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Enhanced Formulary Prescription Drug List – 2020 | 1

Enhanced FormularyThis Prescription Drug List (PDL) is a guide to common cost-effective medications covered on the QualChoice Enhanced Formulary. This list is not all-inclusive. Coverage depends on your benefit plan. Check QualChoice.com for the most up-to-date information.

Print this PDL and take it with you when you see a doctor or other medical provider. We encourage doctors to prescribe drugs on this list when they are medically right for you. In all cases, choices about your healthcare and treatment are between you and your doctor.

How We Select Prescription DrugsThe drugs on this list are chosen for safety, effectiveness and cost, based on the guidance of the QualChoice Pharmacy & Therapeutics Committee. This group is made up of practicing doctors and pharmacists. They look at drugs regulated by the Federal Drug Administration (FDA) — both newly approved and those that have been on the market for some time.

Reading the Drug ListColumn 1 lists the drug name. Generic drugs are listed in lower-case and brand name drugs are listed in all caps.

Column 2 lists the drug’s tier level. Each drug is listed in one of four payment tiers, each with a different cost share. Tiers 1, 2 and 3 are for non-specialty drugs while Tier 5 is for specialty drugs (see definition below).

Tier 1 – Lowest Copayment Most (but not all) generic drugs are in Tier 1. For the lowest out-of-pocket cost, always ask your doctor if a Tier 1 drug would work for you.

Tier 2 – Middle Copayment If your drug is in Tier 2, ask your doctor if a Tier 1 drug might work for you.

Tier 3 – Highest Copayment If your drug is in Tier 3, ask your doctor if a Tier 1 or Tier 2 drug might work for you.

Specialty DrugsThese drugs may have a higher copayment or deductible and coinsurance, based on your plan. They can be filled by our preferred specialty pharmacies, Optum Specialty Pharmacy and Allcare Specialty Pharmacy. For help, call Optum Specialty Pharmacy at 866.791.8679 or Allcare Specialty Pharmacy at 855-780-5500. Check your Benefit Summary about specialty drug coverage under your plan. All specialty drugs are in Tier 5. To see what you will pay for a specialty drug, check your Benefit Summary.

2020 Prescription Drug List | Effective 07/01/2020

1908 CR 030_03 07/2020


Tier 5 – Brand Specialty Drugs

For more on your specific drug coverage, check your Evidence of Coverage (EOC) or Certificate of Coverage (COC). If you do not have a copy of these or your Benefit Summary, sign in to My Account at QualChoice.com and select Your Benefit Booklet. Or call us at 800.235.7111 or 501.228.7111 to ask for a copy to be mailed to you.

Column 3 includes notes such as PA, QL, ST. These give you information on what type of utilization management edits may be applied to a drug. Definitions are included below.

PA (Pre-Authorization)Covered only if pre-authorized (pre-approved). You or your doctor must have approval before filling the prescription. If you don’t get approval, your medication may not be covered. Call OptumRx at 877.629.3118 for a pre-authorization form. Your doctor must fill it out and send to OptumRx.

QL (Quantity Limits)Covered only for a limited number of doses over a certain amount of time. To learn more about QL on a certain drug, call OptumRx at 877.629.3118.

ST (Step Therapy)Requires use of some other drug first before it is covered. Starts with the most cost-effective and safest drugs and moves on to other more costly ones only if needed. Examples are muscle relaxants and some specialty drugs.

Medication Not ListedIf your drug is not listed here, sign in to My Account at QualChoice.com and select Your Drug Formulary. On the OptumRx Dashboard, select Drug Lookup.

Generic DrugsGenerics are FDA-approved and have the same active ingredients as the brand-name drug. They are most often less costly than brand-name drugs. On the drug list, they are identified by all lower-case font.

Appeal ProcessYou have the right to appeal any decision by QualChoice to not provide or pay for a medication. You may file an appeal by filling out the Member Appeal Request Form at QualChoice.com. You may also call us at 501.228.7111 or 800.235.7111 and ask for a copy to be mailed to you.


