFRAN .............................. 71
ZOHYDRO ER .................... 28
ZOLINZA ............................. 20
zolmitriptan .......................... 24
zolpidem ............................... 35
ZOLPIMIST ......................... 35
ZOMIG ................................. 24
ZONALON ........................... 45
zonisamide ............................ 22
ZONTIVITY ........................ 41
ZORBTIVE .......................... 73
ZORTRESS .......................... 20
ZOSTAVAX (PF) ................ 76
zovia 1/35e (28) .................... 84
ZOVIRAX ...................... 12, 50
ZTLIDO ................................ 48
Z-TUSS AC .......................... 91
zumandimine (28) ................. 84
ZUPLENZ ............................ 71
ZYDELIG ............................. 20
ZYFLO ................................. 95
ZYKADIA ............................ 20
ZYLET ................................. 88
ZYLOPRIM .......................... 76
ZYMAXID ........................... 85
ZYPITAMAG ....................... 43
ZYPREXA ............................ 35
ZYPREXA ZYDIS ............... 35
ZYTIGA ............................... 20
ZYVOX ................................ 14