2021 Drug Formulary September
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September 1 2021 Drug Formulary For members covered through large employer groups with a 1- or 2-tier with additional specialty tier in-network pharmacy benefit and no out-of-network pharmacy benefit All plans offered and underwritten by Kaiser Foundation Health Plan of Washington or Kaiser Foundation Health Plan of Washington Options, Inc. XB0001338-50-17
Drug Formulary INTRODUCTION What is a formulary? A formulary is a list of generic, brand, and specialty drugs. It is used by practitioners to identify drugs that offer the best overall value, considering effectiveness, safety, and cost. How is the drug formulary developed? The formulary is developed by the Kaiser Permanente Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is composed of physicians from various medical specialties, pharmacists, and a consumer member. The P&T Committee reviews and selects the most appropriate drugs in each class for the formulary based on safety, effectiveness, and cost. The P&T Committee meets quarterly to review new and existing drugs to ensure that the formulary remains responsive to the needs of members and providers. How do I search the formulary? Drugs on the formulary are listed by therapeutic class. An alphabetical index is included at the end of this document to assist in locating specific drugs. Drugs are listed by generic name if a generic is available. If there is no generic available, drugs are listed by the brand name. Drugs are organized by class and drug formulary tier. Drugs administered in a provider’s office or in a clinic (e.g., drugs given intravenously) may not be listed on the formulary. For coverage of these drugs, refer to your Benefit Booklet. How do I use the formulary to understand my drug coverage? Drug coverage is based on an individual’s contracted benefit. Coverage for a specific drug is subject to each member’s medical coverage agreement. Please consult your Benefit Booklet or call Member Service if you have questions about your drug coverage. Kaiser Permanente will only cover FDA-approved drugs used for non-experimental therapies. Most plans exclude experimental and investigational drugs, over-the-counter drugs, drugs used in the treatment of sexual dysfunction disorders, drugs for anticipated illnesses while traveling, or drugs used for cosmetic purposes. Please consult your Benefit Booklet for limitations and exclusions. Medications not listed in this document are not on the formulary at the time of publication. The most current information is online at www.kp.org/wa/ formulary. Non- formulary drugs are not covered unless approved by the health plan as a coverage exception. The prescriber must contact Kaiser Permanente to determine the medical necessity of the non-formulary medication. An alternative formulary medication will be recommended when clinically appropriate. If a coverage exception is not approved, the patient is responsible for the full price of the drug. Prior authorization, step therapy and nonformulary requests are considered based on
coverage criteria requirements approved by the P&T Committee. To request review of an exception to Kaiser Permanente requirements for coverage of prescription drugs, you or your prescriber may contact Kaiser Permanente Member Services at 1-888-630-4636 and request an exception. If the evidence your prescriber provides meets medical necessity, an exception may be approved. Exceptions to required therapy that may be approved include: contraindications, clinical factors associated with adverse reactions, clinical factors reducing effect, other risks of clinical harm, and barriers to compliance with clinical care. Your prescriber may also request temporary coverage while the exception request is being processed. Generic drugs are substituted when available and allowed by your prescriber. When a generic is available, the brand-name drug is generally considered non-formulary and subject to a higher cost share. The drug formulary is updated periodically and is subject to change. If a drug will be removed from the formulary, members who filled the drug in the prior three months will be notified by letter of the upcoming change. A formulary change notice will also be posted on the member website at least 60 days prior to the effective date. What are the methods that Kaiser Permanente uses to ensure appropriate and safe use of formulary drugs? Prior Authorization (PA) The P&T Committee determines that certain drugs should require prior authorization before they will be covered. These drugs most often have alternatives on the formulary, safety concerns, or a high potential for inappropriate use. To request coverage for prior authorization drugs, you or your prescriber must contact Kaiser Permanente. Drugs requiring prior authorization are indicated with a “PA” superscript next to the drug name. Step Therapy (ST) Step therapy requires you to try certain preferred drugs before receiving coverage for the drug you were prescribed. Step therapy is added by the P&T Committee. Step therapy automatically looks at your prescription history when you fill the drug you were prescribed. If you have tried the preferred drugs required by step therapy, the drug you were prescribed will automatically be covered. To request step therapy exceptions, you or your prescriber must contact Kaiser Permanente. Drugs requiring step therapy are indicated with a “ST” superscript next to the drug name. Quantity Limit (QL) A quantity limit defines how much of a particular drug you can get during a specific time period or the maximum days supply that you can get at once. The P&T Committee determines if a drug should have a quantity limit. To request exceptions to quantity limits, your prescriber must contact Kaiser Permanente. Drugs with quantity limits are indicated with “QL” superscript next to the drug name. High Dose Pain Medicine Prescriber Review Members on high doses of certain pain medicines will need their prescriber to confirm safety standards are in place annually to continue coverage of therapy. Drugs Limited to Select Pharmacies Some drugs are required to be dispensed from a preferred specialty pharmacy vendor.
Members with an out-of-network benefit may use other pharmacies; however, they may pay
a higher cost share.
Please consult your Benefit Booklet for limitations and exclusions. Drugs limited to
select pharmacies are listed on the www.kp.org/wa/formulary webpage.
Covered Diabetic Supplies
Some diabetic supplies may be covered at a Tier 1 cost share if they are filled as a
prescription. These items are:
Preferred blood glucose strips:
o One Touch Verio
o One Touch Ultra
o Prodigy – prior authorization required
o Contour Next – prior authorization required
o Freestyle – prior authorization required
Disposable insulin syringes and needles
Lancing devices and lancets
Preferred blood glucose meters are covered only when filled through mail order pharmacy.
Mail Order Pharmacy Service
Mail order is convenient and efficiently utilizes Kaiser Permanente’s resources. This service
works best for drugs that must be taken on regular basis, such as birth control pills and
drugs for high blood pressure, high cholesterol, or other chronic conditions.
To begin using mail order, ask your prescriber to send your prescription directly to the
Mail Order Pharmacy. To transfer an existing prescription from a retail pharmacy,
contact the Mail Order Pharmacy.
Address: Kaiser Permanente Mail Order Pharmacy
PO Box 34383
Seattle, WA 98124-1383
Phone: 800-245-RXRX (1-800-245-7979)
Fax: 206-630-7950, or toll-free 1-800-350-1683
Specialty Drugs
Specialty drugs are high-cost drugs prescribed by a physician for the treatment of complex
conditions. Some specialty products are dispensed from a preferred specialty pharmacy
vendor.
Over-the-Counter (OTC) Drugs
A few plans offer coverage for OTC drugs. For these plans, a list of covered OTC
drugs can be found in Appendix A. You may contact Member Service at 1-888-630-
4636 to find if you have OTC drug coverage.