Table of ContentsAnalgesics – Drugs for Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Analgesics – Drugs for Pain and Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Anti-Addiction/Substance Abuse Treatment Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Antibacterials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Anticonvulsants – Drugs for Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Antidementia Agents – Drugs for Alzheimer’s Disease and Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Antiemetics – Drugs for Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Antigout Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Antimigraine Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Antineoplastics – Drugs for Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Antiparasitics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Antiparkinson Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Antiplatelets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Antipsychotics – Drugs for Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Anxiolytics – Drugs for Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Bipolar Agents – Drugs for Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Blood Products/Modifiers/Volume Expanders – Drugs for Bleeding Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Cardiovascular Agents – Drugs for Heart and Circulation Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Central Nervous System Agents – Drugs for Attention Deficit Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Central Nervous System Agents – Drugs for Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Central Nervous System Agents – Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Dental and Oral Agents – Drugs for Mouth and Throat Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Dermatological Agents – Drugs for Skin Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Diabetes – Antidiabetic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Diabetes – Glucose Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Diabetes – Glycemic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11


Diabetes – Insulins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Electrolytes/Minerals/Metals/Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Gastrointestinal Agents – Drugs for Acid Reflux and Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Gastrointestinal Agents – Drugs for Bowel, Intestine and Stomach Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Genetic or Enzyme Disorder – Drugs for Replacement, Modification, Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Genitourinary Agents – Drugs for Bladder, Genital and Kidney Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Genitourinary Agents – Drugs for Prostate Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Hormonal Agents – Adrenal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Hormonal Agents – Men’s Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Hormonal Agents – Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Hormonal Agents - Pituitary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Hormonal Agents – Sex Hormones and Birth Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Hormonal Agents – Thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Immunological Agents – Drugs for Immune System Stimulation or Suppression . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Inflammatory Bowel Disease Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Metabolic Bone Disease Agents – Drugs for Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Metabolic Bone Disease Agents – Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Miscellaneous Therapeutic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Ophthalmic Agents – Drugs for Eye Allergy, Infection and Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Ophthalmic Agents – Drugs for Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Ophthalmic Agents – Drugs for Miscellaneous Eye Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Otic Agents – Drugs for Ear Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Respiratory Tract/Pulmonary Agents – Drugs for Allergies, Cough, Cold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Respiratory Tract/Pulmonary Agents – Drugs for Asthma and Other Lung Conditions . . . . . . . . . . . . . . . . . . . . . . . 15

Respiratory Tract/Pulmonary Agents – Drugs for Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Respiratory Tract/Pulmonary Agents – Drugs for Pulmonary Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Skeletal Muscle Relaxants – Drugs for Muscle Pain and Spasm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Sleep Disorder Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15


