2019 Essential Health Benefits Base Formulary
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2019 Essential Health
Benefits Base Formulary
Effective July 1, 2019
For the most current list of covered medications or if you have questions:
Call the number on your member ID card.
Visit your plan’s website on your member ID card to:
• Find a participating retail pharmacy by ZIP code.
• Look up possible lower-cost medication alternatives.
• Compare medication pricing and options.
EHB BaseUnderstanding your formulary
What is a formulary?
A formulary is a list of prescribed medications chosen About this formulary
by your plan for their safety, cost, and effectiveness. Where differences between this
Medications are listed by categories or classes and are formulary and your benefit plan
placed into cost levels known as tiers. It includes both brand exist, the benefit plan documents
and generic prescription medications approved by the rule. This may not be a complete
U.S. Food and Drug Administration (FDA). list of medications that are covered
by your plan. Please review your
OptumRx® is guided by the Pharmacy and Therapeutics
benefit plan for full details.
Committee (a group of doctors, nurses, and pharmacists)
who reviews which medications will be covered, how well
the drugs work, and overall value. They also make sure
there are safe and covered options.
How do I use my formulary?
You and your doctor can use the formulary to help you
choose the most cost-effective prescription medications.
This guide tells you if a medication is generic or brand, and
if special rules apply. Bring this list with you when you see
your doctor. If your medication is not listed here, please
visit your plan’s member website or call the number on your
member ID card.
Some medications on your formulary have extra requirements before they can be covered. A
few of the most common coverage programs are prior authorization (PA), step therapy (ST) and
quantity limits (QL). We use programs like these to help make sure the medication you take is safe
and effective. Check your plan documents for more information. Some Affordable Care Act (ACA)
preventive medication may have coverage restrictions. If you want to learn more about these
programs or to see if you take a medication in one of these programs, please visit your plan’s
member website or call the number on your member ID card.
2Understanding your formulary
What are tiers?
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by
your employer or plan sponsor. This is how much you will pay when you fill a prescription.
When does the formulary change?
• Medications may move to a lower tier at any time.
•M
edications may move to a higher tier when a generic equal becomes available.
•M
edications may move to a higher tier or be excluded from coverage on January 1 or July 1 of
each year.
When a medication changes tiers, you may have to pay a different amount for that medication.
Why are some medications excluded from coverage?
A medication may be excluded from coverage under your pharmacy benefit when it works the
same as or similar to another prescription or over-the-counter (OTC) medication.
What if I don’t agree with a decision about an excluded medication?
You or your authorized representative and your doctor can ask for a coverage request by calling
the number on your member ID card.
3Medication tips
What is the difference between brand-name and
generic medications? Over-the-counter medications
Generic medications contain the same active ingredients (what An over-the-counter (OTC)
makes the medication work) as brand-name medications, medication may be the right
but they often cost less. Once the patent for a brand-name treatment for some conditions.
medication ends, the FDA can approve a generic version with Talk to your doctor about
the same active ingredients. available OTC options. Even
though OTC medications may
What if my doctor writes a brand-name prescription? not be covered by your pharmacy
If your doctor gives you a prescription for a brand-name benefit, they may cost less than
medication, ask if a generic or lower-cost option could be right a prescription medication.
for you. Generic medications are usually your lowest-cost option.
What if I am taking a specialty medication?
Specialty medications are for rare or complex conditions and are usually higher-cost medications.
Please note, not all specialty medications are listed in the formulary. BriovaRx®, the OptumRx
specialty pharmacy, can provide most of your specialty medications along with helpful programs and
services. Call BriovaRx at 1-855-4BRIOVA (1-855-427-4682) and have your prescriptions delivered
right to your home or doctor’s office.
4Reading your formulary
The formulary gives you choices so you and your doctor can decide your best course of treatment.
In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX)
Generic medications are shown in lowercase (for example, clobetasol).
Tier information
Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your
plan may have multiple or no tiers.
Drug Tier Includes Helpful Tips
Tier 1 $ Generic Use Tier 1 drugs for the lowest out-of-pocket costs.
Tier 2 $$ Preferred Preferred brand-name drugs will generally have lower
copayments than non-preferred brand-name drugs.
Tier 3 $$$ N
on-Preferred Many Tier 3 drugs have lower-cost options in Tier 1 or 2.
Ask your doctor if they could work for you.
Tier 4 $$$$ Specialty Tier 4 is generally highest in copayment and cost.
These drugs are sometimes used for complex and chronic
conditions and may require special monitoring
and handling.
Drug list information
In this drug list, some medications are noted with letters next to them to help you see which ones
may have coverage requirements or limits. Your benefit plan decides how these medications may
be covered.
M Authorized generic or cobranded product
PA Prior Authorization – Your doctor is required to give OptumRx more information
to determine coverage.
PV
Preventive drugs – May have coverage and no copayments when health care
reform requirements are met.
PV* Preventive drugs – Available at $0 if prior authorization is approved.
QL Quantity Limit – Medication may be limited to a certain quantity.
ST Step Therapy – Must try lower-cost medication(s) before a higher-cost medication
can be covered.
5Table of Contents
Analgesics.....................................................12 Antimycobacterials...................................... 25
Nonsteroidal Anti-inflammatory Drugs....... 12 Antimycobacterials, Other.......................... 25
Opioid Analgesics, Long-acting................. 13 Antituberculars........................................... 25
Opioid Analgesics, Short-acting................. 13 Antineoplastics.............................................25
