Effective July 1, 2018
Your 2018 Prescription Drug ListTraditional Four-TierThis Prescription Drug List (PDL) is accurate as of July 2018 and is subject to change after this date. The next anticipated update will be January 2019. This PDL applies to members of our UnitedHealthcare medical plans with a pharmacy benefit. Your estimated coverage and copayment/coinsurance may vary based on the benefit plan you choose and the effective date of the plan.
Drug tiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Restrictions on which medications are covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Drugs by category . . . . . . . . . . . . . . . . . . . . . . . 8
Anti-InfectivesAntibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Cardiovascular/Heart DiseaseCoagulation Therapy . . . . . . . . . . . . . . . . . . . . . . 9High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . 9High Cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . 10Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Central Nervous SystemAttention Deficit Disorder . . . . . . . . . . . . . . . . . . 10Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . 11Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . . 11Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . . . 12
Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
DiabetesBlood Glucose Monitoring . . . . . . . . . . . . . . . . . 13Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . . . . . 14Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Thyroid Hormone Replacement . . . . . . . . . . . . 14
Eye ConditionsAllergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Dry Eye Disease . . . . . . . . . . . . . . . . . . . . . . . . . 14Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . . . . . 15Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . . . 15Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Hepatitis C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Inflammatory Conditions: RheumatoidArthritis, Crohn’s Disease, Psoriasis,Ulcerative Colitis . . . . . . . . . . . . . . . . . . . . . . . . 16
Medications for Sexual Dysfuntion . . . . . . . 16
Men’s HealthProstate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Testosterone Therapy . . . . . . . . . . . . . . . . . . . . . 17
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . 17
MusculoskeletalMuscle Spasms . . . . . . . . . . . . . . . . . . . . . . . . . . 17Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Overactive Bladder . . . . . . . . . . . . . . . . . . . . . . 18
RespiratoryAllergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . 18Pulmonary Arterial Hypertension . . . . . . . . . . . 19
Smoking Cessation . . . . . . . . . . . . . . . . . . . . . 19
Transplant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Vitamins/Electrolytes . . . . . . . . . . . . . . . . . . . 19
Women’s HealthContraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . 19Hormone Replacement . . . . . . . . . . . . . . . . . . . 22Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . 22
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Table of Contents
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We want to help you better understand your medication options.Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we’ve included some of the most commonly asked questions about the Prescription Drug List (PDL).
What is a PDL?This document is a list of the most commonly prescribed medications. It includes both brand-name and generic prescription medications approved by the Food and Drug Administration (FDA). Medications are listed by common categories or classes and placed in tiers that represent the cost you pay out-of-pocket. They are then listed in alphabetical order. Bring this list with you when you see your doctor. It makes it easier for you and your doctor to make informed decisions about your medications and may help you save money.
Please note: Where differences are noted between this PDL and your benefit plan documents, the benefit plan documents will rule. It is not a complete list of medications, and not all medications listed may be covered under your plan. Please look at your benefit plan documents provided by your employer or health plan to see which medications are covered under your plan.
What is a tier?Tiers indicate the amount you pay for your prescription, which is determined by your employer or benefit plan. Tier 1 medications provide the highest overall value with the lowest out-of-pocket costs. Choosing medications in lower tiers may save you money. Ask your doctor if a Tier 1, Tier 2 or Tier 3 option could work for you.
Your Cost Drug Tier1 What’s Covered Helpful Hints
$ Lowest 1
Medications that provide the highest overall value. Mostly generic drugs. Some brand drugs may also be included.
Use Tier 1 drugs for the lowest out-of-pocket costs.
$$ Mid-range 2 and 3 Medications that provide good overall value. A
mix of brand-name and generic drugs.
Use Tier 2 or Tier 3 drugs, instead of Tier 4 to help reduce your out-of-pocket costs.
$$$ Higher 4 Medications that provide the lowest overall value.
Mostly brand drugs, as well as some generics.Ask your doctor if a Tier 1, Tier 2 or Tier 3 option could work for you.
1 Some plans may have different tiers. If you have a high deductible plan, the tier cost levels may apply once you hit your deductible.
Who decides which medications are covered? Thousands of medications are already available and more come to the market regularly. Often, several medications are available to treat the same condition.
The UnitedHealthcare® Pharmacy and Therapeutics Committee, which includes both internal and external physicians and pharmacists, meets regularly to provide clinical reviews of all medications. Using this information, the PDL Management Committee, which includes senior UnitedHealth Group® physicians and business leaders, meets to evaluate overall health care value. They also determine coverage and tier status for all medications.
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How is the overall value of a medication determined?Many sources and factors are considered, including:
• Clinical Value: How safe and effective a medication is compared to other medications used to treat the same or similar medical conditions.
• Cost: How much a medication costs compared to other medications used to treat similar medical conditions.
• Outcomes Data: Studies that show how a medication may affect total health care costs.
Why are certain medications excluded?We review medications based on their total value, including effectiveness and safety, how much they cost, and the availability of alternative medications to treat the same or similar medical conditions. Certain medications may be excluded from coverage or subject to prior authorization (sometimes referred to as precertification) if similar alternatives are available at a lower cost.
Examples include medications that work the same way, but one is much more expensive than the other, or options that are available without a prescription (also referred to as over-the-counter medications). There are also some instances where the same product can be made by two or more manufacturers, but greatly vary in cost. In these instances, only the lower-cost product may be covered. You should review your benefit plan documents to confirm if any medications are excluded from your plan. You can log in to the member website listed on your health plan ID card at any time to check your medication coverage. Talk to your doctor to see if there are lower-cost options or over the counter medications available.
What is the difference between brand-name and generic medications?Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes, the same company that makes a brand-name medication also makes the generic version.
What if my doctor writes a brand-name prescription?The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. For some benefit plans, if a brand-name drug is prescribed and a generic equivalent is available, your cost share may be the copay PLUS the cost difference between the brand-name drug and generic equivalent.
How often are PDLs updated?PDL changes typically occur twice per year. However, changes that have a positive impact for you — such as new medications or cost savings — may occur at any time. You can log in to the member website listed on your health plan ID card at any time to check your medication coverage and lower-cost options.
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Can a medication change tiers?Yes. Tier changes may generally occur two times per year. When a medication changes tiers, you may pay more or less for that medication, depending on the tier change. If one of your medications changes tiers, speak with your doctor to determine if a lower-cost option may be available for you.
Are there other restrictions on which medications are covered?Yes. Some medications may have additional requirements or limits depending on your benefit plan. You should review your benefit plan documents to confirm if any of these programs apply to your plan. The medications that have programs that apply are noted with letters next to them. Examples include:
May be excluded from coverage or subject to prior authorization and/or trial/failure of another medication(s). (referred to as First Start in New Jersey) (E) Lower-cost options are available and covered.
Health Care Reform Preventive (H) This medication is part of a health care reform preventive benefit and may be available at no cost to you.
Health Care Reform Preventive with prior authorization (H-PA) May be part of healthcare reform preventive and at no cost to you if prior authorization criteria is met.
Prior Authorization (sometimes referred to as precertification) (PA) Requires your doctor to provide information about why you are taking a medication to determine how it may be covered by your plan.
Refill and Save Program (RS) Save money on your copayment when you refill your prescription on time as prescribed. Program eligibility may vary.
Specialty Medication (SP) Specialty medications treat complex or rare conditions and may require special storage and handling. You may be required to obtain these medications from a specialty pharmacy.
Step Therapy (referred to as First Start in New Jersey) (ST) Requires you to try one or more other medications before the medication you are requesting may be covered.
Supply Limits (SL) Specifies the largest quantity of medication covered per copayment or in a defined period of time.
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I’m taking a specialty medication. Who can I contact for more information?Specialty medications are high-cost and are used to treat rare or complex conditions that require additional care and support. For most plans, these medications are managed through the specialty pharmacy program. Take advantage of personalized support designed to help you get the most out of your treatment plan. Visit the member website listed on your health plan ID card or call the toll-free phone number on your ID card to learn more.
Please note, not all specialty medications are listed here. If you’re taking a specialty medication that is on a higher tier, call the toll-free number on your health plan ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program.
Who can I contact if I have questions about my PDL?Online
Log in to the member website listed on your health plan ID card. Once online, you’ll have access to the following information and tools:• Pharmacy benefit and coverage information• Possible lower-cost medication options• Medication interactions and side effects• Participating retail pharmacies by ZIP code• Your prescription history
And, if home delivery services are included in your pharmacy benefit, you can also:• Refill prescriptions• Check the status of your order• Set up reminders for refills• Manage your account
Check your PDL often for updates.
By phone
Call the toll-free number on your health plan ID card to speak with a customer service representative. We can answer any questions you have about your pharmacy benefit plan including lower-cost options.