Drug Name Drug Tier Notes

Analgesics – Drugs for Pain

acetaminophen-codeine #2 1 QL



acetaminophen-codeine oral tablet 1 QL

butalbital-apap-caffeine 1

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

1 PA; QL

hydrocodone-acetaminophen oral tablet 1 QL

hydromorphone hcl oral tablet 1

morphine sulfate er oral tablet extended release 1 PA

oxycodone hcl oral tablet 1

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

1 QL

OXYCONTIN 2 PA

tramadol hcl oral tablet 50 mg 1

Analgesics – Drugs for Pain and Inflammation

celecoxib oral capsule 100 mg, 200 mg, 50 mg 2

diclofenac sodium oral 1

diclofenac sodium transdermal gel 1% 1

etodolac oral tablet 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1

indomethacin oral capsule 25 mg, 50 mg 1

ketorolac tromethamine oral 1

meloxicam oral 1

nabumetone oral 1

naproxen oral tablet 1

naproxen sodium oral tablet 275 mg, 550 mg 1

Anesthetics

lidocaine external ointment 3 QL

lidocaine external patch 5% 1

lidocaine-prilocaine external cream 1

Anti-Addiction/Substance Abuse Treatment Agents

buprenorphine hcl sublingual 1

buprenorphine hcl-naloxone hcl sublingual tablet sublingual 1

CHANTIX 3 PA


CHANTIX CONTINUING MONTH PAK 3 PA

CHANTIX STARTING MONTH PAK 3 PA

naltrexone hcl oral 5

Antibacterials

amoxicillin oral capsule 1

amoxicillin oral suspension reconstituted 1

amoxicillin oral tablet 1

amoxicillin-potassium clavulanate oral suspension reconstituted 1

amoxicillin-potassium clavulanate oral tablet 1

azithromycin oral suspension reconstituted 1

azithromycin oral tablet 1

cefdinir 1

cefuroxime axetil 1

cephalexin oral capsule 250 mg, 500 mg 1

cephalexin oral suspension reconstituted 1

ciprofloxacin hcl oral tablet 250 mg, 500 mg 1

clarithromycin oral tablet 1

clindamycin hcl oral 1

DIFICID 3 PA; QL

doxycycline hyclate oral capsule 1

doxycycline hyclate oral tablet 100 mg, 20 mg 1

doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg 1

doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg 1

levofloxacin oral tablet 1

metronidazole oral tablet 1

metronidazole vaginal 1

minocycline hcl oral capsule 1

mupirocin external 1

nitrofurantoin macrocrystal oral 1

nitrofurantoin monohydrate macrocrystals 1

penicillin v potassium oral tablet 1

sulfamethoxazole-trimethoprim oral 1

XENLETA ORAL 3 QL



Anticoagulants

BEVYXXA ORAL CAPSULE 40 MG, 80 MG 3

ELIQUIS 2

ELIQUIS DVT/PE STARTER PACK 2

enoxaparin sodium 5

PRADAXA 3

warfarin sodium oral 1

XARELTO 2

XARELTO STARTER PACK 2

Anticonvulsants – Drugs for Seizures

carbamazepine oral tablet 1

divalproex sodium er 1

divalproex sodium oral tablet delayed release 1

EPIDIOLEX 3 PA

gabapentin oral capsule 1

gabapentin oral tablet 1

lamotrigine er 1

lamotrigine oral tablet 1

levetiracetam oral tablet 1

oxcarbazepine oral tablet 1

topiramate oral tablet 1

VIMPAT ORAL 3

zonisamide oral 1

Antidementia Agents – Drugs for Alzheimer’s Disease and Dementia

donepezil hcl oral tablet 10 mg 1

donepezil hcl oral tablet 23 mg 2 PA

memantine hcl oral tablet 10 mg, 5 mg 1

Antidepressants

amitriptyline hcl oral 1

bupropion hcl er (sr) 1

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

1

bupropion hcl oral 1

citalopram hydrobromide oral tablet 1

desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg, 50 mg

1 QL

desvenlafaxine succinate er oral tablet extended release 24 hour 25 mg 1

doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 50 mg, 75 mg 1


duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg 2 QL

duloxetine hcl oral capsule delayed release particles 40 mg 1

escitalopram oxalate oral tablet 1

fluoxetine hcl oral capsule 1

fluvoxamine maleate 1

mirtazapine oral tablet 1

nortriptyline hcl oral capsule 1

paroxetine hcl 1

sertraline hcl oral tablet 1

trazodone hcl oral 1

venlafaxine hcl 1 QL

venlafaxine hcl er oral capsule extended release 24 hour 1

VIIBRYD 3 PA

VIIBRYD STARTER PACK 3 PA

Antiemetics – Drugs for Nausea and Vomiting

meclizine hcl oral tablet 1

metoclopramide hcl oral tablet 10 mg 1

ondansetron hcl oral tablet 4 mg, 8 mg 1

ondansetron odt oral tablet dispersible 4 mg 1

ondansetron odt oral tablet dispersible 8 mg 1 QL