Anesthetics................................................... 15 Alkylating Agents....................................... 25
Local Anesthetics....................................... 15 Antiandrogens............................................ 26
Anti-Addiction/Substance Abuse Antiangiogenic Agents............................... 26
Treatment Agents.......................................16 Antiestrogens/Modifiers............................. 26
Alcohol Deterrents/Anti-craving................. 16 Antimetabolites.......................................... 26
Opioid Dependence Treatments................ 16 Antineoplastics, Other................................ 27
Opioid Reversal Agents............................. 16 Aromatase Inhibitors, 3rd Generation........ 28
Smoking Cessation Agents........................ 16 Enzyme Inhibitors...................................... 28
Antibacterials................................................16 Molecular Target Inhibitors........................ 28
Aminoglycosides........................................ 16 Monoclonal Antibody/Antibody-Drug
Antibacterials, Other.................................. 16 Conjugate................................................ 29
Beta-lactam, Cephalosporins..................... 18 Retinoids.................................................... 30
Beta-lactam, Other..................................... 19 Antiparasitics................................................30
Beta-lactam, Penicillins.............................. 19 Anthelmintics..............................................30
Macrolides..................................................19 Antiprotozoals............................................ 30
Quinolones................................................. 20 Pediculicides/Scabicides............................30
Sulfonamides............................................. 20 Antiparkinson Agents.................................. 30
Tetracyclines.............................................. 20 Anticholinergics.......................................... 30
Anticonvulsants............................................20 Antiparkinson Agents, Other...................... 30
Anticonvulsants, Other............................... 20 Dopamine Agonists.................................... 30
Calcium Channel Modifying Agents........... 21 Dopamine Precursors/L- Amino Acid
Gamma-aminobutyric Acid (GABA) Decarboxylase Inhibitors......................... 31
Augmenting Agents................................. 21 Monoamine Oxidase B (MAO-B) Inhibitors 31
Glutamate Reducing Agents...................... 21 Antipsychotics..............................................31
Sodium Channel Agents............................ 21 1st Generation/Typical............................... 31
Antidementia Agents....................................22 2nd Generation/Atypical.............................31
Antidementia Agents, Other....................... 22 Treatment-Resistant.................................. 31
Cholinesterase Inhibitors........................... 22 Antispasticity Agents...................................32
N-methyl-D-aspartate (NMDA) Receptor Antivirals....................................................... 32
Antagonist................................................22 Anti-cytomegalovirus (CMV) Agents.......... 32
Antidepressants........................................... 22 Anti-hepatitis B (HBV) Agents.................... 32
Antidepressants, Other.............................. 22 Anti-hepatitis C (HBV) Agents....................32
Monoamine Oxidase Inhibitors.................. 22 Antiherpetic Agents.................................... 32
SSRI/SNRI (Selective Serotonin Reuptake Anti-HIV Agents, Integrase Inhibitors
Inhibitors/Serotonin and Norepinephrine (INSTI)..................................................... 33
Reuptake Inhibitors).................................22 Anti-HIV Agents, Non-nucleoside Reverse
Tricyclics.................................................... 23 Transcriptase Inhibitors (NNRTI)............. 33
Antiemetics................................................... 23 Anti-Hiv Agents, Nucleoside And
Antiemetics, Other..................................... 23 Nucleotide Reverse Transcriptase
Emetogenic Therapy Adjuncts................... 23 Inhibitors (Nrti)......................................... 33
Antifungals....................................................24 Anti-HIV Agents, Other.............................. 33
Antigout Agents............................................24 Anti-HIV Agents, Protease Inhibitors......... 33
Antimigraine Agents.................................... 25 Anti-influenza Agents................................. 34
Ergot Alkaloids........................................... 25 Anxiolytics.................................................... 34
Serotonin (5-HT) 1b/1d Receptor Agonists 25 Anxiolytics, Other....................................... 34
Antimyasthenic Agents................................25 Benzodiazepines........................................34
Parasympathomimetics..............................25 Bipolar Agents.............................................. 34
9Mood Stabilizers........................................ 34 Genetic or Enzyme Disorder:
Blood Glucose Monitoring...........................34 Replacement, Modifiers, Treatment..........52
Blood Glucose Regulators.......................... 35 Genitourinary Agents...................................53
Antidiabetic Agents.................................... 35 Antispasmodics, Urinary............................ 53
Glycemic Agents........................................ 36 Benign Prostatic Hypertrophy Agents........ 53
Insulins....................................................... 36 Genitourinary Agents, Other...................... 53
Blood Products/Modifiers/Volume Phosphate Binders.....................................53
Expanders................................................... 37 Hormonal Agents,
Anticoagulants........................................... 37 Stimulant/Replacement/Modifying
Blood Formation Modifiers......................... 38 (Adrenal)......................................................54
Hemostasis Agents.................................... 38 Hormonal Agents,
Platelet Modifying Agents.......................... 39 Stimulant/Replacement/Modifying
Cardiovascular Agents................................ 39 (Pituitary).....................................................55
Alpha-adrenergic Agonists......................... 39 Hormonal Agents, Suppressant (Pituitary).56
Alpha-adrenergic Blocking Agents............. 39 Hormonal Agents,
Angiotensin II Receptor Antagonists.......... 39 Stimulant/Replacement/Modifying