Preventative Medications and Preferred Contraceptives
In accordance with the Affordable Care Act (ACA) requirements for preventive services,most plans cover preventative care medicines and contraceptives in full. If your plan offers ACA benefits, all prescribed FDA approved contraceptive methods from the Kaiser Permanente formulary list will be covered in full when obtained in-network. For plans with out-of-network (OON) benefits, contraceptives will be subject to the OON cost-share. The list of the preventative medications covered in full is available on the www.kp.org/wa/formulary webpage. Please consult your Benefit Booklet under “Preventive Services” or call Member Service if you have questions about your coverage for these drugs. If you request coverage for a non-preferred contraceptive, we will contact your provider to recommend a preferred generic or therapeutically equivalent product. If you and your provider determine that the preferred contraceptive(s) would be medically inappropriate, your provider must request a contraceptive waiver. If waiver is completed, the requested non-preferred contraceptive will be covered in full. Excluded Prescription Products for Medications that have Over-The- Counter (OTC) Alternatives There are certain prescription products that have the same or similar products available over-the- counter (OTC) without a prescription. In certain cases, Kaiser Permanente will not cover the prescription product. The following prescription drug products are excluded from coverage: esomeprazole magnesium (Nexium), omeprazole/sodium bicarbonate (Zegerid), budesonide nasal spray (Rhinocort Aqua), triamcinolone nasal spray (Nasacort), and fluticasone propionate nasal spray (Flonase). Medical Benefit Injectable Drugs Some drugs are given in a non-hospital setting such as home infusion, a medical office, a physician's office, or an infusion suite. These drugs are covered under the medical benefit but may require prior authorization or a non-hospital setting. The list of medical benefit injectable drugs is available on the www.kp.org/wa/formulary webpage. How do I get additional information? Please contact Member Service at 1-888-630-4636 with any questions or concerns regarding the information contained in this document. The most current drug formulary is available at www.kp.org/wa/formulary.
Table of Contents
Analgesics - Drugs for Pain and Inflammation ........................................................................ 11
Analgesics - Drugs for Pain .......................................................................................................... 11
Anesthetics ....................................................................................................................................... 12
Anti-Addiction / Substance Abuse Treatment Agents........................................................... 12
Antibacterials .................................................................................................................................... 12
Anticoagulants ................................................................................................................................. 13
Anticonvulsants - Drugs for Seizures ........................................................................................ 13
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.............................. 14
Antidepressants ............................................................................................................................... 14
Antiemetics - Drugs for Nausea and Vomiting ........................................................................ 15
Antifungals ........................................................................................................................................ 15
Antigout Agents ............................................................................................................................... 15
Antimigraine Agents ....................................................................................................................... 15
Antimyasthenic Agents .................................................................................................................. 16
Antimycobacterials ......................................................................................................................... 16
Antineoplastics - Drugs for Cancer ............................................................................................ 16
Antiparasitics .................................................................................................................................... 17
Antiparkinson Agents..................................................................................................................... 17
Antiplatelets ...................................................................................................................................... 17
Antipsychotics - Drugs for Mood Disorders ............................................................................ 17
Antivirals ............................................................................................................................................ 18
Anxiolytics - Drugs for Anxiety .................................................................................................... 19
Bipolar Agents - Drugs for Mood Disorders............................................................................. 19
Blood Products and Modifiers - Drugs for Blood Disorders ............................................... 19