prochlorperazine maleate oral 1

scopolamine 1

Antifungals

ciclopirox external solution 1

clotrimazole external cream 1

clotrimazole-betamethasone external cream 1

CRESEMBA ORAL 5 PA

fluconazole oral tablet 100 mg, 200 mg, 50 mg 1

fluconazole oral tablet 150 mg 1 QL

GYNAZOLE-1 3

ketoconazole external cream 1

ketoconazole external shampoo 1

nystatin external cream 1

nystatin mouth/throat 1

terbinafine hcl oral 1

terconazole vaginal cream 1



Antigout Agents

allopurinol oral 1

colchicine tablet 0.6 mg oral 1

COLCHICINE TABLET 0.6 MG ORAL 3

COLCRYS 3

Antimigraine Agents

AIMOVIG 2 PA

eletriptan hydrobromide 1 ST; QL

EMGALITY 2 PA

EMGALITY (300 MG DOSE) 2 PA

rizatriptan benzoate 1 QL

sumatriptan succinate oral 1 QL

Antineoplastics – Drugs for Cancer

anastrozole oral 1

CABOMETYX 5 PA

capecitabine 5

IBRANCE ORAL CAPSULE 5 PA

IDHIFA 5 PA

imatinib mesylate 5 PA

IMBRUVICA ORAL TABLET 5 PA

letrozole oral 1

LYNPARZA 5 PA

NUBEQA 5 PA

REVLIMID 5

RUBRACA 5 PA

SPRYCEL 5 PA

tamoxifen citrate oral 1

temozolomide 5

XPOVIO (100 MG ONCE WEEKLY) 5 PA



XPOVIO (80 MG TWICE WEEKLY) 5 PA

XTANDI 5 PA

ZEJULA 5 PA

Antiparasitics

ARAKODA 3

hydroxychloroquine sulfate oral 1

permethrin external 1

Antiparkinson Agents

benztropine mesylate oral 1

carbidopa-levodopa oral tablet 1

INBRIJA 3 PA


pramipexole dihydrochloride 1

ropinirole hcl 1

Antiplatelets

BRILINTA 3

clopidogrel bisulfate oral 1

prasugrel hcl 1

Antipsychotics – Drugs for Mood Disorders

ABILIFY MAINTENA 3

aripiprazole oral tablet 1 QL

ARISTADA 3

ARISTADA INITIO 3

INVEGA SUSTENNA 3

INVEGA TRINZA 3

LATUDA 3 QL

olanzapine oral tablet 1 QL

PERSERIS 3

quetiapine fumarate 1 QL

quetiapine fumarate er 1 QL

REXULTI 3 PA; QL

risperidone oral tablet 1 QL

SAPHRIS 3 PA; QL

VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG 3 PA

VRAYLAR ORAL CAPSULE 6 MG 3

VRAYLAR ORAL CAPSULE THERAPY PACK 3 PA

ziprasidone hcl 1 QL

Antivirals

acyclovir oral tablet 1

BIKTARVY 3

CIMDUO 3

DESCOVY 3

DOVATO 3

entecavir 5

GENVOYA 3

MAVYRET 5 PA

ODEFSEY 3

oseltamivir phosphate oral 1

PREZCOBIX 3

SYMFI 3

SYMFI LO 3

TIVICAY 3

TRIUMEQ 3



TRUVADA 2

valacyclovir hcl oral 1

VEMLIDY 5

VOSEVI 5 PA

Anxiolytics – Drugs for Anxiety

alprazolam oral tablet 1

buspirone hcl oral 1

clonazepam oral tablet 1

diazepam oral tablet 1

hydroxyzine hcl oral tablet 1

hydroxyzine pamoate oral 1

lorazepam oral tablet 1

triazolam 1

Bipolar Agents – Drugs for Mood Disorders

lithium carbonate er 1

lithium carbonate oral capsule 1

Blood Products/Modifiers/Volume Expanders – Drugs for Bleeding Disorders

NEULASTA 2

NEULASTA ONPRO 2

NIVESTYM INJECTION SOLUTION 5

NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE 2

RETACRIT 5

UDENYCA 2

ZARXIO 2

Cardiovascular Agents – Drugs for Heart and Circulation Conditions

amiodarone hcl oral 1

amlodipine besylate oral 1

amlodipine besylate-benazepril hcl 1

amlodipine besylate-valsartan 1

amlodipine-olmesartan 1

atenolol oral 1

atenolol-chlorthalidone 1

atorvastatin calcium oral 1

benazepril hcl oral 1

bisoprolol fumarate 1

bisoprolol-hydrochlorothiazide 1

bumetanide oral 1

BYSTOLIC 3

candesartan cilexetil 1

cartia xt 1


carvedilol 1

chlorthalidone 1

clonidine hcl oral 1

CORLANOR ORAL TABLET 3 PA

digoxin oral tablet 1

diltiazem hcl er coated beads oral capsule extended release 24 hour 1

dilt-xr 1

doxazosin mesylate oral 1

EDARBI ORAL TABLET 40 MG 3 PA; QL

EDARBI ORAL TABLET 80 MG 3 PA

EDARBYCLOR 3 PA

enalapril maleate oral 1

ENTRESTO 2

ezetimibe 1

ezetimibe-simvastatin 1 PA

fenofibrate micronized oral capsule 134 mg, 67 mg 1

fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg 1

fenofibric acid oral capsule delayed release 2

flecainide acetate 1

furosemide oral tablet 1

gemfibrozil oral 1

guanfacine hcl 1

hydralazine hcl oral 1

hydrochlorothiazide oral 1

irbesartan 1

irbesartan-hydrochlorothiazide 1

isosorbide mononitrate er 1

labetalol hcl oral 1

lisinopril oral 1

lisinopril-hydrochlorothiazide 1

losartan potassium oral 1

losartan potassium-hctz 1

lovastatin 1

metoprolol succinate er 1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1

MULTAQ 3