Angiotensin-converting Enzyme (ACE) (Prostaglandins)......................................... 56
Inhibitors.................................................. 40 Hormonal Agents,
Antiarrhythmics.......................................... 40 Stimulant/Replacement/Modifying (Sex
Beta-adrenergic Blocking Agents...............40 Hormones/Modifiers)................................. 56
Calcium Channel Blocking Agents............. 41 Anabolic Steroids....................................... 56
Cardiovascular Agents, Other.................... 42 Androgens..................................................56
Diuretics, Loop........................................... 42 Estrogens................................................... 56
Diuretics, Potassium-sparing..................... 42 Progesterone Agonists/Antagonists........... 59
Diuretics, Thiazide..................................... 42 Progestins.................................................. 59
Dyslipidemics, Fibric Acid Derivatives........42 Selective Estrogen Receptor Modifying
Dyslipidemics, HMG CoA Reductase Agents......................................................60
Inhibitors.................................................. 43 Hormonal Agents,
Dyslipidemics, Other.................................. 43 Stimulant/Replacement/Modifying
Vasodilators, Direct-acting Arterial.............43 (Thyroid)......................................................60
Vasodilators, Direct-acting Arterial/Venous43 Hormonal Agents, Suppressant (Adrenal). 60
Central Nervous System Agents.................43 Hormonal Agents, Suppressant (pituitary) 60
Attention Deficit Hyperactivity Disorder Hormonal Agents, Suppressant (Thyroid). 60
Agents, Amphetamines............................43 Antithyroid Agents...................................... 60
Attention Deficit Hyperactivity Disorder Immunological Agents................................. 61
Agents, Non-amphetamines.................... 44 Angioedema Agents...................................61
Central Nervous System, Other................. 44 Immune Suppressants............................... 61
Fibromyalgia Agents.................................. 44 Immunizing Agents, Passive...................... 62
Multiple Sclerosis Agents........................... 44 Immunomodulators.................................... 63
Dental and Oral Agents................................44 Vaccines.................................................... 63
Dermatological Agents................................ 45 Inflammatory Bowel Disease Agents..........65
Electrolytes/Minerals/Metals/Vitamins....... 47 Aminosalicylates........................................ 65
Electrolyte/Mineral Replacement............... 47 Glucocorticoids.......................................... 65
Electrolyte/Mineral/Metal Modifiers............ 48 Sulfonamides............................................. 65
Vitamins..................................................... 49 Metabolic Bone Disease Agents................. 65
Gastrointestinal Agents............................... 50 Miscellaneous Therapeutic Agents............ 65
Antispasmodics, Gastrointestinal............... 50 Ophthalmic Agents.......................................68
Gastrointestinal Agents, Other................... 51 Aminoglycosides........................................ 68
Histamine2 (H2) receptor Antagonists....... 51 Antibacterials, Other.................................. 68
Irritable Bowel Syndrome Agents...............51 Anti-cytomegalovirus (CMV) Agents.......... 68
Laxatives.................................................... 51 Antifungals................................................. 68
Protectants................................................. 52 Antiherpetic Agents.................................... 68
Proton Pump Inhibitors.............................. 52 Macrolides..................................................68
10Ophthalmic Prostaglandin and
Prostamide Analogs.................................68
Ophthalmic Agents, Other..........................68
Ophthalmic Anti-allergy Agents..................69
Ophthalmic Antiglaucoma Agents.............. 69
Ophthalmic Anti-inflammatories................. 69
Quinolones................................................. 70
Sulfonamides............................................. 70
Otic Agents................................................... 70
Respiratory Tract/Pulmonary Agents......... 70
Antihistamines............................................70
Anti-inflammatories, Inhaled
Corticosteroids.........................................71
Antileukotrienes......................................... 71
Bronchodilators, Anticholinergic.................71
Bronchodilators, Sympathomimetic........... 72
Cystic Fibrosis Agents............................... 72
Mast Cell Stabilizers.................................. 72
Phosphodiesterase Inhibitors, Airways
Disease....................................................72
Pulmonary Antihypertensives.................... 73
Pulmonary Fibrosis Agents........................ 73
Respiratory Tract Agents, Other................ 73
Skeletal Muscle Relaxants...........................73
Sleep Disorder Agents................................. 74
GABA Receptor Modulators.......................74
Sleep Disorders, Other.............................. 74
Index of Drugs................................................ 75
11Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Analgesics diclofenac-misoprostol
butalbital-acetaminophen oral tablet delayed 1
1 release
oral tablet
butalbital-apap 1 DICLOFONO 2
butalbital-apap-caffeine diflunisal oral 1
1
oral capsule etodolac er 1
butalbital-apap-caffeine etodolac oral 1
1
oral tablet 50-325-40 mg fenoprofen calcium oral 1
butalbital-aspirin-caffeine 1
fenortho oral capsule 200 1
duraxin 1 mg
esgic oral capsule 1 flurbiprofen oral 1
phrenilin forte oral ibu oral tablet 600 mg,
1 1
capsule 50-300-40 mg 800 mg
tencon oral tablet 50-325 ibuprofen lysine 1
1
mg ibuprofen oral
1
zebutal oral capsule 50- suspension
1
325-40 mg ibuprofen oral tablet 400
1
Nonsteroidal Anti-inflammatory Drugs mg, 600 mg, 800 mg
aspirin adult 1 PV indomethacin er 1
aspirin childrens 1 PV indomethacin oral 1
aspirin ec low dose 1 PV indomethacin sodium 1
aspirin low dose oral ketoprofen er 1
1 PV
tablet chewable ketoprofen oral capsule 1
aspirin oral tablet 325 mg 1 PV 25 mg
aspirin oral tablet 1 PV ketorolac tromethamine
delayed release 325 mg injection solution 15 1
bayer aspirin ec low dose 1 PV mg/ml, 30 mg/ml
bayer aspirin oral tablet 1 PV ketorolac tromethamine
intramuscular solution 60 1
celecoxib oral 1 QL
mg/2ml
diclofenac potassium 1
ketorolac tromethamine
1 QL
diclofenac sodium er 1 oral
diclofenac sodium oral 1 klofensaid ii 1 PA
diclofenac sodium meclofenamate sodium
1 QL 1
transdermal gel 1 % oral