Cardiovascular Agents - Drugs for Heart and Circulation Conditions ............................. 19
Central Nervous System Agents - Drugs for Attention Deficit Disorder .......................... 22
Central Nervous System Agents - Drugs for Multiple Sclerosis......................................... 22
Central Nervous System Agents - Miscellaneous .................................................................. 22
Dental and Oral Agents - Drugs for Mouth and Throat Conditions ................................... 22
Dermatological Agents - Drugs for Skin Conditions ............................................................. 22
Diabetes - Antidiabetic Agents .................................................................................................... 25
Diabetes - Glucose Monitoring .................................................................................................... 25
Diabetes - Glycemic Agents ......................................................................................................... 26
Diabetes - Insulins ........................................................................................................................... 26
Electrolytes / Minerals / Metals / Vitamins ................................................................................ 27
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer ................................................. 27
9Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions ............ 28
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment .......... 28
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions ................... 28
Genitourinary Agents - Drugs for Prostate Conditions......................................................... 28
Hormonal Agents - Adrenal .......................................................................................................... 28
Hormonal Agents - Men's Health ................................................................................................. 29
Hormonal Agents - Osteoporosis ............................................................................................... 29
Hormonal Agents - Pituitary ......................................................................................................... 29
Hormonal Agents - Sex Hormones and Birth Control ........................................................... 30
Hormonal Agents - Thyroid........................................................................................................... 32
Immunological Agents - Drugs for Immune System Stimulation or Suppression ........ 32
Immunological Agents - Drugs for Vaccination ...................................................................... 33
Inflammatory Bowel Disease Agents ......................................................................................... 34
Metabolic Bone Disease Agents - Drugs for Osteoporosis ................................................. 34
Metabolic Bone Disease Agents - Other ................................................................................... 34
Miscellaneous Therapeutic Agents ............................................................................................ 34
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation ........................ 35
Ophthalmic Agents - Drugs for Glaucoma ............................................................................... 35
Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions ......................................... 36
Otic Agents - Drugs for Ear Conditions..................................................................................... 36
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold ..................... 36
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions
.............................................................................................................................................................. 37
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis ................................... 38
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension ................ 38
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm ........................................ 38
Sleep Disorder Agents ................................................................................................................... 38
Index of Drugs .................................................................................................................................. 40
10Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Analgesics - Drugs for Pain and codeine sulfate 1 QL
Inflammation endocet 1 QL
celecoxib oral 1 fentanyl transdermal
diclofenac potassium 1 patch 72 hour 100
mcg/hr, 12 mcg/hr, 25 1 PA; QL
diclofenac sodium er 1 mcg/hr, 50 mcg/hr, 75
diclofenac sodium oral 1 mcg/hr
diflunisal oral 1 hydrocodone-
acetaminophen oral
etodolac 1
solution 2.5-108 mg/5ml, 1 QL
flurbiprofen oral 1 5-217 mg/10ml, 7.5-325
mg/15ml
ibuprofen 1
hydrocodone-
indomethacin er 1
acetaminophen oral tablet
1 QL
indomethacin oral capsule 10-325 mg, 5-325 mg,
1
25 mg, 50 mg 7.5-325 mg
ketorolac tromethamine hydromorphone hcl oral 1 QL
1
injection hydromorphone hcl rectal 1 QL
ketorolac tromethamine levorphanol tartrate oral 1 PA; QL
1
intramuscular
methadone hcl oral
meclofenamate sodium 1 ST; QL
1 solution
oral
methadone hcl oral tablet 1 ST; QL
meloxicam oral tablet 1
methadone hcl oral tablet
nabumetone oral 1 1 ST; QL
soluble
naproxen oral suspension 1 methadose oral tablet
1 ST; QL
naproxen oral tablet 1 soluble
naproxen sodium oral morphine sulfate