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Bold type = Brand-name drug[Plain type = Generic drug]
E = May be excluded from coverageH = May be part of health care reform preventiveH-PA = May be part of health care reform preventive with prior authorization
PA = Prior authorization requiredRS = May be eligible for the refill and save programSL = Supply limitSP = Specialty medicationST = Step therapy
Drug Name Drug Tier
Requirements & Limits
Anti-Infectives: AntibioticsAmoxicillin Capsule, Chewable Tablet 1
Amoxicillin/Potassium Clavulanate Chewable Tablet, Tablet 1
Azithromycin Tablet 1
Cefadroxil Capsule, Tablet 1
Cefdinir Capsule 1
Cefixime Suspension 1
Cefprozil Tablet 1
Cefuroxime Tablet 1
Cephalexin Capsule 1
Ciprodex 3
Ciprofloxacin Tablet 1
Clarithromycin Tablet 1
Clindamycin Capsule 1
Dificid 3 SL
Doxycycline Hyclate 50, 100 mg Capsule, Tablet 1
Doxycycline Monohydrate 50, 100 mg Capsule 1
Levofloxacin Tablet 1
Metronidazole Tablet 1
Minocycline Capsule 1
Minocycline Tablet 1 E
Moxifloxacin Tablet 1
Nitrofurantoin Capsule 1
Nitrofurantoin Macrocrystal Capsule 1
Ofloxacin Otic Solution 1
Ofloxacin Tablet 1
Penicillin V Potassium Tablet 1
Sulfamethoxazole-Trimethoprim Tablet 1
Suprax Capsule, Chewable Tablet, Tablet 4
Drug Name Drug Tier
Requirements & Limits
Anti-Infectives: Antifungals
Cresemba 3 SL
Econazole Cream 1 SL
Fluconazole Tablet 1
Itraconazole Capsule 1 SL
Ketoconazole Cream 1 SL
Noxafil Tablet, Suspension 2
Nystatin Cream, Ointment 1
Terbinafine Tablet 1 SL
Anti-Infectives: Antivirals
Acyclovir Ointment 1 PA, SL, ST
Acyclovir Tablet 1
Famciclovir Tablet 1
Oseltamivir Capsule, Suspension 1 SL
Valacyclovir Tablet 1 SL
Valganciclovir 1 SL
Zovirax Cream 4 E, SL
Cancer
Alunbrig 2 PA, SL, SP
Bexarotene Capsule 4 E, PA, S, SPL
Bicalutamide 1
Bosulif 2 PA, SL, SP, ST
Cyclophosphamide Capsule 2
Hydroxyurea Capsule 1
Idhifa 2 PA, SL, SP
Imatinib Tablet 1 PA, SL, SP
Imbruvica 2 PA, SL, SP
Leucovorin Calcium Tablet 1
Mercaptopurine Tablet 1
Revlimid 2 PA, SL, SP
Rydapt 2 PA, SL, SP
Sutent 2 PA, SL, SP
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Drug Name Drug Tier
Requirements & Limits
Targretin Capsule 1 SP
Targretin Gel 3 SL
Tasigna 2 PA, SL, SP, ST
Xeloda 1 SL, SP
Zykadia 2 PA, SL, SP
Zytiga 2 PA, SL, SP
Cardiovascular/Heart Disease: Coagulation Therapy
Bevyxxa 3 SL
Brilinta 4 SL
Clopidogrel 1
Eliquis 4 SL
Enoxaparin Sodium 1 SL
Pradaxa 2 SL
Prasugrel 1 SL
Savaysa 4 SL
Warfarin Sodium 1
Xarelto 2 SL
Cardiovascular/Heart Disease: High Blood Pressure
Amlodipine 1
Amlodipine-Benazepril 1
Amlodipine-Valsartan 1
Atenolol 1
Atenolol-Chlorthalidone 1
Benazepril 1
Benazepril-Hydrochlorothiazide 1
Bidil 2
Bisoprolol 1
Bisoprolol-Hydrochlorothiazide 1
Bystolic 2
Byvalson 2 SL
Cartia XT 1
Carvedilol Immediate-Release Tablet 1
Chlorthalidone 1
Clonidine Tablet 1
Diltiazem 24 Hour CD 1
Diltiazem Sustained-Release Capsule 1
Drug Name Drug Tier
Requirements & Limits
Diltiazem Sustained-Release Tablet 1
Doxazosin 1
Edarbi 3 SL
Edarbyclor 3 SL
Enalapril 1
Furosemide 1
Guanfacine 1
Hydralazine 1
Hydrochlorothiazide 1
Irbesartan 1
Labetalol 1
Lisinopril 1
Lisinopril-Hydrochlorothiazide 1
Losartan 1
Losartan-Hydrochlorothiazide 1
Metoprolol Succinate Extended-Release 50, 100, 200 mg 1
Metoprolol Tartrate 25, 50, 100 mg 1
Nadolol 1
Nifedipine Extended-Release 1
Olmesartan 1 SL
Olmesartan-Hydrochlorothiazide 1 SL
Propranolol Extended-Release Capsule 1
Propranolol Tablet 1
Quinapril 1
Ramipril 1
Spironolactone 1
Telmisartan 1
Telmisartan-Hydrochlorothiazide 1
Terazosin 1
Triamterene-Hydrochlorothiazide 1
Valsartan 1
Valsartan-Hydrochlorothiazide 1
Verapamil 1
Verapamil Sustained-Release 1
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Bold type = Brand-name drug[Plain type = Generic drug]
E = May be excluded from coverageH = May be part of health care reform preventiveH-PA = May be part of health care reform preventive with prior authorization
PA = Prior authorization requiredRS = May be eligible for the refill and save programSL = Supply limitSP = Specialty medicationST = Step therapy
Drug Name Drug Tier
Requirements & Limits
Cardiovascular/Heart Disease: High Cholesterol
Atorvastatin 1 H-PA, SL
Choline Fenofibrate 1 E
Ezetimibe Tablet 1 SL
Ezetimibe/Simvastatin 1 SL
Fenofibrate 54, 160 mg Tablet 1
Fluvastatin Extended-Release Tablet 1 SL, ST
Gemfibrozil 1
Livalo 4 E, SL, ST
Lovastatin 1 H
Niacin Extended-Release Tablet 1
Niaspan 3
Omega-3-Acid Ethyl Esters Capsule 1 PA
Praluent 2 PA, SL, SP, ST
Pravastatin 1
Repatha 4 PA, SL, SP, ST
Rosuvastatin 1 SL
Simvastatin 1 H-PA
Vascepa 4 PA
Welchol 2
Cardiovascular/Heart Disease: Other
Amiodarone 1
Corlanor 3 PA, SL
Digoxin 1
Entresto 4 PA, SL
Flecainide 1
Isosorbide Mononitrate ER 1
Multaq 4 PA
Nitroglycerin Sublingual Tablet 1
Ranexa 2
Sotalol 1
Drug Name Drug Tier
Requirements & Limits
Central Nervous System: Attention Deficit Disorder
Adderall XR 1 PA, SL
Amphetamine Salt Combo 1 PA
Atomoxetine 1 SL
Concerta 1 PA, SL
Dexmethylphenidate Immediate-Release Tablet 1 PA
Dextroamphetamine-Amphetamine Immediate-Release Tablet 1 PA
Dextroamphetamine Sulfate Immediate-Release Tablet 1 PA
Guanfacine Extended-Release 1 SL
Methylphenidate Chewable Tablet 1 PAMethylphenidate Extended-Release Capsule (generic Metadate CD, Ritalin LA)
1 PA, SL
Methylphenidate Extended-Release Capsule (Metadate ER, generic Ritalin SR)
1 PA, SL
Methylphenidate Extended-Release Tablet (generic Concerta) 4 E, PA, SL
Methylphenidate Immediate-Release Tablet 1 PA
Vyvanse 2 PA, SL
Central Nervous System: Depression
Amitriptyline Tablet 1
Bupropion Extended-Release Tablet 1
Bupropion Sustained-Release Tablet 1
Bupropion Tablet 1
Citalopram Tablet 1
Desvenlafaxine Extended-Release Tablet (generic Pristiq) 1 SL
Doxepin 1
Duloxetine Capsule 1 SL
Escitalopram Tablet 1
Fetzima 4 SL, ST
Fluoxetine Capsule (generic Prozac) 1
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Drug Name Drug Tier
Requirements & Limits
Fluvoxamine Tablet 1
Mirtazapine Tablet 1
Nortriptyline Capsule 1
Paroxetine Tablet 1
Sertraline Tablet 1
Trazodone Tablet 1
Trintellix 4 SL, ST
Venlafaxine Extended-Release Capsule 1
Venlafaxine Tablet 1
Viibryd 4 SL
Central Nervous System: MigraineAcetaminophen/Butalbital/Caffeine 325 mg/50 mg/40 mg 1 SL
Eletriptan 1 SL
Frovatriptan 1 SL
Naratriptan 1 SL
Rizatriptan ODT, Tablet 1 SL
Sumatriptan Nasal Spray 1 SL
Sumatriptan Succinate Tablet, Injection 1 SL
Central Nervous System: Multiple Sclerosis
Ampyra 2 PA, SL, SP
Aubagio 3 PA, SL, SP
Avonex 2 PA, SL, SP
Betaseron 2 PA, SL, SP
Copaxone 1 PA, SL, SP
Gilenya 3 PA, SL, SP
Glatiramer (generic Copaxone) 4 E, PA, SL, SP, ST
Plegridy 3 PA, SL, SP
Rebif 4 PA, SL, SP, ST
Tecfidera 2 PA, SL, SP
Zinbryta 4 PA, SL, SP
Central Nervous System: OtherAlprazolam Extended-Release Tablet 1
Alprazolam Tablet 1
Aripiprazole Tablet 1 SL
Drug Name Drug Tier
Requirements & Limits
Armodafinil 1 PA, SL
Austedo 2 PA, SL, SP
Buspirone Tablet 1
Carbidopa-Levodopa 1
Diazepam Tablet 1
Donepezil ODT, 5, 10 mg Tablet 1
Ingrezza 4 PA, SL, SP
Latuda 4 SL
Lithium Capsule 1
Lorazepam Tablet 1
Memantine Immediate-Release 1
Modafinil Tablet 1 PA, SL
Naloxone Vial 1
Narcan Nasal Spray 2 SL
Olanzapine Tablet 1 SL
Pramipexole Tablet 1
Quetiapine Extended-Release Tablet 1 SL
Quetiapine Immediate-Release Tablet 1
Risperidone Tablet 1
Ropinirole Tablet 1
Suboxone Film 4 E, PA, SL
Tolcapone 1
Xyrem 4 PA, SL
Zelapar 3
Ziprasidone Capsule 1 SL
Zubsolv 1 SL
Central Nervous System: Sedatives/Hypnotics
Eszopiclone Tablet 1 SL
Temazepam Capsule 1
Triazolam Tablet 1
Zaleplon Capsule 1 SL
Zolpidem Extended-Release Tablet 1 E, SL
Zolpidem Immediate-Release Tablet 1 SL
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Bold type = Brand-name drug[Plain type = Generic drug]
E = May be excluded from coverageH = May be part of health care reform preventiveH-PA = May be part of health care reform preventive with prior authorization