nadolol oral 1

nifedipine er 1



nifedipine er osmotic release 1

nitroglycerin sublingual 1

olmesartan medoxomil oral tablet 20 mg, 40 mg 1

olmesartan medoxomil oral tablet 5 mg 1 QL

olmesartan medoxomil-hctz oral tablet 20-12.5 mg 1 QL

olmesartan medoxomil-hctz oral tablet 40-12.5 mg, 40-25 mg 1

olmesartan-amlodipine-hctz 1

omega-3-acid ethyl esters 1

PRALUENT 3 PA

pravastatin sodium 1

prazosin hcl oral 1

propranolol hcl er 1

propranolol hcl oral tablet 1

quinapril hcl 1

ramipril 1

ranolazine er 1

REPATHA 3 PA; QL

REPATHA PUSHTRONEX SYSTEM 3 PA

REPATHA SURECLICK 3 PA; QL

rosuvastatin calcium 1

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1

simvastatin oral tablet 80 mg 1 PA

sotalol hcl oral 1

spironolactone oral 1

TEKTURNA HCT 3 QL

telmisartan 1 QL

telmisartan-hctz 1 QL

torsemide 1

triamterene-hctz 1

valsartan oral tablet 160 mg, 320 mg, 40 mg 1

valsartan oral tablet 80 mg 1 QL

valsartan-hydrochlorothiazide 1

VASCEPA 3 PA

verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg

1

verapamil hcl er oral tablet extended release 1


Central Nervous System Agents – Drugs for Attention Deficit Disorder

amphetamine-dextroamphetamine 1 QL

amphetamine-dextroamphetamine er 2 QL

atomoxetine hcl 1 QL

dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 20 mg, 25 mg, 35 mg, 5 mg

1 QL

dexmethylphenidate hcl er oral capsule extended release 24 hour 15 mg, 30 mg, 40 mg

2 QL

dexmethylphenidate hcl oral tablet 10 mg, 5 mg 1

guanfacine hcl er 1

methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 40 mg

2 QL

methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg

2 QL

methylphenidate hcl er oral tablet extended release 24 hour 2 QL

methylphenidate hcl oral tablet 1 QL

VYVANSE ORAL CAPSULE 3 PA; QL

VYVANSE ORAL TABLET CHEWABLE 3 PA

Central Nervous System Agents – Drugs for Multiple Sclerosis

AUBAGIO 5

AVONEX PEN 5

AVONEX PREFILLED 5

BETASERON 5

COPAXONE 5

GILENYA 5

glatiramer acetate 5

MAVENCLAD (10 TABS) 5 PA







TECFIDERA 5

Central Nervous System Agents – Miscellaneous

pregabalin oral capsule 1

TIGLUTIK 3



Dental and Oral Agents – Drugs for Mouth and Throat Conditions

chlorhexidine gluconate mouth/throat 1

lidocaine viscous hcl 1

Dermatological Agents – Drugs for Skin Conditions

ACZONE EXTERNAL GEL 7.5% 3

betamethasone dipropionate external cream 1

claravis 1

clindamycin phosphate-benzoyl peroxide external gel 1-5% 1

clindamycin phosphate external gel 1

clindamycin phosphate external lotion 1

clindamycin phosphate external solution 1

clindamycin phosphate external swab 1

clobetasol propionate external cream 1

clobetasol propionate external ointment 1

clobetasol propionate external solution 1

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 5 PA

ENSTILAR 3

EUCRISA 3 PA

fluocinonide external cream 0.05% 1

fluocinonide external cream 0.1% 1 QL

FLUOROPLEX 2

FLUOROURACIL EXTERNAL CREAM 0.5% 3 QL

fluorouracil external cream 5% 1

hydrocortisone external cream 1%, 2.5% 1

hydrocortisone external ointment 1%, 2.5% 1

imiquimod external 1

metronidazole external cream 1

metronidazole external gel 1

mometasone furoate external cream 1

TACLONEX EXTERNAL SUSPENSION 3

tacrolimus external ointment 1

tretinoin external cream 1

triamcinolone acetonide external cream 1


triamcinolone acetonide external ointment 0.025%, 0.1%, 0.5% 1

Diabetes – Antidiabetic Agents

BYDUREON 2

BYDUREON BCISE AUTOINJECTOR 2

BYETTA 10 MCG PEN 2

BYETTA 5 MCG PEN 2

FARXIGA 2

glimepiride 1

glipizide er 1

glipizide ir 1

glyburide oral 1

GLYXAMBI 2

JANUMET 2

JANUMET XR 2

JANUVIA 2

JARDIANCE 2

JENTADUETO 2

JENTADUETO XR 2

metformin hcl er 1

metformin hcl oral tablet 1

OZEMPIC 2

pioglitazone hcl 1

RYBELSUS 2

SYMLINPEN 60 3

SYNJARDY 2

SYNJARDY XR 2

TRADJENTA 2

TRULICITY 2

VICTOZA 2

XIGDUO XR 2

Diabetes – Glucose Monitoring

ACCU-CHEK AVIVA PLUS TEST STRIPS 2

ACCU-CHEK COMPACT PLUS TEST STRIPS 2

ACCU-CHEK FASTCLIX LANCET KIT 2

ACCU-CHEK GUIDE TEST STRIPS 2

ACCU-CHEK MULTICLIX LANCET DEVICE KIT 2

ACCU-CHEK SMARTVIEW TEST STRIPS 2

ACCU-CHEK SOFTCLIX LANCET DEVICE KIT 2



DEXCOM G4/G5/G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC)