diclofenac sodium medique aspirin 1 PV
1 PA
transdermal solution meloxicam oral tablet 1
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
12Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
nabumetone oral 1 methadose oral tablet
1
naproxen dr 1 soluble
naproxen oral tablet 1 mitigo 1
naproxen sodium oral morphine sulfate er 1 PA; QL
1 beads
tablet 275 mg, 550 mg
oxaprozin 1 morphine sulfate er oral
capsule extended 1 PA; QL
piroxicam oral 1 release 24 hour
SPRIX 3 PA; QL morphine sulfate er oral
1 PA; QL
sulindac oral 1 tablet extended release
tolmetin sodium 1 morphine sulfate
1
Opioid Analgesics, Long-acting intramuscular
buprenorphine hcl OXYCODONE HCL ER
injection solution 0.3 1 ORAL TABLET ER 12 3 PA; QL
mg/ml HOUR ABUSE-
DETERRENT
buprenorphine
transdermal patch weekly OXYCONTIN ORAL
1 PA; QL TABLET ER 12 HOUR 2 PA; QL
10 mcg/hr, 15 mcg/hr, 20
mcg/hr, 5 mcg/hr ABUSE-DETERRENT
BUPRENORPHINE oxymorphone hcl er 1 PA; QL
TRANSDERMAL PATCH 3 PA; QL tramadol hcl er (biphasic)
WEEKLY 7.5 MCG/HR oral tablet extended
1 QL
BUTRANS release 24 hour 100 mg,
TRANSDERMAL PATCH 3 PA; QL 200 mg, 300 mg
WEEKLY 7.5 MCG/HR tramadol hcl er oral
EMBEDA 2 PA; QL capsule extended 1 PA; QL
release 24 hour 150 mg
fentanyl 1 PA; QL
tramadol hcl er oral tablet 1 QL
hydromorphone hcl er 1 PA; QL
extended release 24 hour
HYSINGLA ER 2 PA; QL Opioid Analgesics, Short-acting
methadone hcl injection 1 acetaminophen-codeine 1 QL
methadone hcl intensol 1 acetaminophen-codeine 1 QL
methadone hcl oral #2
1
concentrate acetaminophen-codeine
1 QL
methadone hcl oral #3
1
solution acetaminophen-codeine
1 QL
methadone hcl oral tablet 1 PA #4
methadone hcl oral tablet alfentanil hcl intravenous 1
1
soluble
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
13Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
apap-caff-dihydrocodeine lorcet hd 1 QL
1 QL
oral tablet 325-30-16 mg lorcet plus oral tablet 7.5- 1 QL
ascomp-codeine 1 325 mg
butalbital-apap-caff-cod 1 meperidine hcl injection
butalbital-asa-caff- solution 100 mg/ml, 25 1
1 mg/ml, 50 mg/ml
codeine
butorphanol tartrate meperidine hcl oral 1 QL
1
injection morphine sulfate
butorphanol tartrate (concentrate) oral
1 QL 1 QL
nasal solution 100 mg/5ml, 20
mg/ml
codeine sulfate oral
1 QL morphine sulfate (pf)
tablet 30 mg, 60 mg 1
injection
duramorph 1
morphine sulfate (pf)
endocet oral tablet 10- intravenous solution 10
325 mg, 2.5-325 mg, 5- 1 QL 1
mg/ml, 2 mg/ml, 4 mg/ml,
325 mg, 7.5-325 mg 8 mg/ml
fentanyl citrate buccal 1 PA; QL morphine sulfate injection
hydrocodone- solution 10 mg/ml, 2 1
acetaminophen oral mg/ml, 4 mg/ml, 5 mg/ml,
solution 10-325 mg/15ml, 8 mg/ml
1 QL
2.5-108 mg/5ml, 5-217 morphine sulfate
mg/10ml, 7.5-325 intravenous solution 1 1
mg/15ml mg/ml, 150 mg/30ml
hydrocodone- morphine sulfate oral 1 QL
acetaminophen oral
tablet 10-300 mg, 10-325 1 QL nalbuphine hcl injection 1
mg, 5-300 mg, 5-325 mg, oxycodone hcl oral 1 QL
7.5-300 mg, 7.5-325 mg capsule
hydrocodone-ibuprofen oxycodone hcl oral 1 QL
oral tablet 10-200 mg, 5- 1 QL concentrate 100 mg/5ml
200 mg, 7.5-200 mg oxycodone hcl oral 1 QL
hydromorphone hcl solution
injection solution 1 1 oxycodone hcl oral tablet 1 QL
mg/ml, 2 mg/ml, 4 mg/ml
oxycodone-
hydromorphone hcl oral 1 QL acetaminophen oral
hydromorphone hcl pf 1 tablet 10-325 mg, 2.5- 1 QL
levorphanol tartrate oral 325 mg, 5-325 mg, 7.5-
1 QL 325 mg
tablet 2 mg
lorcet 1 QL
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
14Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
oxycodone-aspirin oral lidocaine external patch 5
1 QL 1
tablet 4.8355-325 mg %
oxycodone-ibuprofen 1 QL lidocaine hcl (pf) injection 1
oxymorphone hcl 1 QL solution
pentazocine-naloxone hcl 1 QL lidocaine hcl external gel 1
2%
remifentanil hcl 1
lidocaine hcl external 1
tramadol hcl ir 1 QL solution
tramadol-acetaminophen 1 QL lidocaine hcl injection
1
verdrocet 1 QL solution 0.5 %, 1 %, 2 %
vicodin es oral tablet 7.5- lidocaine hcl
1 QL 1
300 mg mouth/throat
vicodin hp oral tablet 10- lidocaine viscous 1
1 QL
300 mg lidocaine-epinephrine
vicodin oral tablet 5-300 injection solution 0.5 %-
1 QL
mg 1:200000, 1 %-1:100000, 1
Anesthetics 1.5 %-1:200000, 2 %-
1:100000, 2 %-1:200000,
Local Anesthetics
2 %-1:50000
bupivacaine hcl (pf) 1
lidocaine-prilocaine
1
bupivacaine hcl injection external cream
1
solution 0.25 %, 0.5 % polocaine 1
bupivacaine in dextrose 1 polocaine-mpf 1
intrathecal
ropivacaine hcl injection
bupivacaine spinal 1
solution 10 mg/ml, 2
1
bupivacaine-epinephrine mg/ml, 5 mg/ml, 7.5
(pf) injection solution 1 mg/ml
0.25% -1:200000, 0.5% - sensorcaine 1
1:200000
sensorcaine/epinephrine 1
bupivacaine-epinephrine
injection solution 0.25% - sensorcaine-mpf 1
1
1:200000, 0.5% - sensorcaine-
1:200000 mpf/epinephrine injection
chloroprocaine hcl (pf) 1 solution 0.25% - 1
1:200000, 0.5% -
ethyl chloride 1
1:200000
glydo 1 1
xylocaine dental
lidocaine external 1
ointment
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
15Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Anti-Addiction/Substance Abuse Treatment NICOTROL 3 ST; PV; QL
Agents 3 ST; PV; QL
NICOTROL NS
Alcohol Deterrents/Anti-craving Antibacterials
acamprosate calcium 1 Aminoglycosides
disulfiram oral 1 amikacin sulfate injection
VIVITROL 4 solution 1 gm/4ml, 500 1
Opioid Dependence Treatments mg/2ml
buprenorphine hcl gentamicin in saline
1 QL intravenous solution 0.8-
sublingual
0.9 mg/ml-%, 1-0.9
buprenorphine hcl- 1
1 QL mg/ml-%, 1.2-0.9 mg/ml-
naloxone hcl %, 1.6-0.9 mg/ml-%, 2-
naltrexone hcl oral 1 0.9 mg/ml-%
Opioid Reversal Agents gentamicin sulfate 1
naloxone hcl injection external
solution 0.4 mg/ml, 4 1 gentamicin sulfate 1
mg/10ml injection
naloxone hcl injection neomycin sulfate oral 1
1
solution cartridge paromomycin sulfate oral 1
naloxone hcl injection 1 streptomycin sulfate
solution prefilled syringe 1
intramuscular
NARCAN 2
tobramycin sulfate 1
Smoking Cessation Agents injection
bupropion hcl er Antibacterials, Other
1 PV; QL
(smoking det) ALTABAX 3
CHANTIX 3 ST; PV; QL 1
baciim
CHANTIX CONTINUING 3 ST; PV; QL bacitracin intramuscular 1
MONTH PAK
chloramphenicol sod
CHANTIX STARTING 1
3 ST; PV; QL succinate
MONTH PAK
clindamycin hcl oral 1
nicotine polacrilex
1 PV; QL clindamycin palmitate hcl 1
mouth/throat gum
nicotine polacrilex clindamycin phosphate in 1
mouth/throat lozenge 2 1 PV; QL d5w
mg clindamycin phosphate 1
nicotine step 1 1 PV; QL injection
nicotine step 2 1 PV; QL
nicotine step 3 1 PV; QL
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
16Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
clindamycin phosphate nitrofurantoin
intravenous solution 300 monohydrate 1
1
mg/2ml, 600 mg/4ml, 900 macrocrystals
mg/6ml nitrofurantoin oral 1
clindamycin phosphate 1 suspension
vaginal polymyxin b sulfate 1