PA = Prior authorization requiredRS = May be eligible for the refill and save programSL = Supply limitSP = Specialty medicationST = Step therapy
Drug Name Drug Tier
Requirements & Limits
Central Nervous System: Seizure DisordersCarbamazepine Extended-Release Capsule, Tablet 1
Carbamazepine Immediate-Release Tablet 1
Clonazepam Tablet 1
Diazepam Tablet 1
Divalproex Delayed-Release Tablet 1
Divalproex Extended-Release Tablet 1
Gabapentin Capsule, Tablet 1
Lamotrigine Immediate-Release Tablet 1
Levetiracetam Extended-Release Tablet 1
Levetiracetam Immediate-Release Tablet 1
Lyrica 4 SL, ST
Oxcarbazepine Tablet 1
Phenytoin Capsule, Suspension 1
Topiramate Immediate-Release Tablet 1
Zonisamide Capsule 1
Dermatology
Aczone 1 SL
Adapalene 0.1%/Benzoyl Peroxide 2.5% Gel 1 E, SL
Adapalene Cream, Gel, Lotion 1 E, PA, SL
Betamethasone Dipropionate 0.05% Augmented Lotion, Ointment 1
Betamethasone Dipropionate 0.05% Cream, Ointment 1
Calcipotriene/Betamethasone Ointment 1 SL
Carac 2
Ciclopirox Cream, Gel, Lotion, Solution 1
Claravis 1 PA
Clindamycin 1.2%/Benzoyl Peroxide 5% Gel 1 SL
Drug Name Drug Tier
Requirements & Limits
Clindamycin Gel 1 SL
Clindamycin Lotion, Solution, Swabs 1
Clobetasol Propionate Cream, Ointment, Solution 1 SL
Clotrimazole-Betamethasone Cream 1 SL
Clotrimazole-Betamethasone Lotion 1
Dapsone 5% Gel 4 E, SL
Desonide 0.05% Cream, Lotion, Ointment 1 SL
Desoximetasone Cream, Gel, Ointment 1 SL
Diflorasone Diacetate 0.05% Cream 1 SL
Diflorasone Diacetate 0.05% Ointment 1
Dupixent 4 PA, SL, SP, ST
Elidel 3 SL, ST
Enstilar Foam 4 SL
Eucrisa 3 SL, ST
Finacea 4
Fluocinonide 0.05% Cream 1
Fluocinolone Cream, Oil, Ointment, Solution 1 SL
Fluorouracil 0.5% Cream 4 SL
Halobetasol Ointment 1 SL
Hydrocortisone 2.5% Cream, Ointment 1
Imiquimod 5% Cream 1 SL
Metronidazole 0.75% Topical Gel 1
Minocycline Extended-Release 1 E, PA
Mirvaso 4 SL
Mometasone Furoate Cream, Lotion, Ointment 1
Mupirocin Ointment 1 SL
Oracea 4
Oxsoralen-Ultra 2
Picato 3 SL
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Drug Name Drug Tier
Requirements & Limits
Regranex 2 PA, SL
Rhofade 4 PA, SL
Solodyn 4 E, PA
Taclonex Suspension 4 SL
Tacrolimus Ointment 1 SL, ST
Tazarotene 0.1% Cream (generic Tazorac) 4 E, PA, SL
Tazorac 0.1% Cream 1 PA, SL
Tazorac Gel, 0.05% Cream 4 PA, SL
Tretinoin Cream 1 PA, SL
Tretinoin Gel 1 E, PA, SL
Tretinoin Microspheres 1 E, PA, SL
Triamcinolone Acetonide Cream, Lotion, Ointment 1
Vectical 3 SL
Diabetes: Blood Glucose Monitoring
Accu-Chek Test Strips 4 E, SL
Contour Next 2
Contour Next EZ 2
Contour Next One 2
Contour Next Test Strips 2 SL
Contour Test Strips 4 E, SL
FreeStyle Test Strips 4 E, SL
OneTouch Test Strips 1 SL
OneTouch Ultra Mini 1
OneTouch Ultra Test Strips 1 SL
OneTouch Verio 1
OneTouch Verio Flex 1
OneTouch Verio IQ 1
OneTouch Verio Sync 1
OneTouch Verio Test Strips 1 SL
Diabetes: Insulin
Afrezza 4 E, PA, SL
Basaglar 1 SL
Humalog KwikPens (all formulations) 2 SL
Drug Name Drug Tier
Requirements & Limits
Humalog Vials (all formulations) 1 SL
Humulin KwikPens (all formulations) 2 SL
Humulin Vials (all formulations) 1 SL
Lantus Solostar 4 E, SL
Lantus Vials 4 E, SL
Levemir FlexTouch 2 SL
Levemir Vials 2 SL
Novolin Vials (all formulations) 4 SL, ST
Novolog FlexPen (all formulations) 4 SL, ST
Novolog Vials (all formulations) 4 SL, ST
Toujeo SoloStar 4 E, SL
Tresiba FlexTouch 4 E, SL
Diabetes: Non-Insulin
Adlyxin 4 SL
Bydureon 2 SL
Byetta 2 SL
Farxiga 4 SL, ST
Glimepiride 1
Glipizide 1
Glipizide Extended-Release 1
Glyburide 1
Glyxambi 4 E, SL, ST
Invokamet 2 SL
Invokamet XR 2 SL
Invokana 2 SL, ST
Janumet 4 SL, ST
Januvia 4 SL, ST
Jardiance 2 SL, ST
Jentadueto 2 SL
Jentadueto XR 2 SL
Kazano 2 SL
Kombiglyze XR 2 SL
Metformin 1
Metformin Extended-Release Tablet (generic Glucophage XR) 1
14
Bold type = Brand-name drug[Plain type = Generic drug]
E = May be excluded from coverageH = May be part of health care reform preventiveH-PA = May be part of health care reform preventive with prior authorization
PA = Prior authorization requiredRS = May be eligible for the refill and save programSL = Supply limitSP = Specialty medicationST = Step therapy
Drug Name Drug Tier
Requirements & Limits
Nesina 2 SL
Onglyza 2 SL
Oseni 2 SL
Pioglitazone 1 SL
Soliqua 2 PA, SL
Synjardy 2 SL
Synjardy XR 2 SL
Tradjenta 2 SL
Trulicity 3 SL
Victoza 2-Pak 2 SL
Victoza 3-Pak 3 SL
Xigduo XR 4 E, SL, ST
Xultophy 4 E, SL
Endocrine: Growth Hormone
Nutropin, Nutropin AQ 2 PA, SL, SP
Endocrine: Other
Calcitriol Capsule 1
Desmopressin Tablet 1
Dexamethasone Tablet 1
Methylprednisolone Tablet 1
Prenisolone Oral Solution 1
Prednisone Tablet 1
Endocrine: Thyroid Hormone Replacement
Armour Thyroid 3
Levothyroxine Sodium Tablet 1
Liothyronine Sodium Tablet 1
Methimazole Tablet 1
NP Thyroid Tablet 1
Synthroid 2
Drug Name Drug Tier
Requirements & Limits
Eye Conditions: AllergiesAzelastine 0.05% Ophthalmic Solution 1
Lastacaft 3 SL
Olopatadine 0.1% Ophthalmic Solution 1 SL
Eye Conditions: AntibioticsErythromycin 0.5% Ophthalmic Ointment 1
Gentamicin Ophthalmic Ointment, Solution 1
Moxeza 4
Moxifloxacin Ophthalmic Solution 1
Ofloxacin 0.3% Ophthalmic Solution 1
Tobramycin/Dexamethasone 0.3%-0.1% Ophthalmic Suspension 1
Tobramycin Ophthalmic Solution 1
Eye Conditions: Dry Eye Disease
Restasis Single Use Vial 4 PA, SL
Xiidra 4 PA, SL
Eye Conditions: Glaucoma
Alphagan P 0.1% 2 SL
Azopt 2 SL
Combigan 2 SL
Latanoprost 0.005% Ophthalmic Solution 1
Lumigan 2 SL
Timolol 0.25%, 0.5% Ophthalmic Solution 1
Travatan Z 2 SL
15
Drug Name Drug Tier
Requirements & Limits
Gastrointestinal: Acid Suppression
Dexilant 3 SL
Omeclamox-Pak 3 SL
Omeprazole Capsule 1
Pantoprazole Tablet 1
Pylera 3 SL
Rabeprazole Tablet 1 SL
Ranitadine Syrup 1
Sucralfate Tablet 1
Gastrointestinal: Nausea/Vomiting
Akynzeo 4 SL
Aprepitant Capsule 1 SL
Emend Suspension 2 SL
Ondansetron 1
Ondansetron ODT 1
Scopolamine Transdermal Patch 1
Varubi 2 SL
Gastrointestinal: Other
Amitiza 4 PA, SL, ST
Apriso 2
Canasa 2
Cortifoam 2
Creon 2
Diphenoxylate-Atropine Tablet 1
Golytely 2
Hyoscyamine Tablet 1
Lialda 1
Linzess 2 PA, SL
Mesalmine Delayed-Release Tablet (generic Lialda) 4 E
Metoclopramide Tablet 1
Movantik 2 PA, SL
Moviprep 3
Polyethylene Glycol 3350 1
Prepopik 3
Sulfasalazine Tablet 1
Drug Name Drug Tier
Requirements & Limits
Suprep 3
Uceris Foam 2
Uceris Tablet 4
Viberzi 4 PA, SL
Zenpep 2
Gout
Allopurinol Tablet 1
Mitigare 2
Uloric 4 SL, ST
Zurampic 4 PA, SL
Hepatitis C
Daklinza 4 PA, SL, SP, ST
Epclusa 2 PA, SL, SP
Harvoni 2 PA, SL, SP
Mavyret 2 PA, SL, SP
Ribavirin Tablet 1 SP
Sovaldi 4 PA, SL, SP, ST
Technivie 4 PA, SL, SP, ST
Viekira Pak 4 PA, SL, SP, ST
Viekira XR 4 PA, SL, SP, ST
Vosevi 2 PA, SL, SP
Zepatier 4 PA, SL, SP, ST
HIV/AIDS
Abacavir-Lamivudine 1 SP
Atazanavir Capsule 1 SP
Atripla 2 SP
Complera 4 SP
Descovy 4 SP
Efavirenz 1 SP
Epzicom 4 E, SP
Evotaz 2 SP
Genvoya 4 SP, ST
Intelence 2 SP
Isentress 2 SP
Kaletra Tablet 2 SP
16
Bold type = Brand-name drug[Plain type = Generic drug]
E = May be excluded from coverageH = May be part of health care reform preventiveH-PA = May be part of health care reform preventive with prior authorization
PA = Prior authorization requiredRS = May be eligible for the refill and save programSL = Supply limitSP = Specialty medicationST = Step therapy
Drug Name Drug Tier
Requirements & Limits
Lamivudine-Zidovudine 1 SP
Lopinavir-Ritonavir Oral Solution 1 SP
Nevirapine 1 SP
Nevirapine Extended-Release 1 E, SP
Norvir 2 SP
Odefsey 4 SP
Prezcobix 2 SP
Prezista 2 SP
Selzentry 3 PA, SP
Stribild 3 SP, ST
Tenofovir Tablet 1 SP
Tivicay 3 SP
Triumeq 2 SP
Truvada 4 SP
Tybost 2 SP
Vitekta 2 SP
Infertility2
Cetrotide 2 SP
Clomiphene 1 SP
Crinone 2 PA, ST
Endometrin 2 PA
Gonal-F 2 SP
Gonal-F RFF 2 SP
Ovidrel 3 SP2 Coverage is determined by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share.