1 (concentrate) oral solution 1 QL
tablet 275 mg, 550 mg
100 mg/5ml, 20 mg/ml
piroxicam oral 1
morphine sulfate er oral
salsalate oral 1 1 ST; QL
tablet extended release
sulindac oral 1 morphine sulfate oral 1 QL
Analgesics - Drugs for Pain morphine sulfate rectal 1 QL
acetaminophen-codeine 1 QL OXYCODONE HCL ER 2 ST; QL
acetaminophen-codeine oxycodone hcl oral
1 QL 1 QL
#2 concentrate 100 mg/5ml
acetaminophen-codeine oxycodone hcl oral
1 QL 1 QL
#3 solution
acetaminophen-codeine oxycodone hcl oral tablet 1 QL
1 QL
#4 oxycodone-
bac 1 acetaminophen oral tablet
1 QL
10-325 mg, 2.5-325 mg,
butalbital-apap-caffeine
1 5-325 mg, 7.5-325 mg
oral tablet
OXYCONTIN 2 ST; QL
butalbital-aspirin-caffeine 1
Effective Date: 09/01/2021
11Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
tramadol hcl ir 1 QL nicotine polacrilex mini 2
tramadol-acetaminophen 1 QL nicotine polacrilex
2
Anesthetics mouth/throat
glydo 1 nicotine step 1 1
lidocaine external patch 5 nicotine step 2 1
1
% nicotine step 3 1
lidocaine hcl (pf) injection VIVITROL 4 QL
1
solution 1 %, 2 %
Antibacterials
lidocaine hcl injection
1 amoxicillin 1
solution
lidocaine hcl amoxicillin-potassium
1 1
urethral/mucosal clavulanate oral
lidocaine-prilocaine 1 ampicillin 1
prilovix ultralite 1 ampicillin sodium injection
solution reconstituted 1
prilovix ultralite plus 1 1
gm, 125 mg, 250 mg, 500
Anti-Addiction / Substance Abuse mg
Treatment Agents avidoxy 1
acamprosate calcium 1 azithromycin oral 1
APO-VARENICLINE 2 BICILLIN L-A 2
buprenorphine hcl cefadroxil 1
1 QL
sublingual
cefazolin sodium injection
buprenorphine hcl- solution reconstituted 1 1
naloxone hcl sublingual 1 QL gm
tablet sublingual
cefdinir 1
bupropion hcl er (smoking
1 cefixime 1
det)
CHANTIX 2 cefprozil 1
CHANTIX CONTINUING ceftazidime injection
2 solution reconstituted 1 1
MONTH PAK
gm
CHANTIX STARTING
2 ceftriaxone sodium
MONTH PAK
injection solution
disulfiram oral 1 1
reconstituted 1 gm, 2 gm,
goodsense nicotine 250 mg, 500 mg
mouth/throat lozenge 4 2
cefuroxime axetil 1
mg
cephalexin oral capsule
habitrol 1 1
250 mg, 500 mg
naloxone hcl injection 1 cephalexin oral
1
naltrexone hcl oral 1 suspension reconstituted
NARCAN 1 CIPRO ORAL
SUSPENSION
NICORETTE 2
RECONSTITUTED 250
MOUTH/THROAT GUM 2 2
MG/5ML (5%)
MG
Effective Date: 09/01/2021
12Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
ciprofloxacin hcl oral 1 nitrofurantoin
1
macrocrystal
clarithromycin oral 1
nitrofurantoin
clindamycin hcl oral 1 monohydrate 1
clindamycin palmitate hcl 1 macrocrystals
clindamycin phosphate penicillin v potassium 1
injection solution 300 1 2
PRIMSOL
mg/2ml
silver sulfadiazine
clindamycin phosphate 1
1 external
vaginal
SIVEXTRO ORAL 4 QL
dicloxacillin sodium 1
ssd 1
doxycycline hyclate oral
1 sulfamethoxazole-
capsule 1
trimethoprim oral
doxycycline hyclate oral
tablet 100 mg, 150 mg, 50 1 sulfatrim pediatric 1
mg, 75 mg SUPRAX ORAL
doxycycline monohydrate SUSPENSION
1 2
oral capsule RECONSTITUTED 500
MG/5ML
doxycycline monohydrate
1 tazicef injection solution
oral tablet 1
reconstituted 1 gm
FIRVANQ 2
trimethoprim oral 1
gentamicin sulfate
1 vancomycin hcl oral
external 1
solution reconstituted
gentamicin sulfate
injection solution 40 1 vandazole 1
mg/ml Anticoagulants
levofloxacin oral 1 enoxaparin sodium 1 QL
linezolid oral suspension fondaparinux sodium 4 QL
1 QL
reconstituted
heparin sodium (porcine)
linezolid oral tablet 1 injection solution 1000
1
methenamine hippurate 1 unit/ml, 10000 unit/ml,
5000 unit/ml
metronidazole oral tablet 1
heparin sodium (porcine)
metronidazole vaginal 1 1
pf
minocycline hcl oral jantoven 1
1
capsule
LOVENOX 1 QL
mondoxyne nl 1
PRADAXA 2
morgidox oral 1
warfarin sodium oral 1
moxifloxacin hcl oral 1
XARELTO 2 PA
mupirocin calcium 1
XARELTO STARTER
mupirocin external 1 2 PA
PACK
neomycin sulfate oral 1 Anticonvulsants - Drugs for Seizures
nitrofurantoin 1 carbamazepine er 1
Effective Date: 09/01/2021
13Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
carbamazepine oral 1 galantamine
1
hydrobromide
CELONTIN 2
galantamine
DIASTAT PEDIATRIC 1 QL 1
hydrobromide er
diazepam rectal 1 QL
memantine hcl oral tablet
DILANTIN ORAL 1
2 10 mg, 5 mg
CAPSULE 30 MG
rivastigmine tartrate 1
divalproex sodium er 1
Antidepressants
divalproex sodium oral 1
amitriptyline hcl oral 1
epitol 1
amoxapine 1
ethosuximide oral 1
bupropion hcl er (sr) 1
gabapentin oral 1
bupropion hcl er (xl) oral
lamotrigine oral tablet 1 tablet extended release 1
lamotrigine oral tablet 24 hour 150 mg, 300 mg
1
chewable bupropion hcl oral 1
levetiracetam er 1 citalopram hydrobromide 1
levetiracetam oral 1 clomipramine hcl oral 1
NAYZILAM 2 PA; QL desipramine hcl oral 1
oxcarbazepine 1 doxepin hcl oral capsule 1
phenobarbital oral 1 doxepin hcl oral
1
phenobarbital sodium concentrate
injection solution 130 1 duloxetine hcl oral
mg/ml capsule delayed release
1
phenytoin infatabs 1 particles 20 mg, 30 mg,
60 mg
phenytoin oral 1
escitalopram oxalate 1
phenytoin sodium
extended oral capsule 1 fluoxetine hcl oral capsule 1
100 mg fluoxetine hcl oral solution 1
phenytoin sodium fluvoxamine maleate 1
1
injection
imipramine hcl oral 1
primidone oral 1 QL
mirtazapine oral 1
roweepra 1
nortriptyline hcl oral 1
subvenite 1
paroxetine hcl 1
topiramate oral 1
PAXIL ORAL
valproic acid oral 1 2
SUSPENSION
VALTOCO 2 PA; QL perphenazine-
1
zonisamide oral 1 amitriptyline
Antidementia Agents - Drugs for phenelzine sulfate oral 1
Alzheimer's Disease and Dementia protriptyline hcl 1
donepezil hcl oral tablet 1
1 sertraline hcl oral
10 mg, 5 mg
Effective Date: 09/01/2021
14Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