2 PA

DEXCOM G4/G5/G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC) DEVICE

2 PA

FREESTYLE LIBRE 14 DAY READER 2 PA

FREESTYLE LIBRE 14 DAY SENSOR 2 PA

FREESTYLE LIBRE READER 2 PA

FREESTYLE LIBRE SENSOR SYSTEM 2 PA

LANCETS 2

ONETOUCH ULTRA BLUE TEST STRIPS IN VITRO STRIP 2

ONETOUCH VERIO TEST STRIPS 2

Diabetes – Glycemic Agents

BAQSIMI ONE PACK 2

BAQSIMI TWO PACK 2

GLUCAGON EMERGENCY KIT 2

GVOKE PFS 2

Diabetes – Insulins

BD AUTOSHIELD DUO PEN NEEDLES 3

BD ULTRA-FINE INSULIN SYRINGES 3

BD ULTRA-FINE PEN NEEDLES 3

HUMULIN R U-500 KWIKPEN 3

HUMULIN R U-500 VIAL (CONCENTRATED) 3

LANTUS SOLOSTAR 2

LANTUS U-100 VIAL 2

LEVEMIR U-100 FLEXTOUCH 2

LEVEMIR U-100 VIAL 2

NOVOFINE AUTOCOVER PEN NEEDLE 3

NOVOFINE PEN NEEDLE 3

NOVOFINE PLUS PEN NEEDLE 3

NOVOLIN 70/30 FLEXPEN 2

NOVOLIN 70/30 VIAL 2

NOVOLIN N FLEXPEN 2

NOVOLIN N FLEXPEN RELION 2

NOVOLIN N VIAL 2

NOVOLIN R FLEXPEN 2

NOVOLIN R FLEXPEN RELION 2

NOVOLIN R VIAL 2

NOVOLOG FLEXPEN 2

NOVOLOG MIX 70/30 FLEXPEN 2


NOVOLOG MIX 70/30 VIAL 2

NOVOLOG PENFILL 2

NOVOLOG U-100 VIAL 2

NOVOTWIST PEN NEEDLE 3

TOUJEO MAX SOLOSTAR 2

TOUJEO SOLOSTAR 2

TRESIBA 2

TRESIBA FLEXTOUCH 2

Electrolytes/Minerals/Metals/Vitamins

cyanocobalamin injection solution 1000 mcg/ml 1

ergocalciferol oral capsule 1

folic acid oral tablet 1

NASCOBAL 2

potassium chloride crys er 1

potassium chloride er 1

potassium citrate er 1

sodium fluoride oral tablet chewable 1

VELTASSA 3 QL

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) 1

Gastrointestinal Agents – Drugs for Acid Reflux and Ulcer

lansoprazole oral capsule delayed release 2

misoprostol oral 1

omeprazole oral capsule delayed release 1

pantoprazole sodium oral 1

rabeprazole sodium oral tablet delayed release 2

sucralfate oral tablet 1

Gastrointestinal Agents – Drugs for Bowel, Intestine and Stomach Conditions

dicyclomine hcl oral capsule 1

dicyclomine hcl oral tablet 1

diphenoxylate-atropine oral tablet 1

gavilyte-g 1

glycopyrrolate oral tablet 1 mg, 2 mg 1

GLYCOPYRROLATE ORAL TABLET 1.5 MG 1

lactulose oral solution 1

LINZESS 2 PA

MOVANTIK 2 PA

peg 3350-kcl-na bicarb-nacl 1



PLENVU 3

PREPOPIK ORAL PACKET 10-3.5-12 MG-GM-GM 3

PYLERA 3

SUPREP BOWEL PREP KIT 3

SYMPROIC 2 PA

ZELNORM 3 PA

Genetic or Enzyme Disorder – Drugs for Replacement, Modification, Treatment

CERDELGA 5 PA

CREON 2

STRENSIQ 5 PA

ZENPEP 2

Genitourinary Agents – Drugs for Bladder, Genital and Kidney Conditions

AURYXIA 3

INTRAROSA 3 PA

MYRBETRIQ 3 PA

oxybutynin chloride er 1

oxybutynin chloride oral tablet 1

phenazopyridine hcl oral tablet 100 mg, 200 mg 1

sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg 1 PA; QL

solifenacin succinate 1

tadalafil oral 1 PA; QL

tolterodine tartrate er 1

Genitourinary Agents – Drugs for Prostate Conditions

alfuzosin hcl er 1

dutasteride oral 1

finasteride oral tablet 5 mg 1

tamsulosin hcl 1

terazosin hcl oral capsule 1 mg, 10 mg, 5 mg 1

Hormonal Agents – Adrenal

dexamethasone oral tablet 1

hydrocortisone oral 1

methylprednisolone oral 1

prednisolone oral solution 1

prednisolone sodium phosphate oral solution 1

prednisone oral tablet 1

prednisone oral tablet therapy pack 1


Hormonal Agents – Men’s Health

TESTOSTERONE CYPIONATE INJECTION 2 PA

testosterone cypionate intramuscular 2 PA

testosterone transdermal gel 1.62%, 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 40.5 mg/2.5gm (1.62%)