Drug Name Drug Tier
Requirements & Limits
Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s Disease, Psoriasis, Ulcerative ColitisActemra 3 PA, SL, SP, ST
Cimzia 2 PA, SL, SP
Cosentyx 3 PA, SL,SP, ST
Enbrel 4 PA, SL, SP, ST
Humira 2 PA, SL, SP
Hydroxychloroquine Sulfate 1
Kevzara 4 PA, SL, SP, ST
Leflunomide 1
Methotrexate Tablet 1
Orencia 4 PA, SL, SP, ST
Otezla 2 PA, SL, SP
Otrexup 4 E, SL, ST
Rasuvo 4 SL, ST
Siliq 4 PA, SL, SP, ST
Simponi 2 PA, SL, SP
Stelara 2 PA, SL, SP
Taltz 4 PA, SL, SP, ST
Tremfya 2 PA, SL, SP
Xeljanz 3 PA, SL, SP, ST
Xeljanz XR 3 PA, SL, SP, ST
Medications for Sexual Dysfunction2
Addyi 4 PA, SL
Cialis 4 SL
Intrarosa 3 SL
Levitra 4 SL
Osphena 3 SL
Sildenafil Tablet (generic Viagra) 1 SL
Stendra 4 PA, SL2 Coverage is determined by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit coverage and cost-share.
17
Drug Name Drug Tier
Requirements & Limits
Men’s Health: Prostate
Alfuzosin Tablet 1
Doxazosin Tablet 1
Dutasteride Capsule 1
Finasteride Tablet 1
Rapaflo 4
Tamsulosin Capsule 1
Terazosin Capsule, Tablet 1
Men’s Health: Testosterone Therapy
Androderm 2 PA, SL
Androgel 4 E, PA, SL
Methyltestosterone Capsule 1
Testim 1 PA, SL
Testosterone 1% Topical Gel 1 E, PA, SL
Testosterone Cypionate Injection 1
Miscellaneous
Anastrozole Tablet 1
Aranesp 2 SL, SP
Auryxia 3
Bethkis 1 PA, SL, SP
Cayston 2 PA, SL
Cerdelga 2 PA, SP
Chlorhexidine Gluconate 1
Chlorpheniramine/Hydrocodone/Pseudoephedrine Solution 1 PA, SL
Epinephrine (generic EpiPen/EpiPen-Jr.) 2 SL
EpiPen/EpiPen Jr. 4 E, SL
Hydrocodone/Chlorpheniramine Suspension 1 PA, SL
Lanthanum Chewable Tablet 1
Letrozole 1
Lidocaine Transdermal Patch (generic Lidoderm) 1 PA, SL
Nityr 2 PA, SP
Nuedexta 2 PA
Obredon 4 PA, SL, ST
Pegasys 2 PA, SL, SP
Drug Name Drug Tier
Requirements & Limits
Phenazopyridine 1
Procrit 2 SL, SP
Promethazine/Codeine 1 PA
Promethazine/Dextromethorphan 1
Pulmozyme 2 PA, SL, SP
Rectiv 3 SL
Rezira 3
Sevelamer 1
Syprine 3 PA, SP
Tobi Podhaler 3 PA, SL, SP
Velphoro 2
Veltassa 3 PA, SL
Zarxio 2 SP
Musculoskeletal: Muscle Spasms
Baclofen Tablet 1
Carisoprodol 350 mg Tablet 1
Cyclobenzaprine 1
Metaxalone Tablet 1
Methocarbamol Tablet 1
Tizanidine Tablet 1
Musculoskeletal: Osteoporosis
Alendronate Sodium Tablet 1
Forteo 3 PA, SP
Ibandronate Tablet 1 SL
Raloxifene Tablet 1
Risedronate Sodium Tablet 1 SL
Tymlos 3 PA, SP
Musculoskeletal: Pain Relief
Acetaminophen/Codeine Tablet 1 SL
Belbuca 3 PA, SL
Celecoxib 1 SL
Diclofenac Tablet 1
Etodolac Capsule 1
Fentanyl 12, 25, 50, 75, 100 mcg Patch 1 PA, SL
Fentanyl Citrate Lozenge 1 PA, SL
18
Bold type = Brand-name drug[Plain type = Generic drug]
E = May be excluded from coverageH = May be part of health care reform preventiveH-PA = May be part of health care reform preventive with prior authorization
PA = Prior authorization requiredRS = May be eligible for the refill and save programSL = Supply limitSP = Specialty medicationST = Step therapy
Drug Name Drug Tier
Requirements & Limits
Hydrocodone/Acetaminophen 5/325, 7.5/325, 10/325 mg Tablet 1 SL
Hydrocodone/Ibuprofen Tablet 1
Hydromorphone Immediate-Release Tablet 1
Ibuprofen Tablet 1
Indomethacin Capsule 1
Ketorolac Tablet 1
Lazanda 4 PA, SL
Meloxicam Tablet 1
Methadone Tablet, Oral Solution, Concentrate Solution 1 PA, SL
Morphine Sulfate Extended-Release Tablet 1 PA, SL
Morphine Sulfate Oral Solution 1
Nabumetone Tablet 1
Naproxen Tablet 1
Nucynta 4 SL
Nucynta ER 3 PA, SL
Oxycodone/Acetaminophen 5/325, 7.5/325, 10/325 mg Tablet 1 SL
Oxycodone Tablet 1
Oxycontin 4 E, PA, SL, ST
Sprix 3
Tramadol-Acetaminophen 1
Tramadol Immediate-Release Tablet 1
Tramadol Sustained-Release Tablet 1 SL
Trezix 1 SL
Vicodin 5/300, 7.5/300, 10/300 mg Tablet 1 E, SL
Voltaren Gel 2
Xtampza ER 2 PA, SL
Zohydro ER 4 PA, SL, ST
Drug Name Drug Tier
Requirements & Limits
Overactive Bladder
Dicyclomine Tablet 1
Oxybutynin Extended-Release Tablet 1
Oxybutynin Tablet 1
Toviaz 3
Respiratory: Allergies
Azelastine 0.1% Nasal Spray 1
Cyproheptadine Tablet 1
Fluticasone Nasal Spray 1 SL
Hydroxyzine Capsule, Tablet 1
Levocetirizine Tablet 1
Promethazine Tablet 1
Zetonna 3 SL
Respiratory: Asthma/COPD
Advair Diskus/HFA 3 RS, SL
Albuterol Nebs 1
Albuterol Sulfate Tablet 1
Alvesco 1 SL
Anoro Ellipta 3 SL
Arnuity Ellipta 3 SL
Asmanex Twisthaler, HFA 1 SL
Bevespi Aerosphere 2 SL
Breo Ellipta 3 RS, SL
Budesonide Nebs 1 SL
Combivent Respimat 3 SL
Dulera 4 E, SL, ST
Flovent Diskus/HFA 3 SL
Fluticasone/Salmeterol RespiClick (generic AirDuo RespiClick) 1 SL
Incruse Ellipta 2 SL
19
Drug Name Drug Tier
Requirements & Limits
Ipratropium-Albuterol Nebs 1
Ipratropium Nebs 1
Levalbuterol Nebs 1 E, SL
Montelukast 1
Perforomist 3 SL
ProAir HFA/RespiClick 3 SL
Proventil HFA 3 SL
Pulmicort Flexhaler 4 SL, ST
QVAR Redihaler 1 SL
Serevent Diskus 3 SL
Spiriva Handihaler/Respimat 4 SL
Striverdi Respimat 2 SL
Symbicort 3 RS, SL
Tudorza 2 SL
Ventolin HFA 2 SL
Xopenex HFA 3 SL
Respiratory: Pulmonary Arterial Hypertension
Adcirca 4 PA, SL, SP
Adempas 2 PA, SL, SP
Letairis 2 PA, SL, SP
Opsumit 2 PA, SL, SP
Orenitram 4 PA, SL, SP
Sildenafil Tablet (generic Revatio) 1 SL, SP
Tracleer 2 PA, SL, SP
Tyvaso 2 PA, SP
Uptravi 4 PA, SL, SP
Smoking Cessation
Bupropion Sustained-Release Tablet 1 H-PA
Chantix Tablet 4 H-PA
Nicoderm CQ 4 H-PA
Nicorette Gum 4 H-PA
Nicorette Lozenge 2 H-PA
Nicorette Mini-Lozenge 2 H-PA
Nicotine Gum 1 H-PA
Nicotine Lozenge 1 H-PA
Drug Name Drug Tier
Requirements & Limits
Nicotine Patch 1 H-PA
Nicotrol Inhaler 4 H-PA
Nicotrol Nasal Spray 4 H-PA
Thrive Gum 1 H-PA
Transplant
Azathioprine Tablet 1
Cyclosporine Modified Capsule 1 SP
Mycophenolate Capsule, Suspension 1 SP
Mycophenolic Acid Tablet 1 SP
Sirolimus Tablet 1 SP
Tacrolimus Capsule 1 SP
Vitamins/Electrolytes
Fluoride 1
Folic Acid 1
Klor-Con M10 1
Klor-Con M20 1
Potassium Chloride 1
Potassium Citrate 1
Women’s Health: Contraceptives
Aftera 1 H
Altavera 1 H
Alyacen 7/7/7, 1/35 1 H
Amethia 1 H
Amethia Lo 1 H
Amethyst 1 H
Apri 1 H
Aranelle 1 H
Ashlyna 1 H
Aubra 1 H
Aviane 1 H
Azurette 1 H
Balziva 1 H
Bekyree 1 H
Blisovi Fe 1 H
Blisovi 24 Fe 1 H
20
Bold type = Brand-name drug[Plain type = Generic drug]
E = May be excluded from coverageH = May be part of health care reform preventiveH-PA = May be part of health care reform preventive with prior authorization
PA = Prior authorization requiredRS = May be eligible for the refill and save programSL = Supply limitSP = Specialty medicationST = Step therapy
Drug Name Drug Tier
Requirements & Limits
Briellyn 1 H
Camila 1 H
Camrese 1 H
Camrese Lo 1 H
Caziant 1 H
Cesia 1 H
Chateal 1 H
Cryselle 1 H
Cyclafem 7/7/7, 1/35 1 H
Cyred 1 H
Dasetta 7/7/7, 1/35 1 H
Daysee 1 H
Deblitane 1 H
Delyla 1 H
Desogestrel-Ethinyl Estradiol 1 H
Drospirenone/Ethinyl Estradiol 1 H
Drospirenone/Ethinyl Estradiol/Levomefolate Calcium 1 E
Econtra EZ 1 H
Elinest 1 H
Ella 1 H, SL
Emoquette 1 H
Enpresse 1 H
Enskyce 1 H
Errin 1 H
Estarylla 1 H
Fallback 1 H
Falmina 1 H
Fayosim 1 E
Gianvi 1 H
Gildagia 1 H
Gildess 1 H
Gildess 24 Fe 1 H
Drug Name Drug Tier
Requirements & Limits
Gildess Fe 1 H
Heather 1 H
Introvale 1 H
Jencycla 1 H
Jolessa 1 H
Jolivette 1 H
Juleber 1 H
Junel 1 H
Junel 24 Fe 1 H
Junel Fe 1 H
Kariva 1 H
Kimidess 1 H
Kurvelo 1 H
Kelnor 1/35 1 H
Larin 1 H
Larin 24 Fe 1 H
Larin Fe 1 H
Larissia 1 H
Leena 1 H
Lessina 1 H
Levonest 1 H
Levonorgestrel 1.5 mg 1 H
Levonorgestrel-Ethinyl Estradiol 1 H
Levora-28 1 H
Lo Loestrin Fe 3
LoMedia 24 Fe 1 H
Loryna 1 H
Low-Ogestrel 1 H
Lutera 1 H
Lyza 1 H
Marlissa 1 H
Medroxyprogesterone Acetate 1 H
21
Drug Name Drug Tier
Requirements & Limits
Mibelas 24 Fe Chewable Tablet 1 E
Microgestin 1 H
Microgestin Fe 1 H
Mono-Linyah 1 H
Mononessa 1 H
My Way 1 H
Myzilra 1 H
Natazia 2
Necon 7/7/7, 0.5/35, 1/35, 1/50, 10/11 1 H
Next Choice 1 H
Nikki 1 H
Nora BE 1 H
Norethindrone 0.35 mg 1 H
Norethindrone-Ethinyl Estradiol-Ferrous Fumarate 1 H
Norgestimate-Ethinyl Estradiol 1 H
Norlyroc 1 H
Nortrel 7/7/7, 0.5/35, 1/35 1 H
Nuvaring 2 H
Ocella 1 H
Ogestrel 1 H
Opcicon 1 H
Orsythia 1 H
Philith 1 H
Pimtrea 1 H
Pirmella 7/7/7, 1/35 1 H
Plan B One Step 1 H
Portia 1 H
Previfem 1 H
Quasense 1 H
Rajani 1 E
Reclipsen 1 H
Rivelsa 1 E
Setlakin 1 H
Drug Name Drug Tier
Requirements & Limits
Sharobel 1 H
Solia 1 H
Sprintec 1 H
Sronyx 1 H
Syeda 1 H
Take Action 1 H
Tarina Fe 1 H
Tilia Fe 1 H
Tri-Estarylla 1 H
Tri-Legest Fe 1 H
Tri-Linyah 1 H
Tri-Lo-Estarylla 1 H
Tri-Lo-Marzia 1 H
Tri-Lo-Sprintec 1 H
Tri-Previfem 1 H
Tri-Sprintec 1 H
Trinessa 1 H
Trinessa Lo 1 H
Trivora-28 1 H
Velivet 1 H
Vestura 1 H
Vienva 1 H
Viorele 1 H
Vyfemla 1 H
Wera 1 H
Wymza Fe 1 H
Xulane 1 H
Yasmin 28 3
Yaz 3
Zarah 1 H
Zenchent 1 H
Zenchent Fe 1 H
Zovia 1/35E, 1/50E 1 H
22
Bold type = Brand-name drug[Plain type = Generic drug]
E = May be excluded from coverageH = May be part of health care reform preventiveH-PA = May be part of health care reform preventive with prior authorization
PA = Prior authorization requiredRS = May be eligible for the refill and save programSL = Supply limitSP = Specialty medicationST = Step therapy
Drug Name Drug Tier
Requirements & Limits
Women’s Health: Hormone Replacement
Climara Pro 3 SL
Divigel 3
Duavee 3 SL
Estrace Cream 1
Estradiol Cream (generic Estrace) 4 E
Estradiol/Norethindrone Acetate Tablet 1
Estradiol Tablet 1
Estradiol Twice-Weekly Transdermal Patch (generic Vivelle-Dot) 4 E, SL
Estradiol Weekly Transdermal Patch (generic Climara) 1 SL
Estring 2 SL
Estrogen/Methyltestosterone Tablet 1
Evamist 2
Medroxyprogesterone 1
Minivelle 3 SL
Premarin 3
Premphase 3
Prempro 3
Progesterone Micronized Capsule 1
Vivelle-Dot 1 SL
Yuvafem 1
Drug Name Drug Tier
Requirements & Limits
Women’s Health: Miscellaneous
Raloxifene 1 H-PA
Tamoxifen 1 H-PA
Women’s Health: Prenatal Vitamins
Brand Prenatal Vitamins 3
23
IndexA
Abacavir-Lamivudine ............................. 15Accu-Chek Test Strips ........................... 13Acetaminophen/Butalbital/Caffeine
325 mg/50 mg/40 mg ...................... 11Acetaminophen/Codeine Tablet ........ 17Actemra ..................................................... 16Acyclovir Ointment ................................... 8Acyclovir Tablet ......................................... 8Aczone ...................................................... 12Adapalene 0.1%/Benzoyl Peroxide
2.5% Gel................................................ 12Adapalene Cream, Gel, Lotion ............ 12Adcirca ...................................................... 19Adderall XR .............................................. 10Addyi .......................................................... 16Adempas .................................................. 19Adlyxin ....................................................... 13Advair Diskus/HFA ................................. 18Afrezza....................................................... 13Aftera ......................................................... 19AirDuo RespiClick .................................. 18Akynzeo .................................................... 15Albuterol Nebs ........................................ 18Albuterol Sulfate Tablet ......................... 18Alendronate Sodium Tablet ................. 17Alfuzosin Tablet ....................................... 17Allopurinol Tablet .................................... 15Alphagan P 0.1% ..................................... 14Alprazolam Extended-Release
Tablet ..................................................... 11Alprazolam Tablet ................................... 11Altavera ..................................................... 19Alunbrig ....................................................... 8Alvesco ...................................................... 18Alyacen 7/7/7, 1/35 ................................ 19Amethia ..................................................... 19Amethia Lo ............................................... 19Amethyst ................................................... 19Amiodarone ............................................. 10Amitiza ....................................................... 15Amitriptyline Tablet ................................. 10Amlodipine ................................................. 9Amlodipine-Benazepril ............................ 9Amlodipine-Valsartan .............................. 9Amoxicillin Capsule, Chewable
Tablet ....................................................... 8
Amoxicillin/Potassium Clavulanate Chewable Tablet, Tablet ..................... 8