tranylcypromine sulfate 1 fluconazole oral 1
trazodone hcl oral 1 flucytosine oral 4 QL
venlafaxine hcl 1 griseofulvin microsize oral 1
venlafaxine hcl er oral griseofulvin ultramicrosize 1
capsule extended release 1 itraconazole oral 1 PA
24 hour
ketoconazole external
Antiemetics - Drugs for Nausea and 1
cream
Vomiting
ketoconazole external
aprepitant oral 1 1
shampoo
aprepitant oral capsule ketoconazole oral 1
125 mg, 80 & 125 mg, 80 1
mg nyamyc 1
compro 1 nystatin external 1
dimenhydrinate injection 1 nystatin mouth/throat 1
dronabinol 1 nystatin oral 1
metoclopramide hcl nystatin-triamcinolone 1
1
injection nystop 1
metoclopramide hcl oral 1
1 terbinafine hcl oral
solution
voriconazole oral 1 PA
metoclopramide hcl oral
1 Antigout Agents
tablet
ondansetron hcl injection 1 allopurinol oral 1
ondansetron hcl oral 1 COLCHICINE ORAL
1
CAPSULE
ondansetron odt 1
colchicine oral tablet 1
perphenazine oral 1
colchicine-probenecid 1
prochlorperazine 1
probenecid 1
prochlorperazine
1 Antimigraine Agents
edisylate injection
prochlorperazine maleate dihydroergotamine
1 1 QL
oral mesylate injection
Antifungals dihydroergotamine
4
mesylate nasal
ciclodan 1
ERGOMAR 2
ciclopirox external gel 1
ergotamine-caffeine 1
ciclopirox external
1 MIGERGOT 2
solution
ciclopirox olamine naratriptan hcl 1
1
external rizatriptan benzoate 1
clotrimazole mouth/throat 1 1
sumatriptan nasal
clotrimazole- sumatriptan succinate
1 1
betamethasone oral
CRESEMBA ORAL 4 PA; QL
Effective Date: 09/01/2021
15Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
sumatriptan succinate GILOTRIF 2 PA; QL
1
refill 2
GLEOSTINE
sumatriptan succinate
1 hydroxyurea oral 1
subcutaneous
imatinib mesylate 1 QL
zolmitriptan oral 1
IMBRUVICA ORAL
Antimyasthenic Agents 2 PA; QL
CAPSULE
MESTINON ORAL IMBRUVICA ORAL
2
SOLUTION TABLET 140 MG, 420 2 PA; QL
pyridostigmine bromide er 1 MG, 560 MG
pyridostigmine bromide IRESSA 2 PA; QL
1
oral lapatinib ditosylate 1 PA; QL
Antimycobacterials letrozole oral 1
dapsone oral 1 leucovorin calcium oral 1
ethambutol hcl oral 1 LEUKERAN 2
isoniazid oral 1 MATULANE 2 QL
PRIFTIN 2 MEKINIST 2 PA; QL
pyrazinamide oral 1 melphalan 1 QL
rifabutin 1 mercaptopurine oral 1
rifampin oral 1 mesna 1
Antineoplastics - Drugs for Cancer MESNEX ORAL 2
abiraterone acetate 1 QL MYLERAN 2 QL
AFINITOR DISPERZ 2 PA; QL NEXAVAR 2 PA
AFINITOR ORAL REVLIMID 2 PA; QL
2 PA; QL
TABLET 10 MG ROZLYTREK 2 PA; QL
anastrozole oral 1 RYDAPT 2 PA; QL
bicalutamide 1 SPRYCEL 2 PA; QL
BRUKINSA 2 PA; QL STIVARGA 2 PA
CALQUENCE 2 PA; QL SUTENT 2 PA; QL
capecitabine 1 QL TABLOID 2
COTELLIC 2 PA; QL TAFINLAR 2 PA; QL
cyclophosphamide oral TAGRISSO 2 PA; QL
1
capsule
tamoxifen citrate oral 1
DROXIA 2
temozolomide 1 QL
erlotinib hcl 1 PA
THALOMID 2 PA; QL
etoposide oral 1 QL
tretinoin oral 1 QL
everolimus oral tablet 2.5
1 PA; QL VENCLEXTA 2 PA; QL
mg, 5 mg, 7.5 mg
1 VENCLEXTA STARTING
exemestane 2 PA; QL
PACK
flutamide 1
VOTRIENT 2 PA; QL
Effective Date: 09/01/2021
16Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
XTANDI ORAL CAPSULE 2 PA; QL trihexyphenidyl hcl 1
ZELBORAF 2 PA Antiplatelets
ZYDELIG 2 PA; QL aspirin-dipyridamole er 1
Antiparasitics BRILINTA 2
albendazole oral 1 cilostazol 1
ALINIA ORAL clopidogrel bisulfate oral 1
SUSPENSION 2
RECONSTITUTED dipyridamole oral 1
atovaquone oral 4 prasugrel hcl 1
chloroquine phosphate Antipsychotics - Drugs for Mood Disorders
1
oral ABILIFY MAINTENA 4 QL
hydroxychloroquine aripiprazole oral solution 1
1
sulfate oral
aripiprazole oral tablet 1
KRINTAFEL 2
ARISTADA 4 QL
nitazoxanide oral 2
ARISTADA INITIO 4 QL
permethrin external 1
chlorpromazine hcl
praziquantel oral 1 1
injection
primaquine phosphate 1 chlorpromazine hcl oral
1
pyrimethamine oral 4 PA; QL tablet
Antiparkinson Agents clozapine oral tablet 1
1 fluphenazine decanoate
amantadine hcl oral 1
injection
benztropine mesylate 1
fluphenazine hcl 1
bromocriptine mesylate
1 haloperidol decanoate
oral 1
intramuscular
carbidopa oral 1
haloperidol lactate 1
carbidopa-levodopa er 1
haloperidol oral 1
carbidopa-levodopa oral
1 INVEGA SUSTENNA 4
tablet
carbidopa-levodopa oral INVEGA TRINZA 4 QL
tablet dispersible 10-100 1 loxapine succinate 1
mg, 25-100 mg
olanzapine 1
carbidopa-levodopa-
1 PERSERIS 4
entacapone
DUOPA 4 PA pimozide 1
entacapone 1 quetiapine fumarate 1
pramipexole quetiapine fumarate er 1
1
dihydrochloride RISPERDAL CONSTA 2
rasagiline mesylate oral 1 PA risperidone oral solution 1
ropinirole hcl 1 risperidone oral tablet 1
selegiline hcl oral 1 thiothixene 1
Effective Date: 09/01/2021
17Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
trifluoperazine hcl 1 INTELENCE 2
ziprasidone hcl 1 INTRON A 2 QL
ZYPREXA RELPREVV 2 INVIRASE 2
Antivirals ISENTRESS HD 2
abacavir sulfate 1 ISENTRESS ORAL
2
TABLET
abacavir sulfate-
1 QL ISENTRESS ORAL
lamivudine 2
TABLET CHEWABLE
abacavir-lamivudine-
4 QL JULUCA 4 QL
zidovudine
acyclovir oral 1 KALETRA ORAL TABLET 2
adefovir dipivoxil 1 QL lamivudine 1
APTIVUS 4 QL lamivudine-zidovudine 1
atazanavir sulfate 1 QL LEDIPASVIR-
4 PA; QL
BARACLUDE ORAL SOFOSBUVIR
4 QL
SOLUTION LEXIVA ORAL
4 QL
BIKTARVY 4 QL SUSPENSION
CIMDUO 4 QL lopinavir-ritonavir 1
COMPLERA 4 PA; QL nevirapine er 1
CRIXIVAN 2 nevirapine oral tablet 1
DESCOVY 4 QL NORVIR ORAL PACKET 2
DOVATO 4 QL NORVIR ORAL
2
SOLUTION
EDURANT 2
ODEFSEY 4 QL
efavirenz 1
oseltamivir phosphate
efavirenz-emtricitab- 1
4 QL oral
tenofovir
PEGASYS 4 QL
efavirenz-lamivudine-
1 PREVYMIS ORAL 4 PA; QL
tenofovir
emtricitabine 1 PREZCOBIX 2 QL
emtricitabine-tenofovir df 1 PREZISTA 2
EMTRIVA ORAL RELENZA DISKHALER 2
2
SOLUTION REYATAZ ORAL
2
entecavir 1 QL PACKET
EPCLUSA 4 PA; QL ribavirin oral 1 QL