colistimethate sodium 1 injection
(cba) PRIMSOL 3
CORTISPORIN silver sulfadiazine
3 1
EXTERNAL external
daptomycin intravenous ssd 1
solution reconstituted 1
500 mg SULFAMYLON
3
EXTERNAL CREAM
IMPAVIDO 3
tigecycline 1
iodine tincture external 1
tincture 2 % trimethoprim oral 1
lincomycin hcl injection 1 vancomycin hcl in
dextrose intravenous
linezolid in sodium 1 solution 1-5 gm/200ml-%, 1
chloride 500-5 mg/100ml-%, 750-
linezolid intravenous 1 5 mg/150ml-%
solution 600 mg/300ml vancomycin hcl in nacl
linezolid oral 1 QL intravenous solution 1-
1
mafenide acetate 0.9 gm/200ml-%, 500-0.9
1 mg/100ml-%
external
methenamine hippurate 1 VANCOMYCIN HCL IN
NACL SOLUTION 750- 3
metronidazole in nacl 0.9 MG/150ML-%
intravenous solution 5- INTRAVENOUS
1
0.79 mg/ml-%, 500-0.79
mg/100ml-% vancomycin hcl in nacl
solution 750-0.9 1
metronidazole oral 1 mg/150ml-% intravenous
metronidazole vaginal 1 vancomycin hcl
MONUROL 3 intravenous solution
mupirocin calcium 1 reconstituted 1 gm, 1.25
1
gm, 1.5 gm, 10 gm, 100
mupirocin external 1 gm, 250 mg, 5 gm, 500
NEO-SYNALAR mg, 750 mg
3
EXTERNAL CREAM vancomycin hcl oral 1
nitrofurantoin 1 vandazole 1
macrocrystal oral
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
17Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
XIFAXAN 3 PA cefotetan disodium-
ZYVOX INTRAVENOUS dextrose intravenous
SOLUTION 200 3 solution reconstituted 1- 1
MG/100ML 3.58 gm-%(50ml), 2-2.08
gm-%(50ml)
Beta-lactam, Cephalosporins
cefoxitin sodium 1
cefaclor 1
cefoxitin sodium-dextrose
cefaclor er 1
intravenous solution
cefadroxil 1 reconstituted 1-4 gm- 1
cefazolin sodium %(50ml), 2-2.2 gm-
1 %(50ml)
injection
cefazolin sodium cefpodoxime proxetil 1
intravenous solution 1 cefprozil 1
reconstituted ceftazidime and dextrose
cefazolin sodium- intravenous solution
dextrose intravenous reconstituted 1-5 gm- 1
1
solution 1-4 gm/50ml-%, %(50ml), 2-5 gm-
2-4 gm/100ml-% %(50ml)
cefazolin sodium- ceftazidime injection
dextrose intravenous solution reconstituted 1 1
solution reconstituted 1-4 1 gm, 2 gm, 6 gm
gm-%(50ml), 2-3 gm- ceftriaxone sodium in
%(50ml) 1
dextrose
cefdinir 1
ceftriaxone sodium 1
cefditoren pivoxil 1 injection
cefepime hcl 1 ceftriaxone sodium 1
cefepime-dextrose intravenous
intravenous solution ceftriaxone sodium-
reconstituted 1-5 gm- 1 dextrose intravenous
%(50ml), 2-5 gm- solution reconstituted 1- 1
%(50ml) 3.74 gm-%(50ml), 2-2.22
cefixime 1 gm-%(50ml)
cefotaxime sodium cefuroxime axetil oral
1
injection solution tablet
1
reconstituted 1 gm, 500 cefuroxime sodium
mg injection solution 1
cefotetan disodium 1 reconstituted 7.5 gm, 750
mg
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
18Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
cefuroxime sodium ampicillin-sulbactam
1
intravenous solution 1 sodium injection
reconstituted 1.5 gm ampicillin-sulbactam
cephalexin 1 sodium intravenous 1
MAXIPIME solution reconstituted 1.5
INTRAVENOUS (1-0.5) gm, 15 (10-5) gm
3
SOLUTION AUGMENTIN ORAL
RECONSTITUTED 2 GM SUSPENSION
3
tazicef injection 1 RECONSTITUTED 125-
31.25 MG/5ML
tazicef intravenous
1 BICILLIN L-A 3
solution reconstituted
Beta-lactam, Other dicloxacillin sodium 1
AZACTAM IN nafcillin sodium injection
DEXTROSE solution reconstituted 1 1
3 gm, 2 gm
INTRAVENOUS
SOLUTION 1 GM/50ML nafcillin sodium 1
aztreonam 1 intravenous
ertapenem sodium 1 oxacillin sodium 1
imipenem-cilastatin 1 penicillin g potassium 1
meropenem 1 penicillin g procaine 1
Beta-lactam, Penicillins penicillin g sodium 1
amoxicillin oral capsule 1 penicillin v potassium 1
amoxicillin oral piperacillin sod-
1 1
suspension reconstituted tazobactam so
amoxicillin oral tablet 1 Macrolides
amoxicillin oral tablet azithromycin intravenous
chewable 125 mg, 250 1 solution reconstituted 1
mg 500 mg
amoxicillin-potassium azithromycin oral packet 1
1
clavulanate er azithromycin oral 1
amoxicillin-potassium suspension reconstituted
1
clavulanate oral azithromycin oral tablet 1
ampicillin oral capsule 250 mg, 500 mg, 600 mg
1
500 mg clarithromycin er 1
ampicillin sodium clarithromycin oral 1
1
injection DIFICID 3
ampicillin sodium 1 e.e.s. 400 oral tablet 1
intravenous
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
19Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
ERY-TAB ORAL sulfamethoxazole-
TABLET DELAYED 3 trimethoprim oral 1
RELEASE 333 MG suspension 200-40
erythromycin base oral mg/5ml
capsule delayed release 1 sulfamethoxazole- 1
particles trimethoprim oral tablet
erythromycin base oral sulfatrim pediatric 1
1
tablet Tetracyclines
erythromycin avidoxy 1
1
ethylsuccinate oral
coremino 1
ZITHROMAX ORAL
2 demeclocycline hcl oral 1
PACKET
Quinolones doxy 100 1
AVELOX doxycycline hyclate
3 1
INTRAVENOUS intravenous
CIPRO ORAL doxycycline hyclate oral
1
SUSPENSION capsule
3
RECONSTITUTED 250 doxycycline hyclate oral
MG/5ML (5%) tablet 100 mg, 150 mg, 1
ciprofloxacin hcl oral 1 20 mg, 50 mg, 75 mg
ciprofloxacin in d5w 1 doxycycline hyclate oral 1
tablet delayed release
ciprofloxacin oral
suspension reconstituted 1 doxycycline monohydrate 1
500 mg/5ml (10%) oral
ciprofloxacin-ciproflox hcl minocycline hcl er 1
1
er minocycline hcl oral 1
levofloxacin in d5w 1 mondoxyne nl 1
levofloxacin intravenous 1 morgidox oral 1
levofloxacin oral 1 okebo oral capsule 75
1
moxifloxacin hcl in nacl 1 mg
moxifloxacin hcl oral 1 soloxide 1
ofloxacin oral tablet 300 tetracycline hcl oral 1
1
mg, 400 mg Anticonvulsants
Sulfonamides Anticonvulsants, Other
sulfadiazine oral 1 BRIVIACT ORAL 3
sulfamethoxazole- FYCOMPA 3
1
trimethoprim intravenous levetiracetam er 1
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
20Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
levetiracetam in nacl 1 valproic acid oral solution 1
levetiracetam vigabatrin 4 PA
1
intravenous vigadrone 4 PA
levetiracetam oral 1 Glutamate Reducing Agents
roweepra 1 felbamate 1
roweepra xr 1 lamotrigine er 1
Calcium Channel Modifying Agents lamotrigine oral tablet 1
CELONTIN 3 lamotrigine oral tablet 1
ethosuximide oral 1 chewable
LYRICA ORAL 2 QL lamotrigine oral tablet 1
CAPSULE dispersible
LYRICA ORAL 3 QL lamotrigine starter kit- 1
SOLUTION blue
zonisamide oral 1 lamotrigine starter kit-
1
Gamma-aminobutyric Acid (GABA) green
Augmenting Agents lamotrigine starter kit-
1
clobazam 1 PA orange
clonazepam oral 1 QL subvenite 1
diazepam rectal 1 QL subvenite starter kit-blue 1
divalproex sodium er oral subvenite starter kit- 1
tablet extended release 1 green
24 hour subvenite starter kit- 1
divalproex sodium oral orange
capsule delayed release 1 topiramate er 1
sprinkle topiramate oral 1
divalproex sodium oral 1 Sodium Channel Agents
tablet delayed release
BANZEL 3
gabapentin oral 1
carbamazepine er 1
phenobarbital oral 1
carbamazepine oral 1
primidone oral 1
DILANTIN ORAL 3
tiagabine hcl 1 CAPSULE 30 MG
valproate sodium epitol 1