Amphetamine Salt Combo................... 10Ampyra ...................................................... 11Anastrozole Tablet .................................. 17Androderm ............................................... 17Androgel ................................................... 17Anoro Ellipta ............................................. 18Aprepitant Capsule ................................ 15Apri ............................................................. 19Apriso ........................................................ 15Aranelle ..................................................... 19Aranesp ..................................................... 17Aripiprazole Tablet ................................. 11Armodafinil ............................................... 11Armour Thyroid ....................................... 14Arnuity Ellipta ........................................... 18Ashlyna ...................................................... 19Asmanex Twisthaler, HFA ..................... 18Atazanavir Capsule ................................ 15Atenolol ....................................................... 9Atenolol-Chlorthalidone .......................... 9Atomoxetine ............................................. 10Atorvastatin .............................................. 10Atripla......................................................... 15Aubagio ..................................................... 11Aubra ......................................................... 19Auryxia ...................................................... 17Austedo ..................................................... 11Aviane ........................................................ 19Avonex ....................................................... 11Azathioprine Tablet ................................ 19Azelastine 0.05% Ophthalmic
Solution ................................................. 14Azelastine 0.1% Nasal Spray ................ 18Azithromycin Tablet.................................. 8Azopt.......................................................... 14Azurette ..................................................... 19
B
Baclofen Tablet ....................................... 17Balziva ....................................................... 19Basaglar .................................................... 13Bekyree ..................................................... 19Belbuca ..................................................... 17Benazepril .................................................. 9Benazepril-Hydrochlorothiazide ........... 9
Betamethasone Dipropionate 0.05% Augmented Lotion, Ointment .......... 12
Betamethasone Dipropionate 0.05% Cream, Ointment ................................ 12
Betaseron ................................................. 11Bethkis ...................................................... 17Bevespi Aerosphere............................... 18Bevyxxa....................................................... 9Bexarotene Capsule ................................ 8Bicalutamide .............................................. 8Bidil .............................................................. 9Bisoprolol .................................................... 9Bisoprolol-Hydrochlorothiazide ............ 9Blisovi 24 Fe ............................................. 19Blisovi Fe ................................................... 19Bosulif .......................................................... 8Brand Prenatal Vitamins .......................22Breo Ellipta ............................................... 18Briellyn .......................................................20Brilinta.......................................................... 9Budesonide Nebs ................................... 18Bupropion Extended-Release
Tablet ..................................................... 10Bupropion Sustained-Release
Tablet .............................................. 10, 19Bupropion Tablet .................................... 10Buspirone Tablet ..................................... 11Bydureon .................................................. 13Byetta ........................................................ 13Bystolic ........................................................ 9Byvalson ..................................................... 9
C
Calcipotriene/Betamethasone Ointment ............................................... 12
Calcitriol Capsule.................................... 14Camila........................................................20Camrese....................................................20Camrese Lo ..............................................20Canasa ...................................................... 15Carac ......................................................... 12Carbamazepine Extended-Release
Capsule, Tablet ................................... 12Carbamazepine Immediate-Release
Tablet ..................................................... 12Carbidopa-Levodopa ............................ 11Carisoprodol 350 mg Tablet ................ 17Cartia XT ..................................................... 9
24
Carvedilol Immediate-Release Tablet .. 9Cayston ..................................................... 17Caziant ......................................................20Cefadroxil Capsule, Tablet ..................... 8Cefdinir Capsule ....................................... 8Cefixime Suspension ............................... 8Cefprozil Tablet ......................................... 8Cefuroxime Tablet .................................... 8Celecoxib .................................................. 17Cephalexin Capsule ................................. 8Cerdelga ................................................... 17Cesia ..........................................................20Cetrotide ................................................... 16Chantix Tablet .......................................... 19Chateal ......................................................20Chlorhexidine Gluconate ...................... 17Chlorpheniramine/Hydrocodone/
Pseudoephedrine Solution .............. 17Chlorthalidone ........................................... 9Choline Fenofibrate ................................ 10Cialis .......................................................... 16Ciclopirox Cream, Gel, Lotion,
Solution ................................................. 12Cimzia ........................................................ 16Ciprodex ..................................................... 8Ciprofloxacin Tablet ................................. 8Citalopram Tablet ................................... 10Claravis ...................................................... 12Clarithromycin Tablet ............................... 8Climara ......................................................22Climara Pro ..............................................22Clindamycin 1.2%/Benzoyl Peroxide
5% Gel ................................................... 12Clindamycin Capsule ............................... 8Clindamycin Gel ...................................... 12Clindamycin Lotion, Solution,
Swabs .................................................... 12Clobetasol Propionate Cream,
Ointment, Solution .............................. 12Clomiphene .............................................. 16Clonazepam Tablet ................................ 12Clonidine Tablet ........................................ 9Clopidogrel ................................................. 9Clotrimazole-Betamethasone
Cream .................................................... 12Clotrimazole-Betamethasone
Lotion ..................................................... 12Combigan ................................................. 14Combivent Respimat ............................. 18Complera .................................................. 15
Concerta ................................................... 10Contour Next ........................................... 13Contour Next EZ ..................................... 13Contour Next One .................................. 13Contour Next Test Strips ...................... 13Contour Test Strips ................................ 13Copaxone ................................................. 11Corlanor .................................................... 10Cortifoam .................................................. 15Cosentyx ................................................... 16Creon ......................................................... 15Cresemba ................................................... 8Crinone ...................................................... 16Cryselle .....................................................20Cyclafem 7/7/7, 1/35 .............................20Cyclobenzaprine ..................................... 17Cyclophosphamide Capsule ................. 8Cyclosporine Modified Capsule ......... 19Cyproheptadine Tablet .......................... 18Cyred .........................................................20
D
Daklinza .................................................... 15Dapsone 5% Gel ..................................... 12Dasetta 7/7/7, 1/35 ................................20Daysee .......................................................20Deblitane ...................................................20Delyla .........................................................20Descovy .................................................... 15Desmopressin Tablet ............................. 14Desogestrel-Ethinyl Estradiol ...............20Desonide 0.05% Cream, Lotion,
Ointment ............................................... 12Desoximetasone Cream, Gel,
Ointment ............................................... 12Desvenlafaxine Extended-Release
Tablet ..................................................... 10Dexamethasone Tablet ......................... 14Dexilant ..................................................... 15Dexmethylphenidate
Immediate-Release Tablet ................ 10Dextroamphetamine Sulfate
Immediate-Release Tablet ................ 10Dextroamphetamine-Amphetamine
Immediate-Release Tablet ................ 10Diazepam Tablet ...............................11, 12Diclofenac Tablet .................................... 17Dicyclomine Tablet ................................. 18Dificid ........................................................... 8
Diflorasone Diacetate 0.05% Cream .................................................... 12
Diflorasone Diacetate 0.05% Ointment ............................................... 12
Digoxin ...................................................... 10Diltiazem 24 Hour CD .............................. 9Diltiazem Sustained-Release
Capsule ................................................... 9Diltiazem Sustained-Release Tablet .... 9Diphenoxylate-Atropine Tablet ............ 15Divalproex Delayed-Release Tablet ... 12Divalproex Extended-Release
Tablet ..................................................... 12Divigel ........................................................22Donepezil ODT, 5, 10 mg Tablet ......... 11Doxazosin .............................................9, 17Doxazosin Tablet .................................... 17Doxepin ..................................................... 10Doxycycline Hyclate 50, 100 mg
Capsule, Tablet ..................................... 8Doxycycline Monohydrate
50, 100 mg Capsule ............................ 8Drospirenone/Ethinyl Estradiol ...........20Drospirenone/Ethinyl Estradiol/
Levomefolate Calcium .......................20Duavee ......................................................22Dulera ........................................................ 18Duloxetine Capsule ................................ 10Dupixent .................................................... 12Dutasteride Capsule .............................. 17
E
Econazole Cream ..................................... 8Econtra EZ................................................20Edarbi .......................................................... 9Edarbyclor .................................................. 9Efavirenz .................................................... 15Eletriptan ................................................... 11Elidel .......................................................... 12Elinest ........................................................20Eliquis .......................................................... 9Ella ..............................................................20Emend Suspension ................................ 15Emoquette ................................................20Enalapril ...................................................... 9Enbrel ........................................................ 16Endometrin ............................................... 16Enoxaparin Sodium .................................. 9Enpresse ...................................................20Enskyce.....................................................20