1 PA

Hormonal Agents – Osteoporosis

OSPHENA 3 PA

raloxifene hcl 1

Hormonal Agents - Pituitary

cabergoline 1

FOLLISTIM AQ 5 PA

ganirelix acetate 5 PA

GONAL-F RFF REDIJECT 5 PA

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 7.5 MG 5

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG 5

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG 5

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG 5

MENOPUR 5 PA

NORDITROPIN FLEXPRO 5 PA

ORILISSA 3 PA; QL

OVIDREL 5 PA

Hormonal Agents – Sex Hormones and Birth Control

apri 1

aviane 1

BIJUVA 3

blisovi 24 fe 1

blisovi fe 1.5/30 1

blisovi fe 1/20 1

CLIMARA PRO 2

cryselle-28 1

DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM

3

drospirenone-ethinyl estradiol 1

DUAVEE 3 PA

ELESTRIN 3

ENDOMETRIN 3

enskyce 1



errin 1

estarylla 1

estradiol oral 1

estradiol transdermal 1

estradiol vaginal 1

EVAMIST 3

femynor 1

gianvi 1

IMVEXXY MAINTENANCE PACK 3

IMVEXXY STARTER PACK 3

isibloom 1

junel 1.5/30 1

junel 1/20 1

junel fe 1.5/30 1

junel fe 1/20 1

junel fe 24 1

kariva 1

kurvelo 1

larin fe 1/20 1

larissia 1

lessina 1

levonorgest-eth est & eth est 1

levonorgest-eth estrad 91-day oral tablet 0.15-0.03 &0.01 mg, 0.15-0.03 mg

1

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg 1

LO LOESTRIN FE 3

low-ogestrel 1

medroxyprogesterone acetate intramuscular 1 QL

medroxyprogesterone acetate oral 1

mono-linyah 1

NATAZIA 2

nikki 1

norethindrone acetate oral 1

norethindrone acet-ethinyl est 1

norethindrone oral 1

norgestimate-ethinyl estradiol triphasic 1

nortrel 1/35 (21) 1

nortrel 1/35 (28) 1

PREMARIN ORAL 2


PREMARIN VAGINAL 2

PREMPHASE 2

PREMPRO 2

progesterone micronized oral 1

sprintec 28 1

syeda 1

tri femynor 1

tri-linyah 1

tri-lo-marzia 1

tri-lo-sprintec 1

tri-sprintec 1

vienva 1

viorele 1

xulane 2

Hormonal Agents – Thyroid

ARMOUR THYROID 3

euthyrox 1

levothyroxine sodium oral 1

liothyronine sodium oral 1

methimazole oral 1

NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG

2

np thyroid oral tablet 60 mg 1

SYNTHROID 3

Immunological Agents – Drugs for Immune System Stimulation or Suppression

ACTEMRA ACTPEN 5 PA

ACTEMRA SUBCUTANEOUS 5 PA

azathioprine oral 1

CIMZIA 5 PA

CIMZIA PREFILLED KIT 5 PA

CIMZIA STARTER KIT 5 PA

cyclosporine modified oral capsule 1

HAEGARDA 5 PA

HUMIRA 5 PA

HUMIRA PEDIATRIC CROHNS START 5 PA

HUMIRA PEN 5 PA

HUMIRA PEN-CD/UC/HS STARTER 5 PA

HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

5 PA



leflunomide oral 1

methotrexate oral 1

methotrexate sodium oral 1

mycophenolate mofetil oral capsule 1

mycophenolate mofetil oral tablet 1

mycophenolate sodium 1

ORENCIA CLICKJECT 5 PA

ORENCIA SUBCUTANEOUS 5 PA

OTEZLA 5 PA

RINVOQ 5 PA

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML 5

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/0.5ML 5 PA

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML 5

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/0.5ML 5 PA

sirolimus oral tablet 1

SKYRIZI (150 MG DOSE) 5 PA

STELARA SUBCUTANEOUS SOLUTION 5

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 5 PA

tacrolimus oral 1

TAKHZYRO 5 PA

TALTZ 5 PA

TREMFYA 5 PA

XELJANZ 5 PA

XELJANZ XR 5 PA

Inflammatory Bowel Disease Agents

APRISO 3

mesalamine oral tablet delayed release 1.2 gm 1

mesalamine oral tablet delayed release 800 mg 1 ST

PENTASA 3

PROCTOFOAM HC 2