EPIVIR HBV ORAL rimantadine hcl 1
2
SOLUTION ritonavir 1
etravirine 1 SELZENTRY ORAL
4 QL
fosamprenavir calcium 4 QL SOLUTION
GENVOYA 4 SELZENTRY ORAL
TABLET 150 MG, 300 4 QL
HARVONI 4 PA; QL MG
Effective Date: 09/01/2021
18Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
SELZENTRY ORAL hydroxyzine pamoate oral 1
4
TABLET 25 MG, 75 MG
lorazepam injection
SOFOSBUVIR- 1 QL
4 PA; QL solution 2 mg/ml
VELPATASVIR
lorazepam intensol 1 QL
stavudine 1 lorazepam oral
1 QL
STRIBILD 4 PA; QL concentrate 2 mg/ml
SYMFI 1 lorazepam oral tablet 1 QL
SYMFI LO 1 midazolam hcl (pf)
injection solution 10 1 QL
SYMTUZA 4 QL
mg/2ml, 5 mg/ml
TAMIFLU 2 midazolam hcl injection
TEMIXYS 4 QL solution 10 mg/2ml, 5 1 QL
tenofovir disoproxil mg/ml
1
fumarate oxazepam 1 QL
TIVICAY 2 triazolam 1 QL
TIVICAY PD 2 Bipolar Agents - Drugs for Mood Disorders
TRIUMEQ 4 QL lithium carbonate er 1
TYBOST 2 PA lithium carbonate oral 1
valacyclovir hcl oral 1 Blood Products and Modifiers - Drugs for
valganciclovir hcl 4 QL Blood Disorders
VIRACEPT 2 anagrelide hcl 1
VIREAD ORAL POWDER 2 EPOGEN 2 PA
VIREAD ORAL TABLET HEMLIBRA 4 PA; QL
150 MG, 200 MG, 250 2 LEUKINE 2
MG NEUPOGEN 4 QL
VOSEVI 4 PA; QL NIVESTYM 4 QL
zidovudine 1 PROCRIT 2 PA
Anxiolytics - Drugs for Anxiety tranexamic acid oral 1 QL
alprazolam er 1 QL ZARXIO 4 QL
alprazolam oral tablet 1 QL Cardiovascular Agents - Drugs for Heart
alprazolam xr 1 QL and Circulation Conditions
buspirone hcl oral 1 acebutolol hcl oral 1
chlordiazepoxide hcl 1 QL ALDACTAZIDE ORAL
2
TABLET 50-50 MG
clonazepam oral 1 QL
alprostadil injection 1
clorazepate dipotassium 1 QL
diazepam injection 1 QL amiloride hcl oral 1
diazepam intramuscular 1 QL amiloride-
1
hydrochlorothiazide
diazepam oral solution 1 QL
amiodarone hcl oral tablet
diazepam oral tablet 1 QL 1
200 mg
hydroxyzine hcl oral 1 amlodipine besylate oral 1
Effective Date: 09/01/2021
19Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
amlodipine besylate- enalapril maleate oral 1
1
benazepril hcl
enalapril-
1
amlodipine-olmesartan 1 hydrochlorothiazide
atenolol oral 1 ENTRESTO 2 PA
atenolol-chlorthalidone 1 epinephrine pf 1
atorvastatin calcium oral 1 eplerenone 1
benazepril hcl oral 1 ethacrynic acid 1 PA
benazepril- ezetimibe 1
1
hydrochlorothiazide ezetimibe-simvastatin 1
betaxolol hcl oral 1 felodipine er 1
bisoprolol fumarate oral 1 fenofibrate micronized 1
bisoprolol- fenofibrate oral capsule
1 1
hydrochlorothiazide 134 mg, 200 mg, 67 mg
bumetanide oral 1 fenofibrate oral tablet 160
1
captopril oral 1 mg, 54 mg
cartia xt 1 fenofibric acid oral tablet 1
carvedilol 1 flecainide acetate 1
chlorthalidone 1 fosinopril sodium 1
cholestyramine light 1 fosinopril sodium-hctz 1
cholestyramine oral 1 furosemide injection 1
clonidine 1 furosemide oral 1
clonidine hcl oral 1 gemfibrozil oral 1
colestipol hcl 1 guanfacine hcl 1
digitek 1 hydralazine hcl oral 1
digox 1 hydrochlorothiazide oral 1
digoxin injection 1 indapamide 1
digoxin oral 1 irbesartan 1
diltiazem hcl er 1 irbesartan-
1
hydrochlorothiazide
diltiazem hcl er coated
beads oral capsule isosorbide dinitrate 1
extended release 24 hour 1 isosorbide mononitrate 1
120 mg, 180 mg, 240 mg,
300 mg isosorbide mononitrate er 1
diltiazem hcl oral 1 isradipine 1
dilt-xr 1 labetalol hcl oral 1
disopyramide phosphate 1 lisinopril oral 1
DIURIL 2 lisinopril-
1
hydrochlorothiazide
doxazosin mesylate oral 1
losartan potassium oral 1
Effective Date: 09/01/2021
20Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
losartan potassium-hctz 1 phenoxybenzamine hcl
4
oral
lovastatin oral 1
phentolamine mesylate
methyldopa 1 1
injection
metolazone 1 pindolol 1
metoprolol succinate er 1 pravastatin sodium 1
metoprolol tartrate oral 1 prazosin hcl oral 1
metoprolol- 1
1 prevalite
hydrochlorothiazide
procainamide hcl injection 1
mexiletine hcl oral 1
propafenone hcl 1
midodrine hcl 1
propranolol hcl er 1
minitran 1
propranolol hcl oral 1
minoxidil oral 1
quinapril hcl 1
moexipril hcl 1
quinapril-
nadolol oral 1 1
hydrochlorothiazide
nicardipine hcl oral 1 quinidine gluconate er 1
nifedipine er 1 quinidine sulfate 1
nifedipine er osmotic 1
1 ramipril
release
RECTIV 2
nifedipine oral 1
rosuvastatin calcium 1
nimodipine oral 1
simvastatin oral 1
NITRO-BID 2
sorine 1
NITRO-DUR
TRANSDERMAL PATCH sotalol hcl (af) 1
2
24 HOUR 0.3 MG/HR, 0.8 1
sotalol hcl oral
MG/HR
spironolactone oral 1
nitroglycerin sublingual 1
spironolactone-hctz 1
nitroglycerin transdermal 1
timolol maleate oral 1
nitro-time oral capsule
1
extended release 9 mg torsemide 1
NORPACE CR 2 trandolapril 1
olmesartan medoxomil triamterene oral 1
1
oral
triamterene-hctz 1
olmesartan medoxomil-
1 valsartan 1
hctz
pacerone oral tablet 200 valsartan-
1 1
mg hydrochlorothiazide
1 verapamil hcl er oral
papaverine hcl injection
capsule extended release
pentoxifylline er 1 1
24 hour 120 mg, 180 mg,
perindopril erbumine 1 240 mg, 360 mg
Effective Date: 09/01/2021
21Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
verapamil hcl er oral REBIF REBIDOSE
1 4 PA; QL
tablet extended release TITRATION PACK
verapamil hcl oral 1 REBIF TITRATION PACK 4 PA; QL
Central Nervous System Agents - Drugs for Central Nervous System Agents -
Attention Deficit Disorder Miscellaneous
amphetamine- caffeine citrate oral 1
1
dextroamphetamine pregabalin oral 1 QL
amphetamine- riluzole 1 QL
1 QL
dextroamphetamine er
Dental and Oral Agents - Drugs for Mouth
atomoxetine hcl 1 and Throat Conditions
dexmethylphenidate hcl 1 chlorhexidine gluconate
1
dextroamphetamine mouth/throat
1 QL
sulfate er lidocaine viscous hcl 1
dextroamphetamine oralone 1
1
sulfate oral tablet
periogard 1
guanfacine hcl er 1
pilocarpine hcl oral tablet