1
intravenous
fosphenytoin sodium 1
valproate sodium oral
1 oxcarbazepine 1
solution
valproic acid oral capsule 1 PEGANONE 3
phenytoin infatabs 1
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
21Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
phenytoin oral mirtazapine oral 1
1
suspension 125 mg/5ml Monoamine Oxidase Inhibitors
phenytoin oral tablet 1 EMSAM 3 QL
chewable
MARPLAN 3
phenytoin sodium 1 phenelzine sulfate oral 1
extended
tranylcypromine sulfate 1
phenytoin sodium 1
injection SSRI/SNRI (Selective Serotonin Reuptake
3 Inhibitors/Serotonin and Norepinephrine
VIMPAT ORAL
Reuptake Inhibitors)
Antidementia Agents
citalopram hydrobromide 1
Antidementia Agents, Other
desvenlafaxine succinate 1 QL
ergoloid mesylates oral 1 er
Cholinesterase Inhibitors 1 QL
duloxetine hcl oral
donepezil hcl 1 1
escitalopram oxalate
galantamine FETZIMA 3 ST; QL
1
hydrobromide
FETZIMA TITRATION 3 ST; QL
galantamine
1 fluoxetine hcl (pmdd) 1
hydrobromide er
rivastigmine 1 fluoxetine hcl oral
1
capsule
rivastigmine tartrate 1
fluoxetine hcl oral
N-methyl-D-aspartate (NMDA) Receptor 1 QL
capsule delayed release
Antagonist
fluoxetine hcl oral 1
memantine hcl er 1 QL
solution
memantine hcl oral 1 1
fluoxetine hcl oral tablet
NAMENDA XR 2 QL fluvoxamine maleate 1
TITRATION PACK
fluvoxamine maleate er 1 QL
NAMZARIC ORAL
CAPSULE EXTENDED 2 QL maprotiline hcl 1
RELEASE 24 HOUR nefazodone hcl 1
Antidepressants olanzapine-fluoxetine hcl 1 QL
Antidepressants, Other paroxetine hcl er 1
APLENZIN 3 ST; QL paroxetine hcl oral tablet 1
bupropion hcl er (sr) 1 QL paroxetine mesylate 1 QL
bupropion hcl er (xl) oral PAXIL ORAL 2
tablet extended release 1 QL SUSPENSION
24 hour 150 mg, 300 mg sertraline hcl oral 1
bupropion hcl oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
22Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
trazodone hcl oral 1 prochlorperazine 1
TRINTELLIX 3 ST; QL prochlorperazine 1
venlafaxine hcl 1 edisylate injection
venlafaxine hcl er oral prochlorperazine maleate 1
capsule extended 1 oral
release 24 hour promethazine hcl 1
venlafaxine hcl er oral injection
tablet extended release 1 promethazine hcl oral 1
24 hour 225 mg promethazine hcl rectal 1
VIIBRYD ORAL TABLET 3 QL 1
promethegan
VIIBRYD STARTER TIGAN
3 QL 3
PACK INTRAMUSCULAR
Tricyclics
TRANSDERM-SCOP
3
amitriptyline hcl oral 1 (1.5 MG)
amoxapine 1 trimethobenzamide hcl
1
chlordiazepoxide- oral
1
amitriptyline Emetogenic Therapy Adjuncts
clomipramine hcl oral 1 ANZEMET ORAL 3 QL
desipramine hcl oral 1 aprepitant 1 QL
doxepin hcl oral 1 CESAMET 3 PA; QL
imipramine hcl oral 1 dronabinol 1 PA; QL
imipramine pamoate 1 granisetron hcl
nortriptyline hcl oral 1 intravenous solution 1 1
mg/ml, 4 mg/4ml
perphenazine- 1
amitriptyline granisetron hcl oral 1 QL
protriptyline hcl 1 ondansetron hcl injection
solution 4 mg/2ml, 40 1
trimipramine maleate oral 1 mg/20ml
Antiemetics
ondansetron hcl oral
1 QL
Antiemetics, Other solution
AKYNZEO ORAL 3 QL ondansetron hcl oral
1 QL
compro 1 tablet 24 mg
dimenhydrinate injection 1 ondansetron hcl oral 1
tablet 4 mg, 8 mg
droperidol injection 1
ondansetron odt 1
meclizine hcl oral tablet 1
palonosetron hcl 1
phenadoz 1
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
23Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Antifungals ketoconazole external
1
ABELCET 3 shampoo
AMBISOME 3 ketoconazole oral 1
amphotericin b injection 1 MENTAX 3
caspofungin acetate 1 miconazole 3 vaginal 1
suppository
ciclodan external solution 1
MYCAMINE 3
ciclopirox 1
naftifine hcl 1
ciclopirox olamine 1
external NOXAFIL ORAL TABLET 3
DELAYED RELEASE
clotrimazole external 1
nyamyc 1
clotrimazole mouth/throat 1
nystatin external 1
clotrimazole- 1
betamethasone nystatin mouth/throat 1
CRESEMBA 3 nystatin oral tablet 1
econazole nitrate nystatin-triamcinolone 1
1
external nystop 1
ERAXIS INTRAVENOUS OXISTAT EXTERNAL
3
SOLUTION LOTION
3
RECONSTITUTED 50 terbinafine hcl oral 1 QL
MG
terconazole 1
fluconazole in sodium
chloride intravenous voriconazole intravenous 1
solution 200-0.9 1 voriconazole oral 1
mg/100ml-%, 400-0.9 XOLEGEL 3
mg/200ml-%
Antigout Agents
fluconazole oral 1
allopurinol oral 1
flucytosine oral 1
allopurinol sodium 1
griseofulvin microsize
1 COLCHICINE ORAL
oral 3
TABLET
griseofulvin
1 colchicine-probenecid 1
ultramicrosize
GYNAZOLE-1 3 COLCRYS 2
itraconazole oral 1 PA probenecid oral 1
JUBLIA 3 PA ULORIC 2 ST
KERYDIN 3 PA ZURAMPIC 3 ST
ketoconazole external 1
cream
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
24Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Antimigraine Agents MESTINON ORAL
2
Ergot Alkaloids SYRUP
dihydroergotamine neostigmine
1 methylsulfate intravenous 1
mesylate injection
solution
dihydroergotamine 1 QL
mesylate nasal pyridostigmine bromide 1
er
ergotamine-caffeine 1
pyridostigmine bromide
Serotonin (5-HT) 1b/1d Receptor Agonists 1
oral tablet
almotriptan malate 1 QL Antimycobacterials
eletriptan hydrobromide 1 QL Antimycobacterials, Other
naratriptan hcl 1 QL 1
dapsone oral
rizatriptan benzoate 1 QL 1
rifabutin
sumatriptan nasal 1 QL Antituberculars
sumatriptan succinate 1 QL CAPASTAT SULFATE 3
oral
cycloserine oral 1
sumatriptan succinate
refill subcutaneous 1 QL ethambutol hcl oral 1
solution cartridge isoniazid injection 1
sumatriptan succinate isoniazid oral 1
subcutaneous solution 6 1 QL PASER 3
mg/0.5ml
PRIFTIN 3
sumatriptan succinate
subcutaneous solution pyrazinamide oral 1
1 QL
auto-injector 4 mg/0.5ml, rifampin intravenous 1
6 mg/0.5ml rifampin oral 1
sumatriptan succinate RIFATER 3
subcutaneous solution
1 QL SIRTURO 3
prefilled syringe 6
mg/0.5ml TRECATOR 3
sumatriptan-naproxen Antineoplastics
1 QL
sodium Alkylating Agents
zolmitriptan oral 1 QL busulfan 4
ZOMIG NASAL 3 QL carboplatin intravenous 4
Antimyasthenic Agents solution
Parasympathomimetics carmustine 4
GUANIDINE HCL ORAL 1
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
25Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
cisplatin intravenous flutamide 1
solution 100 mg/100ml, 4 nilutamide 4
200 mg/200ml, 50
mg/50ml XTANDI 4 PA
cyclophosphamide ZYTIGA ORAL TABLET 4 PA
4 500 MG
injection
Antiangiogenic Agents
cyclophosphamide oral 1
capsule POMALYST 4 PA
dacarbazine intravenous 4 REVLIMID 4 PA
GLEOSTINE ORAL THALOMID 4 PA
CAPSULE 10 MG, 100 4 Antiestrogens/Modifiers
MG, 40 MG
EMCYT 2
ifosfamide 4
FASLODEX
LEUKERAN 4 INTRAMUSCULAR 4
MATULANE 4 SOLUTION 250 MG/5ML
melphalan 1 SOLTAMOX 3
melphalan hcl 4 tamoxifen citrate oral 1 PV*
MYLERAN 4 toremifene citrate 1
oxaliplatin 4 Antimetabolites
TEMODAR adrucil 4
4
INTRAVENOUS ALIMTA 4
temozolomide 4 PA ARRANON 4
TEPADINA 4 capecitabine 4 PA
thiotepa injection 4 cladribine intravenous
4
TREANDA solution 10 mg/10ml
INTRAVENOUS clofarabine 4
4
SOLUTION
cytarabine (pf) 4
RECONSTITUTED
VYXEOS cytarabine injection 4