sulfasalazine oral tablet 1

UCERIS RECTAL 3

Metabolic Bone Disease Agents – Drugs for Osteoporosis

alendronate sodium oral tablet 1

ibandronate sodium oral 3 PA

PROLIA 5 PA

TYMLOS 5 PA


Metabolic Bone Disease Agents – Other

calcitriol oral capsule 1

Miscellaneous Therapeutic Agents

BOTOX 5 PA

Ophthalmic Agents – Drugs for Eye Allergy, Infection and Inflammation

AZASITE 3

BESIVANCE 3

ciprofloxacin hcl ophthalmic 1

erythromycin ophthalmic 1

gentamicin sulfate ophthalmic 1

INVELTYS 3

ketorolac tromethamine ophthalmic 1

moxifloxacin hcl ophthalmic 1

ofloxacin ophthalmic 1

olopatadine hcl ophthalmic 1

PAZEO 2

prednisolone acetate ophthalmic 1

Ophthalmic Agents – Drugs for Glaucoma

ALPHAGAN P OPHTHALMIC SOLUTION 0.1% 2

AZOPT 2

BETIMOL 3

brimonidine tartrate ophthalmic 1

COMBIGAN 2

dorzolamide hcl-timolol mal 1

dorzolamide hcl-timolol mal pf 1

latanoprost ophthalmic 1

LUMIGAN 2

SIMBRINZA 2

timolol maleate ophthalmic solution 1

Ophthalmic Agents – Drugs for Miscellaneous Eye Conditions

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 1

polymyxin b-trimethoprim 1

RESTASIS 2 PA

RESTASIS MULTIDOSE 2 PA

tobramycin-dexamethasone 1

XIIDRA 2 PA

Otic Agents – Drugs for Ear Conditions

CIPRODEX 2



neomycin-polymyxin-hc otic suspension 1

ofloxacin otic 1

Respiratory Tract/Pulmonary Agents – Drugs for Allergies, Cough, Cold

azelastine hcl nasal solution 0.1%, 137 mcg/spray 1

benzonatate 1

cyproheptadine hcl oral tablet 1

fluticasone propionate nasal 1

ipratropium bromide nasal 1

mometasone furoate nasal 1 PA

NUCALA 5 PA

promethazine hcl oral tablet 1

promethazine-codeine 1

promethazine-dm 1

pseudoephedrine-bromphen-dm 1

XOLAIR 5 PA

Respiratory Tract/Pulmonary Agents – Drugs for Asthma and Other Lung Conditions

ADVAIR DISKUS 2

ADVAIR HFA 2

albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation 1 QL

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION

3 QL

albuterol sulfate inhalation 1 QL

ANORO ELLIPTA 2

ARNUITY ELLIPTA 2

ATROVENT HFA 3

BREO ELLIPTA 2

budesonide inhalation 1

COMBIVENT RESPIMAT 3

epinephrine injection solution auto-injector 0.15 mg/0.3ml, 0.3 mg/0.3ml 1 QL

FLOVENT DISKUS 2

FLOVENT HFA 2

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

1

INCRUSE ELLIPTA 2

ipratropium-albuterol 1

montelukast sodium oral tablet 1


montelukast sodium oral tablet chewable 1

PERFOROMIST 3

PROAIR HFA 2 QL

PROAIR RESPICLICK 2 QL

PULMICORT FLEXHALER 2

SEREVENT DISKUS 2

SPIRIVA HANDIHALER 2

SPIRIVA RESPIMAT 2

STIOLTO RESPIMAT 2

SYMBICORT 2

TRELEGY ELLIPTA 3 PA

VENTOLIN HFA 2 QL

wixela inhub 1

Respiratory Tract/Pulmonary Agents – Drugs for Cystic Fibrosis

PULMOZYME 5

Respiratory Tract/Pulmonary Agents – Drugs for Pulmonary Hypertension

ADEMPAS 5 PA

OPSUMIT 5 PA

sildenafil citrate oral tablet 20 mg 5 PA

Skeletal Muscle Relaxants – Drugs for Muscle Pain and Spasm

baclofen oral tablet 10 mg, 20 mg 1

carisoprodol oral tablet 350 mg 1

cyclobenzaprine hcl oral 1

metaxalone oral tablet 800 mg 2 PA

methocarbamol oral 1

tizanidine hcl oral tablet 1

Sleep Disorder Agents

armodafinil 1 PA; QL

eszopiclone 2 QL

modafinil 1 PA; QL

SUNOSI 3 PA

temazepam 1

WAKIX 5 PA

XYREM 5 PA

zolpidem tartrate er 2 QL

zolpidem tartrate oral 1 QL

enhanced formulary - qualchoice health insuranceuserfiles/pdfs/... · safest drugs and moves on to...

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