25
Enstilar Foam ........................................... 12Entresto ..................................................... 10Epclusa ..................................................... 15Epinephrine .............................................. 17EpiPen/EpiPen Jr.................................... 17EpiPen/EpiPen-Jr. .................................. 17Epzicom .................................................... 15Errin ............................................................20Erythromycin 0.5% Ophthalmic
Ointment ............................................... 14Escitalopram Tablet ............................... 10Estarylla .....................................................20Estrace ......................................................22Estrace Cream .........................................22Estradiol Cream ......................................22Estradiol Tablet ........................................22Estradiol Twice-Weekly Transdermal
Patch ......................................................22Estradiol Weekly Transdermal
Patch ......................................................22Estradiol/Norethindrone Acetate
Tablet .....................................................22Estring .......................................................22Estrogen/Methyltestosterone
Tablet .....................................................22Eszopiclone Tablet ................................. 11Etodolac Capsule ................................... 17Eucrisa ....................................................... 12Evamist ......................................................22Evotaz ........................................................ 15Ezetimibe Tablet...................................... 10Ezetimibe/Simvastatin ........................... 10
F
Fallback .....................................................20Falmina ......................................................20Famciclovir Tablet ..................................... 8Farxiga ....................................................... 13Fayosim .....................................................20Fenofibrate 54, 160 mg Tablet ............ 10Fentanyl 12, 25, 50, 75, 100 mcg
Patch ...................................................... 17Fentanyl Citrate Lozenge ...................... 17Fetzima ...................................................... 10Finacea ...................................................... 12Finasteride Tablet ................................... 17Flecainide ................................................. 10Flovent Diskus/HFA ............................... 18Fluconazole Tablet ................................... 8
Fluocinolone Cream, Oil, Ointment, Solution ................................................. 12
Fluocinonide 0.05% Cream ................. 12Fluoride ..................................................... 19Fluorouracil 0.5% Cream ...................... 12Fluoxetine Capsule ................................. 10Fluticasone Nasal Spray ....................... 18Fluticasone/Salmeterol RespiClick .... 18Fluvastatin Extended-Release
Tablet ..................................................... 10Fluvoxamine Tablet ................................ 11Folic Acid .................................................. 19Forteo ........................................................ 17FreeStyle Test Strips .............................. 13Frovatriptan .............................................. 11Furosemide ................................................ 9
G
Gabapentin Capsule, Tablet ................ 12Gemfibrozil ............................................... 10Gentamicin Ophthalmic Ointment,
Solution ................................................. 14Genvoya .................................................... 15Gianvi .........................................................20Gildagia .....................................................20Gildess ......................................................20Gildess 24 Fe ...........................................20Gildess Fe .................................................20Gilenya ....................................................... 11Glatiramer ................................................. 11Glimepiride ............................................... 13Glipizide .................................................... 13Glipizide Extended-Release ................ 13Glucophage XR ....................................... 13Glyburide .................................................. 13Glyxambi ................................................... 13Golytely ..................................................... 15Gonal-F ...................................................... 16Gonal-F RFF ............................................. 16Guanfacine ...........................................9, 10Guanfacine Extended-Release ........... 10
H
Halobetasol Ointment ........................... 12Harvoni ...................................................... 15Heather......................................................20Humalog KwikPens ................................ 13Humalog Vials ......................................... 13Humira ....................................................... 16Humulin KwikPens ................................. 13Humulin Vials ........................................... 13
Hydralazine ................................................ 9Hydrochlorothiazide ................................. 9Hydrocodone/Acetaminophen 5/325,
7.5/325, 10/325 mg Tablet .............. 18Hydrocodone/Chlorpheniramine
Suspension .......................................... 17Hydrocodone/Ibuprofen Tablet .......... 18Hydrocortisone 2.5% Cream,
Ointment ............................................... 12Hydromorphone Immediate-Release
Tablet ..................................................... 18Hydroxychloroquine Sulfate ................. 16Hydroxyurea Capsule .............................. 8Hydroxyzine Capsule, Tablet ............... 18Hyoscyamine Tablet ............................... 15
I
Ibandronate Tablet ................................. 17Ibuprofen Tablet ...................................... 18Idhifa ............................................................ 8Imatinib Tablet ........................................... 8Imbruvica .................................................... 8Imiquimod 5% Cream ............................ 12Incruse Ellipta .......................................... 18Indomethacin Capsule .......................... 18Ingrezza ..................................................... 11Intelence ................................................... 15Intrarosa .................................................... 16Introvale .....................................................20Invokamet ................................................. 13Invokamet XR .......................................... 13Invokana .................................................... 13Ipratropium Nebs .................................... 19Ipratropium-Albuterol Nebs.................. 19Irbesartan ................................................... 9Isentress .................................................... 15Isosorbide Mononitrate ER .................. 10Itraconazole Capsule ............................... 8
J
Janumet .................................................... 13Januvia ...................................................... 13Jardiance .................................................. 13Jencycla ....................................................20Jentadueto ............................................... 13Jentadueto XR ......................................... 13Jolessa ......................................................20Jolivette .....................................................20Juleber .......................................................20Junel ..........................................................20Junel 24 Fe ...............................................20
26
Junel Fe .....................................................20
K
Kaletra Tablet ........................................... 15Kariva .........................................................20Kazano ...................................................... 13Kelnor 1/35 ..............................................20Ketoconazole Cream ............................... 8Ketorolac Tablet ...................................... 18Kevzara ..................................................... 16Kimidess ...................................................20Klor-Con M10 .......................................... 19Klor-Con M20 .......................................... 19Kombiglyze XR ........................................ 13Kurvelo ......................................................20
L
Labetalol ..................................................... 9Lamivudine-Zidovudine ........................ 16Lamotrigine Immediate-Release
Tablet ..................................................... 12Lanthanum Chewable Tablet .............. 17Lantus Solostar ....................................... 13Lantus Vials .............................................. 13Larin ...........................................................20Larin 24 Fe ...............................................20Larin Fe .....................................................20Larissia ......................................................20Lastacaft ................................................... 14Latanoprost 0.005% Ophthalmic
Solution ................................................. 14Latuda ....................................................... 11Lazanda .................................................... 18Leena .........................................................20Leflunomide ............................................. 16Lessina ......................................................20Letairis ....................................................... 19Letrozole ................................................... 17Leucovorin Calcium Tablet..................... 8Levalbuterol Nebs .................................. 19Levemir FlexTouch .................................. 13Levemir Vials ............................................ 13Levetiracetam Extended-Release
Tablet ..................................................... 12Levetiracetam Immediate-Release
Tablet ..................................................... 12Levitra ........................................................ 16Levocetirizine Tablet .............................. 18Levofloxacin Tablet ................................... 8Levonest ...................................................20Levonorgestrel 1.5 mg ..........................20
Levonorgestrel-Ethinyl Estradiol .........20Levora-28 ..................................................20Levothyroxine Sodium Tablet .............. 14Lialda ......................................................... 15Lidocaine Transdermal Patch.............. 17Lidoderm .................................................. 17Linzess ...................................................... 15Liothyronine Sodium Tablet ................. 14Lisinopril ...................................................... 9Lisinopril-Hydrochlorothiazide .............. 9Lithium Capsule ...................................... 11Livalo .......................................................... 10Lo Loestrin Fe ..........................................20LoMedia 24 Fe ........................................20Lopinavir-Ritonavir Oral Solution ........ 16Lorazepam Tablet ................................... 11Loryna .......................................................20Losartan ...................................................... 9Losartan-Hydrochlorothiazide ............... 9Lovastatin ................................................. 10Low-Ogestrel ...........................................20Lumigan .................................................... 14Lutera .........................................................20Lyrica ......................................................... 12Lyza ............................................................20
M
Marlissa .....................................................20Mavyret ...................................................... 15Medroxyprogesterone ....................20, 22Medroxyprogesterone Acetate ...........20Meloxicam Tablet.................................... 18Memantine Immediate-Release .......... 11Mercaptopurine Tablet ............................ 8Mesalmine Delayed-Release Tablet ... 15Metadate CD ............................................ 10Metadate ER ............................................ 10Metaxalone Tablet .................................. 17Metformin ................................................. 13Metformin Extended-Release