INTRAVENOUS solution
SUSPENSION 4 PA decitabine 4 PA
RECONSTITUTED 44- DROXIA 3
100 MG
ELITEK 3
ZANOSAR 4
floxuridine injection 4
Antiandrogens
fludarabine phosphate 4
abiraterone acetate 4 PA
fluorouracil intravenous 4
bicalutamide 1
FOLOTYN 4 PA
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
26Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
gemcitabine hcl 4 epirubicin hcl intravenous
hydroxyurea oral 1 solution 200 mg/100ml, 4
50 mg/25ml
KEPIVANCE 4
ERWINAZE INJECTION 4
LONSURF 4 PA
ETHYOL 4
mercaptopurine oral 4
FARYDAK 4 PA
NIPENT 4
FLUOROPLEX 3
TABLOID 4
fluorouracil external 1
Antineoplastics, Other
cream 5 %
ABRAXANE 4
fluorouracil external 4
adriamycin intravenous 4 solution
solution HALAVEN 4 PA
adriamycin intravenous IBRANCE 4 PA
solution reconstituted 10 4
mg, 50 mg idarubicin hcl 4
arsenic trioxide ISTODAX (OVERFILL) 4 PA
4
intravenous IXEMPRA KIT 4
azacitidine 4 JEVTANA 4 PA
bleomycin sulfate 4 KYPROLIS
COTELLIC 4 PA INTRAVENOUS
SOLUTION 4 PA
dactinomycin 4
RECONSTITUTED 10
daunorubicin hcl MG
4
intravenous solution leucovorin calcium 1
dexrazoxane 4 injection
diclofenac sodium leucovorin calcium oral 1
1 ST; QL
transdermal gel 3 % levoleucovorin calcium
4
docetaxel (non-alcohol) 4 intravenous solution
docetaxel intravenous LEVOLEUCOVORIN
concentrate 160 mg/8ml, 4 CALCIUM
20 mg/ml, 200 mg/10ml, INTRAVENOUS
4
80 mg/4ml SOLUTION
docetaxel intravenous RECONSTITUTED 175
solution 160 mg/16ml, 20 4 MG
mg/2ml, 80 mg/8ml levoleucovorin calcium
doxorubicin hcl intravenous solution 4
4 reconstituted 50 mg
intravenous solution
doxorubicin hcl liposomal 4 levoleucovorin calcium pf 4
lipodox 50 4
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
27Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
LYNPARZA ORAL exemestane 1
4 PA
TABLET letrozole oral 1
MARQIBO 4 Enzyme Inhibitors
mesna 4 CAMPTOSAR
MESNEX ORAL 4 INTRAVENOUS 4
mitomycin intravenous 4 SOLUTION 300
MG/15ML
mitoxantrone hcl 4 PA
etoposide intravenous
mutamycin 4 solution 1 gm/50ml, 100 4
NINLARO 4 PA mg/5ml, 500 mg/25ml
ONCASPAR INJECTION 4 etoposide oral 4
paclitaxel 4 HYCAMTIN ORAL 4
PICATO 3 ST irinotecan hcl 4
PROLEUKIN 4 KYPROLIS
ROMIDEPSIN 4 PA INTRAVENOUS
SOLUTION 4 PA
RUBRACA 4 PA RECONSTITUTED 30
SYLATRON MG, 60 MG
SUBCUTANEOUS KIT ONIVYDE 4
4 PA
200 MCG, 300 MCG, 600
MCG toposar intravenous
solution 1 gm/50ml, 100 4
SYNRIBO 4 PA mg/5ml, 500 mg/25ml
teniposide 4 topotecan hcl 4
TOTECT 4 ZYDELIG 4 PA
TRISENOX Molecular Target Inhibitors
INTRAVENOUS 4
AFINITOR 4 PA; QL
SOLUTION 12 MG/6ML
4 PA AFINITOR DISPERZ 4 PA
VELCADE INJECTION
BOSULIF 4 PA
vinblastine sulfate 4
intravenous solution CABOMETYX 4 PA
vincasar pfs 4 CAPRELSA ORAL
4 PA; QL
vincristine sulfate TABLET 100 MG
4
intravenous CAPRELSA ORAL 4 PA
vinorelbine tartrate 4 TABLET 300 MG
ZALTRAP 4 PA COMETRIQ (100 MG 4 PA
DAILY DOSE)
ZOLINZA 4 PA
COMETRIQ (140 MG 4 PA
Aromatase Inhibitors, 3rd Generation DAILY DOSE)
anastrozole oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
28Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
COMETRIQ (60 MG SUTENT 4 PA
4 PA
DAILY DOSE) TAFINLAR 4 PA
ERIVEDGE 4 PA TAGRISSO ORAL 4 PA; QL
GILOTRIF 4 PA; QL TABLET 40 MG
ICLUSIG ORAL TABLET 4 PA; QL TAGRISSO ORAL 4 PA
15 MG TABLET 80 MG
ICLUSIG ORAL TABLET TARCEVA 4 PA
4 PA
45 MG TASIGNA 4 PA
imatinib mesylate 4 PA temsirolimus 4
IMBRUVICA 4 PA TYKERB 4 PA
INLYTA 4 PA VENCLEXTA 4 PA
JAKAFI ORAL TABLET VENCLEXTA STARTING
4 PA; QL 4 PA
10 MG PACK
JAKAFI ORAL TABLET VOTRIENT 4 PA
15 MG, 20 MG, 25 MG, 5 4 PA
MG XALKORI 4 PA
LENVIMA 10 MG DAILY ZELBORAF 4 PA
4 PA
DOSE ZYKADIA 4 PA
LENVIMA 12 MG DAILY Monoclonal Antibody/Antibody-Drug Conjugate
4 PA
DOSE ADCETRIS 4 PA
LENVIMA 14 MG DAILY 4 PA ARZERRA 4 PA
DOSE
AVASTIN 4
LENVIMA 18 MG DAILY 4 PA BAVENCIO 4 PA
DOSE
BLINCYTO 4 PA
LENVIMA 20 MG DAILY
4 PA
DOSE DARZALEX 4 PA
LENVIMA 24 MG DAILY EMPLICITI 4 PA
4 PA
DOSE ERBITUX 4 PA
LENVIMA 4 MG DAILY GAZYVA 4 PA
4 PA
DOSE
HERCEPTIN 4 PA
LENVIMA 8 MG DAILY 4 PA KADCYLA 4 PA
DOSE
4 PA LARTRUVO 4 PA
MEKINIST
4 PA OPDIVO 4 PA
NEXAVAR
4 PA PERJETA 4 PA
RYDAPT
SPRYCEL 4 PA RITUXAN
INTRAVENOUS 4 PA
STIVARGA 4 PA SOLUTION
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
29Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
TECENTRIQ Pediculicides/Scabicides
INTRAVENOUS 4 PA crotan 1
SOLUTION 1200
MG/20ML EURAX EXTERNAL 2
CREAM
UNITUXIN 4 PA
lindane external 1
YERVOY 4 PA shampoo
Retinoids malathion external 1
bexarotene 4 PA permethrin external 1
PANRETIN 3 cream
TARGRETIN EXTERNAL 3 PA SKLICE 3
tretinoin oral 4 spinosad 1
Antiparasitics sulfurated lime 1
Anthelmintics ULESFIA 3
albendazole oral 1 PA Antiparkinson Agents
EMVERM 2 Anticholinergics
ivermectin oral 1 benztropine mesylate
1
praziquantel oral 1 injection
Antiprotozoals benztropine mesylate
1
oral
ALINIA 2
trihexyphenidyl hcl 1
atovaquone oral 1
Antiparkinson Agents, Other
atovaquone-proguanil hcl 1
entacapone 1
BENZNIDAZOLE 3
tolcapone 1
chloroquine phosphate
1 Dopamine Agonists
oral
COARTEM 3 APOKYN
SUBCUTANEOUS 4 PA; QL
DARAPRIM 4 PA SOLUTION CARTRIDGE
hydroxychloroquine 1 bromocriptine mesylate
sulfate oral 1
oral
mefloquine hcl 1 NEUPRO 3
NEBUPENT 2 pramipexole
1
primaquine phosphate dihydrochloride
1
oral pramipexole
1
quinine sulfate oral 1 PA dihydrochloride er
tinidazole oral 1 ropinirole hcl 1
ropinirole hcl er 1
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
30Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Dopamine Precursors/L- Amino Acid 2nd Generation/Atypical
Decarboxylase Inhibitors ABILIFY MAINTENA
carbidopa oral 1 INTRAMUSCULAR 3
carbidopa-levodopa 1 PREFILLED SYRINGE
carbidopa-levodopa er ABILIFY MAINTENA
oral tablet extended INTRAMUSCULAR 3
1 SUSPENSION
release 25-100 mg, 50-
200 mg RECONSTITUTED ER
carbidopa-levodopa- aripiprazole 1 QL
1
entacapone FANAPT 3 ST; QL
Monoamine Oxidase B (MAO-B) Inhibitors FANAPT TITRATION
3 ST; QL
rasagiline mesylate oral 1 PACK
selegiline hcl oral 1 GEODON
3
INTRAMUSCULAR
Antipsychotics
INVEGA SUSTENNA 3
1st Generation/Typical
INVEGA TRINZA 3
chlorpromazine hcl
1 LATUDA 3 QL
injection
chlorpromazine hcl oral 1 olanzapine intramuscular 1
fluphenazine decanoate olanzapine oral 1 QL
1
injection paliperidone er 1 QL
fluphenazine hcl injection 1 quetiapine fumarate 1 QL
fluphenazine hcl oral 1 quetiapine fumarate er 1 QL
haloperidol decanoate REXULTI 3 QL
intramuscular solution 1 3
RISPERDAL CONSTA
100 mg/ml, 50 mg/ml
risperidone 1 QL
haloperidol lactate
1 risperidone m-tab oral
injection solution 5 mg/ml
tablet dispersible 0.5 mg, 1 QL
haloperidol lactate oral 1
1 mg, 2 mg
haloperidol oral 1 2 QL
SAPHRIS
loxapine succinate oral 1 1 QL
ziprasidone hcl
molindone hcl 1 3
ZYPREXA RELPREVV
perphenazine oral 1 Treatment-Resistant
pimozide 1 1 QL
clozapine oral tablet
thioridazine hcl oral 1
clozapine oral tablet
thiothixene oral 1 dispersible 100 mg, 150 1 QL
trifluoperazine hcl oral 1 mg, 200 mg, 25 mg
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
31Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
clozapine oral tablet moderiba oral tablet 200
1 PA; QL 4
dispersible 12.5 mg mg
Antispasticity Agents PEGASYS PROCLICK
baclofen intrathecal 1 SUBCUTANEOUS 4 PA
SOLUTION 180
baclofen oral 1
MCG/0.5ML
PA; Non-
4 PEGASYS
BOTOX Cosmetic 4 PA
SUBCUTANEOUS
dantrolene sodium oral 1 SOLUTION
revonto 1 PEGINTRON
tizanidine hcl oral 1 SUBCUTANEOUS KIT 4 PA
50 MCG/0.5ML
Antivirals
REBETOL ORAL 4
Anti-cytomegalovirus (CMV) Agents
SOLUTION
cidofovir intravenous 1 4
ribasphere
ganciclovir sodium 1
ribasphere ribapak oral 4
valganciclovir hcl 1 tablet 400 mg, 600 mg
Anti-hepatitis B (HBV) Agents RIBASPHERE RIBAPAK
adefovir dipivoxil 4 ORAL TABLET 4
THERAPY PACK 200 &
BARACLUDE ORAL 400 MG
4 QL
SOLUTION
ribasphere ribapak oral
entecavir 4 QL 4
tablet therapy pack 400 &
EPIVIR HBV ORAL 600 mg
4
SOLUTION ribavirin oral capsule 4
INTRON A 4 PA
ribavirin oral tablet 200 4
lamivudine oral tablet 4 mg
100 mg SOFOSBUVIR- 4 PA; M; QL
VEMLIDY 4 VELPATASVIR
Anti-hepatitis C (HBV) Agents SOVALDI 4 PA; QL
DAKLINZA ORAL 4 PA; QL TECHNIVIE 4 PA; QL
TABLET 30 MG, 60 MG 4 PA; QL
VIEKIRA PAK
EPCLUSA 4 PA; QL
ZEPATIER 4 PA; QL
HARVONI 4 PA; QL Antiherpetic Agents
LEDIPASVIR- 4 PA; M; QL acyclovir external 1
SOFOSBUVIR
acyclovir oral 1
MAVYRET 4 PA; QL
acyclovir sodium
MODERIBA 1200 DOSE 1
4 intravenous solution
PACK
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
32Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
DENAVIR 3 didanosine oral capsule
famciclovir oral 1 delayed release 200 mg, 1
250 mg, 400 mg
valacyclovir hcl oral 1 QL
EMTRIVA 2
Anti-HIV Agents, Integrase Inhibitors (INSTI)
lamivudine oral solution 1
BIKTARVY 3
lamivudine oral tablet 1
GENVOYA 2
150 mg, 300 mg
ISENTRESS 2 1
lamivudine-zidovudine
ISENTRESS HD 2
RETROVIR 2
JULUCA 2 INTRAVENOUS
STRIBILD 2 stavudine oral capsule 1
TIVICAY 2 tenofovir disoproxil
1
TRIUMEQ 2 fumarate
Anti-HIV Agents, Non-nucleoside Reverse TRUVADA 2
Transcriptase Inhibitors (NNRTI) VIDEX 2
ATRIPLA 2 VIDEX EC ORAL
COMPLERA 2 CAPSULE DELAYED 2
RELEASE 125 MG
EDURANT 2
VIREAD ORAL 2
efavirenz 1
POWDER
INTELENCE 2
VIREAD ORAL TABLET
nevirapine 1 150 MG, 200 MG, 250 2
nevirapine er 1 MG
ODEFSEY 2 zidovudine 1
RESCRIPTOR ORAL Anti-HIV Agents, Other
2
TABLET 200 MG FUZEON
SYMFI 2 SUBCUTANEOUS
2 QL
SOLUTION
SYMFI LO 2
RECONSTITUTED
Anti-Hiv Agents, Nucleoside And Nucleotide 2 PA
SELZENTRY
Reverse Transcriptase Inhibitors (Nrti)
TYBOST 2
abacavir sulfate 1
Anti-HIV Agents, Protease Inhibitors
abacavir sulfate- 1
lamivudine APTIVUS 2
abacavir-lamivudine- atazanavir sulfate 1
1
zidovudine CRIXIVAN ORAL
CIMDUO 2 CAPSULE 200 MG, 400 2
MG
DESCOVY 2
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
33Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
EVOTAZ 2 alprazolam xr 1 QL
fosamprenavir calcium 1 chlordiazepoxide hcl 1 QL
INVIRASE ORAL clorazepate dipotassium 1 QL
2
TABLET diazepam injection 1
KALETRA ORAL 2 diazepam intensol 1
TABLET
diazepam intramuscular 1
LEXIVA ORAL 2 solution auto-injector
SUSPENSION
diazepam oral 1
lopinavir-ritonavir 1 concentrate
NORVIR ORAL PACKET 2 diazepam oral solution 5 1
NORVIR ORAL 2 mg/5ml
SOLUTION diazepam oral tablet 1
PREZCOBIX 2 estazolam 1 QL
PREZISTA ORAL flurazepam hcl 1 PA; QL
2
SUSPENSION
lorazepam injection 1
PREZISTA ORAL
TABLET 150 MG, 600 2 lorazepam intensol 1 QL
MG, 75 MG, 800 MG lorazepam oral 1 QL
REYATAZ ORAL oxazepam 1 QL
2
PACKET quazepam 1 QL
ritonavir 1 1 QL
temazepam
VIRACEPT ORAL 2 triazolam 1 QL
TABLET
Bipolar Agents
Anti-influenza Agents
Mood Stabilizers
amantadine hcl oral 1
lithium 1
oseltamivir phosphate 1 QL lithium carbonate er 1
oral
3 QL lithium carbonate oral 1
RELENZA DISKHALER
1 Blood Glucose Monitoring
rimantadine hcl
Anxiolytics ACCU-CHEK FASTCLIX 2
LANCET KIT
Anxiolytics, Other
ACCU-CHEK FASTCLIX 2
buspirone hcl oral 1
LANCETS
meprobamate 1
ACCU-CHEK
Benzodiazepines MULTICLIX LANCET 2
alprazolam er 1 QL DEVICE KIT
alprazolam oral 1 QL ACCU-CHEK
2
MULTICLIX LANCETS
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
34Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
ACCU-CHEK SOFT ONETOUCH VERIO IQ
2 3
TOUCH LANCETS SYSTEM KIT W/DEVICE
ACCU-CHEK SOFTCLIX 2 ONETOUCH VERIO IQ 2
LANCET DEVICE KIT SYSTEM KIT W/DEVICE
ACCU-CHEK SOFTCLIX 2 ONETOUCH VERIO 3 QL
LANCETS STRIP IN VITRO
CHEMSTRIP UGK 3 ONETOUCH VERIO 2 QL
INPEN 100-BLUE-LILLY 3 STRIP IN VITRO
INPEN 100-BLUE-NOVO 3 ONETOUCH VERIO
SYNC SYSTEM KIT 2
INPEN 100-GRAY-LILLY 3 W/DEVICE
INPEN 100-GREY- 3 SURESTEP PRO HIGH
NOVO 3
GLUCOSE
INPEN 100-PINK-LILLY 3 SURESTEP PRO LOW 3
INPEN 100-PINK-NOVO 3 GLUCOSE
KETOCARE 3 SURESTEP PRO 3
KETOSTIX 3 NORMAL GLUCOSE
2 Blood Glucose Regulators
LANCETS
3 Antidiabetic Agents
NOVOPEN ECHO
acarbose 1
ONETOUCH DELICA
3
LANCING DEV ACTOPLUS MET XR 3 ST
ONETOUCH ULTRA 2 AVANDIA ORAL 3 ST
3
KIT W/DEVICE TABLET 2 MG, 4 MG
ONETOUCH ULTRA 2 BYDUREON BCISE
2 2 ST; QL
KIT W/DEVICE AUTOINJECTOR
ONETOUCH ULTRA BYDUREON PEN 2 ST; QL
2 QL
BLUE TEST STRIPS BYETTA 10 MCG PEN 2 ST; QL
ONETOUCH ULTRA 3 BYETTA 5 MCG PEN 2 ST; QL
MINI KIT W/DEVICE
chlorpropamide 1
ONETOUCH ULTRA
2 CYCLOSET 3 ST
MINI KIT W/DEVICE
2 glimepiride 1
ONETOUCH VERIO
glipizide er 1
ONETOUCH VERIO
FLEX SYSTEM KIT 2 glipizide ir 1
W/DEVICE glipizide xl 1
ONETOUCH VERIO IN 3 glipizide-metformin hcl 1
VITRO SOLUTION HIGH
glyburide micronized 1
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
35Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
glyburide oral 1 TRADJENTA 2 ST
glyburide-metformin 1 TRULICITY 2 ST; QL
GLYXAMBI 2 ST VICTOZA 2 ST; QL
INVOKAMET 2 ST Glycemic Agents
INVOKAMET XR 2 ST GLUCAGEN HYPOKIT 2
INVOKANA 2 ST GLUCAGON 2
JANUMET 2 ST EMERGENCY
2 ST PROGLYCEM 2
JANUMET XR
2 ST Insulins
JANUVIA
JARDIANCE 2 ST HUMALOG U-100 AND 2
U-200 KWIKPEN
JENTADUETO 2 ST
HUMALOG MIX 50/50 2
JENTADUETO XR 2 ST KWIKPEN
metformin hcl er 1 HUMALOG MIX 50/50
2
METFORMIN HCL ORAL VIAL
3
SOLUTION HUMALOG MIX 75/25
2
metformin hcl oral tablet 1 KWIKPEN
miglitol 1 HUMALOG MIX 75/25
2
nateglinide 1 VIAL
OZEMPIC 2 ST; QL HUMALOG U-100 2
JUNIOR KWIKPEN
pioglitazone hcl 1
HUMALOG U-100 VIAL 2
pioglitazone hcl- AND CARTRIDGE
1
glimepiride
HUMULIN 70/30 2
pioglitazone hcl- KWIKPEN
1
metformin hcl
HUMULIN 70/30 VIAL 2
QTERN 3 ST
HUMULIN N KWIKPEN 2
repaglinide 1
HUMULIN N VIAL 2
repaglinide-metformin hcl 1
HUMULIN R U-500
RIOMET 3 2
KWIKPEN
SYMLINPEN 120 3 PA HUMULIN R U-500 VIAL
2
SYMLINPEN 60 3 PA (CONCENTRATED)
SYNJARDY 2 ST HUMULIN R VIAL 2
SYNJARDY XR 2 ST LANTUS U-100
2
tolazamide 1 SOLOSTAR
1 LANTUS U-100 VIAL 2
tolbutamide
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
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