Tablet ..................................................... 13Methadone Tablet, Oral Solution,
Concentrate Solution ......................... 18Methimazole Tablet ................................ 14Methocarbamol Tablet .......................... 17Methotrexate Tablet ............................... 16Methylphenidate Chewable Tablet ..... 10Methylphenidate Extended-Release
Capsule ................................................. 10
Methylphenidate Extended-Release Tablet ..................................................... 10
Methylphenidate Immediate-Release Tablet ..................................................... 10
Methylprednisolone Tablet ................... 14Methyltestosterone Capsule ................ 17Metoclopramide Tablet ......................... 15Metoprolol Succinate
Extended-Release 50, 100, 200 mg ................................... 9
Metoprolol Tartrate 25, 50, 100 mg ..... 9Metronidazole 0.75% Topical Gel ....... 12Metronidazole Tablet ............................... 8Mibelas 24 Fe Chewable Tablet.......... 21Microgestin .............................................. 21Microgestin Fe ......................................... 21Minivelle ....................................................22Minocycline Capsule ............................... 8Minocycline Extended-Release .......... 12Minocycline Tablet .................................... 8Mirtazapine Tablet .................................. 11Mirvaso ...................................................... 12Mitigare ..................................................... 15Modafinil Tablet ....................................... 11Mometasone Furoate Cream, Lotion,
Ointment ............................................... 12Mono-Linyah ............................................ 21Mononessa .............................................. 21Montelukast ............................................. 19Morphine Sulfate Extended-Release
Tablet ..................................................... 18Morphine Sulfate Oral Solution ........... 18Movantik ................................................... 15Moviprep ................................................... 15Moxeza ...................................................... 14Moxifloxacin Ophthalmic Solution ...... 14Moxifloxacin Tablet ................................... 8Multaq........................................................ 10Mupirocin Ointment ............................... 12My Way ...................................................... 21Mycophenolate Capsule, Suspension 19Mycophenolic Acid Tablet .................... 19Myzilra ....................................................... 21
N
Nabumetone Tablet ............................... 18Nadolol ........................................................ 9Naloxone Vial ........................................... 11Naproxen Tablet ...................................... 18Naratriptan ............................................... 11
27
Narcan Nasal Spray ............................... 11Natazia ...................................................... 21Necon 7/7/7, 0.5/35, 1/35,
1/50, 10/11 ........................................... 21Nesina ....................................................... 14Nevirapine ................................................ 16Nevirapine Extended-Release ............. 16Next Choice ............................................. 21Niacin Extended-Release Tablet ........ 10Niaspan ..................................................... 10Nicoderm CQ .......................................... 19Nicorette Gum ......................................... 19Nicorette Lozenge .................................. 19Nicorette Mini-Lozenge ......................... 19Nicotine Gum ........................................... 19Nicotine Lozenge .................................... 19Nicotine Patch ......................................... 19Nicotrol Inhaler ........................................ 19Nicotrol Nasal Spray .............................. 19Nifedipine Extended-Release ................ 9Nikki ........................................................... 21Nitrofurantoin Capsule ............................ 8Nitrofurantoin Macrocrystal Capsule ... 8Nitroglycerin Sublingual Tablet ........... 10Nityr ............................................................ 17Nora BE ..................................................... 21Norethindrone 0.35 mg ........................ 21Norethindrone-Ethinyl
Estradiol-Ferrous Fumarate.............. 21Norgestimate-Ethinyl Estradiol ............ 21Norlyroc..................................................... 21Nortrel 7/7/7, 0.5/35, 1/35 ................... 21Nortriptyline Capsule ............................. 11Norvir ......................................................... 16Novolin Vials ............................................ 13Novolog FlexPen ..................................... 13Novolog Vials ........................................... 13Noxafil Tablet, Suspension ..................... 8NP Thyroid Tablet ................................... 14Nucynta ..................................................... 18Nucynta ER .............................................. 18Nuedexta .................................................. 17Nutropin, Nutropin AQ ........................... 14Nuvaring .................................................... 21Nystatin Cream, Ointment ...................... 8
O
Obredon .................................................... 17Ocella ......................................................... 21Odefsey ..................................................... 16
Ofloxacin 0.3% Ophthalmic Solution ................................................. 14
Ofloxacin Otic Solution............................ 8Ofloxacin Tablet ........................................ 8Ogestrel ..................................................... 21Olanzapine Tablet ................................... 11Olmesartan ................................................ 9Olmesartan-Hydrochlorothiazide ......... 9Olopatadine 0.1% Ophthalmic
Solution ................................................. 14Omeclamox-Pak ..................................... 15Omega-3-Acid Ethyl Esters Capsule . 10Omeprazole Capsule ............................. 15Ondansetron ............................................ 15Ondansetron ODT .................................. 15OneTouch Test Strips ............................ 13OneTouch Ultra Mini .............................. 13OneTouch Ultra Test Strips .................. 13OneTouch Verio....................................... 13OneTouch Verio Flex .............................. 13OneTouch Verio IQ ................................. 13OneTouch Verio Sync ............................ 13OneTouch Verio Test Strips .................. 13Onglyza ..................................................... 14Opcicon .................................................... 21Opsumit .................................................... 19Oracea ....................................................... 12Orencia ...................................................... 16Orenitram .................................................. 19Orsythia ..................................................... 21Oseltamivir Capsule, Suspension ......... 8Oseni .......................................................... 14Osphena ................................................... 16Otezla ......................................................... 16Otrexup ..................................................... 16Ovidrel ....................................................... 16Oxcarbazepine Tablet ........................... 12Oxsoralen-Ultra ....................................... 12Oxybutynin Extended-Release
Tablet ..................................................... 18Oxybutynin Tablet .................................. 18Oxycodone Tablet .................................. 18Oxycodone/Acetaminophen 5/325,
7.5/325, 10/325 mg Tablet .............. 18Oxycontin ................................................. 18
P
Pantoprazole Tablet ............................... 15Paroxetine Tablet .................................... 11Pegasys ..................................................... 17
Penicillin V Potassium Tablet ................. 8Perforomist ............................................... 19Phenazopyridine ..................................... 17Phenytoin Capsule, Suspension ......... 12Philith ......................................................... 21Picato ......................................................... 12Pimtrea ...................................................... 21Pioglitazone ............................................. 14Pirmella 7/7/7, 1/35 ............................... 21Plan B One Step ..................................... 21Plegridy ..................................................... 11Polyethylene Glycol 3350..................... 15Portia ......................................................... 21Potassium Chloride ................................ 19Potassium Citrate ................................... 19Pradaxa ....................................................... 9Praluent ..................................................... 10Pramipexole Tablet ................................. 11Prasugrel ..................................................... 9Pravastatin ................................................ 10Prednisone Tablet................................... 14Premarin ...................................................22Premphase ...............................................22Prempro ....................................................22Prenisolone Oral Solution ..................... 14Prepopik ................................................... 15Previfem .................................................... 21Prezcobix .................................................. 16Prezista ...................................................... 16Pristiq ......................................................... 10ProAir HFA/RespiClick .......................... 19Procrit ........................................................ 17Progesterone Micronized Capsule .....22Promethazine Tablet .............................. 18Promethazine/Codeine ......................... 17Promethazine/Dextromethorphan ..... 17Propranolol Extended-Release
Capsule ................................................... 9Propranolol Tablet .................................... 9Proventil HFA ........................................... 19Prozac........................................................ 10Pulmicort Flexhaler ................................ 19Pulmozyme .............................................. 17Pylera ......................................................... 15
Q
Quasense ................................................. 21Quetiapine Extended-Release
Tablet ..................................................... 11
28
Quetiapine Immediate-Release Tablet ..................................................... 11
Quinapril ..................................................... 9QVAR Redihaler ...................................... 19
R
Rabeprazole Tablet ................................ 15Rajani ......................................................... 21Raloxifene ...........................................17, 22Raloxifene Tablet .................................... 17Ramipril ....................................................... 9Ranexa ...................................................... 10Ranitadine Syrup .................................... 15Rapaflo ...................................................... 17Rasuvo ...................................................... 16Rebif ........................................................... 11Reclipsen .................................................. 21Rectiv ......................................................... 17Regranex .................................................. 13Repatha ..................................................... 10Restasis Single Use Vial ....................... 14Revatio ....................................................... 19Revlimid ...................................................... 8Rezira ......................................................... 17Rhofade..................................................... 13Ribavirin Tablet ........................................ 15Risedronate Sodium Tablet.................. 17Risperidone Tablet ................................. 11Ritalin LA .................................................. 10Ritalin SR .................................................. 10Rivelsa ....................................................... 21Rizatriptan ODT, Tablet ......................... 11Ropinirole Tablet ..................................... 11Rosuvastatin ............................................ 10Rydapt ......................................................... 8
S
Savaysa ....................................................... 9Scopolamine Transdermal Patch ....... 15Selzentry ................................................... 16Serevent Diskus ...................................... 19Sertraline Tablet ...................................... 11Setlakin ...................................................... 21Sevelamer ................................................. 17Sharobel .................................................... 21Sildenafil Tablet ................................ 16, 19Siliq ............................................................. 16Simponi ..................................................... 16Simvastatin ............................................... 10Sirolimus Tablet ....................................... 19Solia ........................................................... 21
Soliqua ...................................................... 14Solodyn ..................................................... 13Sotalol ........................................................ 10Sovaldi ....................................................... 15Spiriva Handihaler/Respimat ............... 19Spironolactone .......................................... 9Sprintec ..................................................... 21Sprix ........................................................... 18Sronyx........................................................ 21Stelara ....................................................... 16Stendra ...................................................... 16Stribild ....................................................... 16Striverdi Respimat .................................. 19Suboxone Film ........................................ 11Sucralfate Tablet ..................................... 15Sulfamethoxazole-Trimethoprim
Tablet ....................................................... 8Sulfasalazine Tablet ............................... 15Sumatriptan Nasal Spray ...................... 11Sumatriptan Succinate Tablet,
Injection ................................................. 11Suprax Capsule, Chewable Tablet,
Tablet ....................................................... 8Suprep ....................................................... 15Sutent .......................................................... 8Syeda ......................................................... 21Symbicort ................................................. 19Synjardy .................................................... 14Synjardy XR .............................................. 14Synthroid ................................................... 14Syprine ...................................................... 17
T
Taclonex Suspension ............................ 13Tacrolimus Capsule ............................... 19Tacrolimus Ointment .............................. 13Take Action .............................................. 21Taltz ............................................................ 16Tamoxifen .................................................22Tamsulosin Capsule ............................... 17Targretin Capsule ..................................... 9Targretin Gel .............................................. 9Tarina Fe ................................................... 21Tasigna ........................................................ 9Tazarotene 0.1% Cream ........................ 13Tazorac ...................................................... 13Tazorac 0.1% Cream .............................. 13Tazorac Gel, 0.05% Cream .................. 13Tecfidera ................................................... 11Technivie ................................................... 15
Telmisartan ................................................. 9Telmisartan-Hydrochlorothiazide.......... 9Temazepam Capsule ............................. 11Tenofovir Tablet ....................................... 16Terazosin...............................................9, 17Terazosin Capsule, Tablet .................... 17Terbinafine Tablet ..................................... 8Testim ........................................................ 17Testosterone 1% Topical Gel ............... 17Testosterone Cypionate Injection ....... 17Thrive Gum ............................................... 19Tilia Fe ....................................................... 21Timolol 0.25%, 0.5% Ophthalmic
Solution ................................................. 14Tivicay ........................................................ 16Tizanidine Tablet ..................................... 17Tobi Podhaler .......................................... 17Tobramycin Ophthalmic Solution ....... 14Tobramycin/Dexamethasone
0.3%-0.1% Ophthalmic Suspension .......................................... 14
Tolcapone ................................................. 11Topiramate Immediate-Release
Tablet ..................................................... 12Toujeo SoloStar ....................................... 13Toviaz ......................................................... 18Tracleer ..................................................... 19Tradjenta ................................................... 14Tramadol Immediate-Release
Tablet ..................................................... 18Tramadol Sustained-Release Tablet .. 18Tramadol-Acetaminophen .................... 18Travatan Z ................................................. 14Trazodone Tablet .................................... 11Tremfya ..................................................... 16Tresiba FlexTouch ................................... 13Tretinoin Cream ....................................... 13Tretinoin Gel ............................................. 13Tretinoin Microspheres .......................... 13Trezix .......................................................... 18Tri-Estarylla ............................................... 21Tri-Legest Fe ............................................ 21Tri-Linyah .................................................. 21Tri-Lo-Estarylla ......................................... 21Tri-Lo-Marzia ............................................ 21Tri-Lo-Sprintec ......................................... 21Tri-Previfem .............................................. 21Tri-Sprintec ............................................... 21Triamcinolone Acetonide Cream,
Lotion, Ointment ................................. 13
29
Triamterene-Hydrochlorothiazide ......... 9Triazolam Tablet ...................................... 11Trinessa ..................................................... 21Trinessa Lo ............................................... 21Trintellix ..................................................... 11Triumeq ..................................................... 16Trivora-28 .................................................. 21Trulicity ...................................................... 14Truvada...................................................... 16Tudorza ..................................................... 19Tybost ........................................................ 16Tymlos ....................................................... 17Tyvaso ....................................................... 19
U
Uceris Foam ............................................. 15Uceris Tablet ............................................ 15Uloric .......................................................... 15Uptravi ....................................................... 19
V
Valacyclovir Tablet .................................... 8Valganciclovir ............................................. 8Valsartan ..................................................... 9Valsartan-Hydrochlorothiazide .............. 9Varubi......................................................... 15Vascepa .................................................... 10Vectical ...................................................... 13Velivet ........................................................ 21Velphoro .................................................... 17Veltassa ..................................................... 17Venlafaxine Extended-Release
Capsule ................................................. 11Venlafaxine Tablet .................................. 11Ventolin HFA ............................................ 19Verapamil .................................................... 9Verapamil Sustained-Release ............... 9Vestura ...................................................... 21Viagra......................................................... 16Viberzi ........................................................ 15Vicodin 5/300, 7.5/300, 10/300 mg
Tablet ..................................................... 18Victoza 2-Pak ........................................... 14Victoza 3-Pak ........................................... 14Viekira Pak ............................................... 15Viekira XR ................................................. 15Vienva ........................................................ 21Viibryd ....................................................... 11Viorele ........................................................ 21Vitekta........................................................ 16Vivelle-Dot ................................................22Voltaren Gel ............................................. 18
Vosevi ........................................................ 15Vyfemla ..................................................... 21Vyvanse ..................................................... 10
W
Warfarin Sodium ....................................... 9Welchol ..................................................... 10Wera ........................................................... 21Wymza Fe ................................................. 21
X
Xarelto ......................................................... 9Xeljanz ....................................................... 16Xeljanz XR ................................................. 16Xeloda .......................................................... 9Xigduo XR................................................. 14Xiidra .......................................................... 14Xopenex HFA ........................................... 19Xtampza ER ............................................. 18Xulane ........................................................ 21Xultophy .................................................... 14Xyrem ......................................................... 11
Y
Yasmin 28 ................................................. 21Yaz .............................................................. 21Yuvafem ....................................................22
Z
Zaleplon Capsule ................................... 11Zarah.......................................................... 21Zarxio ......................................................... 17Zelapar ...................................................... 11Zenchent ................................................... 21Zenchent Fe ............................................. 21Zenpep ...................................................... 15Zepatier ..................................................... 15Zetonna ..................................................... 18Zinbryta ..................................................... 11Ziprasidone Capsule.............................. 11Zohydro ER .............................................. 18Zolpidem Extended-Release Tablet .. 11Zolpidem Immediate-Release
Tablet ..................................................... 11Zonisamide Capsule .............................. 12Zovia 1/35E, 1/50E ................................ 21Zovirax Cream ........................................... 8Zubsolv ...................................................... 11Zurampic ................................................... 15Zykadia ........................................................ 9Zytiga ........................................................... 9
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M56950©2018 United HealthCare Services, Inc. 72315-022018100-17905 2018 Prescription Drug List — Traditional Four-Tier 2/18