methylphenidate hcl er 1 QL 1
5 mg
methylphenidate hcl er triamcinolone acetonide
1 QL 1
(cd) mouth/throat
methylphenidate hcl er Dermatological Agents - Drugs for Skin
(la) oral capsule extended Conditions
1 ST; QL
release 24 hour 20 mg,
30 mg, 40 mg, 60 mg accutane 1
methylphenidate hcl oral acitretin 1 QL
1
tablet adapalene external cream 1
relexxii 1 QL adapalene external gel 1
zenzedi tablet 10 mg oral 1 ala-cort external cream
1
zenzedi tablet 5 mg oral 1 2.5 %
Central Nervous System Agents - Drugs for alclometasone
1
Multiple Sclerosis dipropionate
AVONEX PEN 4 PA; QL AMELUZ 2 QL
AVONEX PREFILLED 4 PA; QL amnesteem 1
dimethyl fumarate oral 1 avar cleanser 1
dimethyl fumarate starter avita 1
1
pack 2
AZELEX
EXTAVIA 4 QL benzoyl peroxide-
GILENYA 4 PA; QL 1
erythromycin
glatiramer acetate 4 QL betamethasone
1
glatopa 4 QL dipropionate aug
REBIF 4 PA; QL betamethasone
1
dipropionate external
REBIF REBIDOSE 4 PA; QL
Effective Date: 09/01/2021
22Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
betamethasone valerate desonide external cream 1
1
external
desonide external lotion 1
calcipotriene external
1 desonide external
cream 1
ointment
calcipotriene external
1 desoximetasone external
ointment 1
cream
calcipotriene external
1 desoximetasone external
solution 1
gel
calcitrene 1
desoximetasone external
1
calcitriol external 1 ointment
CAPEX 2 DIFFERIN EXTERNAL
1
CREAM
CARAC 2
DIFFERIN EXTERNAL
claravis 1 2
LOTION
clindacin etz external 2
1 DRYSOL
swab
erythromycin external 1
clindacin-p 1
FINACEA EXTERNAL
clindamycin phos-benzoyl 2
FOAM
perox external gel 1-5 %, 1
1.2-5 % fluocinolone acetonide
1
body
clindamycin phosphate
1 fluocinolone acetonide
external gel 1
external
clindamycin phosphate
1 fluocinolone acetonide
external lotion 1
scalp
clindamycin phosphate
1 fluocinonide emulsified
external solution 1
base
clindamycin phosphate
1 fluocinonide external
external swab 1
cream 0.05 %
clobetasol prop emollient
1 fluocinonide external gel 1
base
clobetasol propionate e 1 fluocinonide external
1
ointment
clobetasol propionate
1 fluocinonide external
external cream 1
solution
clobetasol propionate
1 FLUOROPLEX 2
external gel
clobetasol propionate FLUOROURACIL
1 EXTERNAL CREAM 0.5 2
external lotion
%
clobetasol propionate
1 fluorouracil external
external ointment 1
cream 5 %
clobetasol propionate
1 fluorouracil external
external solution 1
solution
CONDYLOX 2
fluticasone propionate
CORDRAN EXTERNAL 1
2 external cream
TAPE
Effective Date: 09/01/2021
23Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
fluticasone propionate PRAMOSONE
1
external ointment EXTERNAL CREAM 1-1 2
halobetasol propionate %
1
external cream PRAMOSONE
2
halobetasol propionate EXTERNAL LOTION
1
external ointment RETIN-A 1
hydrocortisone ace- RETIN-A MICRO GEL
pramoxine external cream 1 1
0.04 %, 0.1 %
2.5-1 %
RETIN-A MICRO PUMP
hydrocortisone butyrate EXTERNAL GEL 0.04 %, 1
1
external cream 0.1 %
hydrocortisone butyrate rosadan external cream 1
1
external ointment
rosadan external gel 1
hydrocortisone butyrate
1 SANTYL 2
external solution
hydrocortisone external selenium sulfide external
1 1
cream 2.5 % lotion
hydrocortisone external sodium sulfacetamide 1
1
lotion 2.5 % sulfacetamide sodium
1
hydrocortisone external (acne)
1
ointment 2.5 % sulfacetamide sodium-
1
hydrocortisone ointment 1 sulfur external emulsion
1
% external (rx) sulfacetamide sodium-
hydrocortisone valerate 1 sulfur external lotion 10-5 1
%
imiquimod external cream
1 sulfacetamide-sulfur in
5% 1
urea
isotretinoin oral 1
synalar external cream 1
LEVULAN KERASTICK 2 QL
synalar external ointment 1
methoxsalen rapid 4 QL
tacrolimus external 1
metronidazole external
1
cream tazarotene external cream 1
metronidazole external TAZORAC EXTERNAL
1 2
gel 0.75 % CREAM 0.05 %
mometasone furoate TAZORAC EXTERNAL
1 2
external GEL
myorisan 1 tretinoin external cream 1
neuac external gel 1 tretinoin external gel 0.01
1
%, 0.025 %
pimecrolimus cream 1 %
1
external tretinoin microsphere 1
PIMECROLIMUS CREAM tretinoin microsphere
1 1
1 % EXTERNAL pump
podofilox external 1 triamcinolone acetonide
1
external cream
Effective Date: 09/01/2021
24Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
triamcinolone acetonide BLULINK CONTROL
1 1
external lotion HIGH & LOW
triamcinolone acetonide CARETOUCH CONTROL
1
external ointment 0.025 1 SOL LEVEL 2
%, 0.1 %, 0.5 % CARETOUCH
1
triderm 1 LANCING/EJECTOR
urea external cream 40 % 1 CONTOUR CONTROL
1
SOLUTION
uremez-40 1
CONTOUR NEXT
VECTICAL 1 1
CONTROL SOLUTION
zenatane 1 CONTOUR NEXT TEST
1 PA; QL
Diabetes - Antidiabetic Agents STRIPS
acarbose oral 1 DIATHRIVE GLUCOSE
1
CONTROL SOLN
glimepiride 1
DIATHRIVE LANCING
glipizide er 1 1
DEVICE
glipizide ir 1 DROPLET GENTEEL
1
glipizide xl 1 LANCING DEVICE
1 EASY TRAK II CONTROL 1
glyburide oral
JARDIANCE 2 PA; QL EASYMAX 15 LEVEL 2-3
1
CONTROL
metformin hcl er 1
EASYMAX CONTROL 1
metformin hcl ir 1
GLUCOSE CONTROL
1 1
tolbutamide SOLUTIONS
Diabetes - Glucose Monitoring EMBRACE LANCING
1
DEVICE/EJECTOR
EMBRACE TALK
ACCU-CHEK COMPACT 1
1 GLUCOSE CONTROL
PLUS CONTROL
FORTISCARE CONTROL 1
ACCU-CHEK FASTCLIX
1
LANCET KIT FREESTYLE TEST 1 PA; QL
ACCU-CHEK GUIDE GENTEEL LANCING KIT
1 1
CONTROL (BLUE)
ACCU-CHEK GUIDE GOJJI CONTROL 1
1 PA; QL
TEST STRIPS GOJJI LANCING
1
ACCU-CHEK DEVICE/CLEAR CAP
1
SMARTVIEW CONTROL 1
LANCETS
ACCU-CHEK SOFTCLIX
1 MICROLET NEXT
LANCET DEVICE KIT 1
LANCING DEVICE
AGAMATRIX CONTROL
1 ONETOUCH DELICA
LEVEL 2 1
LANCING DEVICE
AGAMATRIX CONTROL
1 ONETOUCH DELICA
LEVEL 4 1
PLUS LANCING DEVICE
AUTOLET LANCING
1 ONETOUCH ULTRA 1 QL
DEVICE
Effective Date: 09/01/2021
25Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
ONETOUCH VERIO IN HUMULIN 70/30
1 1
VITRO SOLUTION HIGH KWIKPEN
ONETOUCH VERIO HUMULIN 70/30 VIAL 1
1 QL
TEST STRIPS
HUMULIN N KWIKPEN 1
SURESTEP PRO HIGH
1 HUMULIN N VIAL 1
GLUCOSE
SURESTEP PRO LOW HUMULIN R U-500
1 1
GLUCOSE KWIKPEN
SURESTEP PRO HUMULIN R U-500 VIAL 1
1
NORMAL GLUCOSE HUMULIN R VIAL 1
TRUE METRIX LEVEL 1 1 INSULIN LISPRO 2
TRUE METRIX LEVEL 2 1 INSULIN LISPRO (1
2
TRUE METRIX LEVEL 3 1 UNIT DIAL)
UNISTRIP CONTROL IN INSULIN PEN NEEDLES 1
1
VITRO SOLUTION LOW INSULIN SYRINGES 27G
VIVAGUARD INO X 1/2" 0.5 ML, 27G X 1/2"
1 1 ML, 28G X 1/2" 0.5 ML,
CONTROL SOLUTION
28G X 1/2" 1 ML, 29G X
VIVAGUARD LANCING 1/2" 0.3 ML, 29G X 1/2"
1
DEVICE 0.5 ML, 29G X 1/2" 1 ML,
Diabetes - Glycemic Agents 30G X 1/2" 0.3 ML, 30G X
1/2" 0.5 ML, 30G X 1/2" 1
BAQSIMI ONE PACK 2 1
ML, 30G X 5/16" 0.3 ML,
BAQSIMI TWO PACK 2 30G X 5/16" 0.5 ML, 30G
diazoxide oral 2 X 5/16" 1 ML, 31G X
15/64" 0.3 ML, 31G X
GLUCAGEN HYPOKIT 2 15/64" 0.5 ML, 31G X
glucagon emergency kit 1 15/64" 1 ML, 31G X 5/16"
1 0.3 ML, 31G X 5/16" 0.5
mg injection 1 mg
ML, 31G X 5/16" 1 ML
GLUCAGON
EMERGENCY KIT 1 MG 2 LANTUS SOLOSTAR 2 PA
INJECTION 1 MG LANTUS U-100 VIAL 2 PA
Diabetes - Insulins LEVEMIR U-100
2 PA
BD AUTOSHIELD DUO FLEXTOUCH
1
PEN NEEDLES LEVEMIR U-100 VIAL 2 PA
BD ULTRA-FINE NOVOFINE
1
INSULIN SYRINGES AUTOCOVER PEN 1
BD ULTRA-FINE PEN NEEDLE 30G X 8 MM
1
NEEDLES NOVOFINE PEN
1
BD VEO INSULIN SYR NEEDLE 32G X 6 MM
1
U/F 1/2UNIT NOVOFINE PLUS PEN
1
HUMALOG 2 NEEDLE 32G X 4 MM
NOVOTWIST PEN
HUMALOG KWIKPEN 2 1
NEEDLE 32G X 5 MM
HUMALOG U-100
2 ULTIGUARD SAFEPACK
JUNIOR KWIKPEN 1
SYR/NEEDLE
Effective Date: 09/01/2021
26Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Electrolytes / Minerals / Metals / Vitamins potassium chloride er 1
argyle sterile saline 1 potassium chloride oral 1
CARNITOR ORAL 1 potassium citrate er 1
CARNITOR SF 1 potassium citrate-citric
1
acid
curity sterile saline 1
sod citrate-citric acid 1
cyanocobalamin injection
1
solution 1000 mcg/ml sodium chloride (pf) 1
cytra k crystals 1 sodium chloride irrigation 1
ergocalciferol oral capsule 1 sodium fluoride oral
1
solution 1.1 (0.5 f) mg/ml
folic acid injection 1
sodium fluoride oral tablet
folic acid oral tablet 1 mg 1 1
1.1 (0.5 f) mg
klor-con 1 sodium fluoride oral tablet
1
klor-con 10 1 chewable
klor-con m10 1 sodium polystyrene
1
sulfonate
klor-con m15 2
sps 1
klor-con m20 1
tricitrates 1
K-TAB ORAL TABLET
EXTENDED RELEASE 1 virt-phos 250 neutral 1
10 MEQ vitamin d (ergocalciferol)
K-TAB ORAL TABLET oral capsule 1.25 mg 1
EXTENDED RELEASE 2 (50000 ut)
20 MEQ, 8 MEQ vitamin k1 injection 1
levocarnitine oral solution 1 Gastrointestinal Agents - Drugs for Acid
levocarnitine oral tablet 1 Reflux and Ulcer
levocarnitine sf 1 cimetidine hcl 1
MEPHYTON 1 cimetidine oral 1
nafrinse 1 famotidine oral
1
suspension reconstituted
ORACIT 2
famotidine oral tablet 20
phospha 250 neutral 1 1
mg, 40 mg
phosphorous 1 lansoprazole oral capsule
1
phospho-trin 250 neutral 1 delayed release
1 misoprostol oral 1
phytonadione injection
omeprazole oral capsule
phytonadione oral 1 1
delayed release
potassium chloride crys er
pantoprazole sodium oral
oral tablet extended 1 1
tablet delayed release
release 10 meq, 20 meq
rabeprazole sodium oral
potassium chloride crys er 1 ST
tablet delayed release
oral tablet extended 2
release 15 meq sucralfate oral 1
Effective Date: 09/01/2021
27Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Gastrointestinal Agents - Drugs for Bowel, calcium acetate (phos
1
Intestine and Stomach Conditions binder)
belladonna alkaloids- calcium acetate oral tablet
1 QL 1
opium 667 mg
chlordiazepoxide- CERVIDIL 2
1 QL
clidinium
CUPRIMINE 4 PA; QL
constulose 1 darifenacin hydrobromide
1
dicyclomine hcl oral 1 er
diphenoxylate-atropine 1 ELMIRON 2
enulose 1 flavoxate hcl 1
gavilyte-c 1 oxybutynin chloride er 1
gavilyte-g 1 oxybutynin chloride oral 1
gavilyte-n with flavor pack 1 penicillamine oral 4 PA; QL
generlac 1 PENTOSAN
POLYSULFATE SODIUM 2
glycopyrrolate injection ORAL
1
solution
phenazo oral tablet 200
glycopyrrolate oral 1 1
mg
HELIDAC THERAPY 2 phenazopyridine hcl oral
1
lactulose encephalopathy 1 tablet 100 mg, 200 mg
lactulose oral solution 1 PREPIDIL 2
loperamide hcl oral PROSTIN E2 2
1
capsule sevelamer carbonate 1
opium 1 QL sevelamer hcl 1
peg 3350-kcl-na bicarb- 1
1 solifenacin succinate
nacl
tolterodine tartrate 1
peg-3350/electrolytes 1
tolterodine tartrate er 1
PYLERA 2
trospium chloride 1
RELISTOR
2 PA
SUBCUTANEOUS trospium chloride er 1
ursodiol oral 1 Genitourinary Agents - Drugs for Prostate
Conditions
Genetic or Enzyme Disorder - Drugs for
Replacement, Modification, Treatment alfuzosin hcl er 1
CERDELGA 4 PA; QL dutasteride oral 1
CREON 2 finasteride oral tablet 5
1
CYSTAGON 2 PA mg
ZENPEP 2 tamsulosin hcl 1
Genitourinary Agents - Drugs for Bladder, terazosin hcl 1
Genital and Kidney Conditions Hormonal Agents - Adrenal
acetic acid irrigation 1
bethanechol chloride oral 1
Effective Date: 09/01/2021
28Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
DEPO-MEDROL testosterone transdermal
INJECTION 2 gel 1.62 %, 12.5 mg/act
SUSPENSION 20 MG/ML (1%), 20.25 mg/act 1 PA; QL
2 (1.62%), 25 mg/2.5gm
dexamethasone intensol
(1%), 50 mg/5gm (1%)
dexamethasone oral elixir 1
Hormonal Agents - Osteoporosis
dexamethasone oral
1 raloxifene hcl 1
solution
dexamethasone oral Hormonal Agents - Pituitary
1
tablet ACTHAR 4 PA; QL
dexamethasone sod cabergoline 1
phosphate pf injection 1
desmopressin ace spray
solution 1
refrig
dexamethasone sodium
1 desmopressin acetate
phosphate injection 1
injection
fludrocortisone acetate
1 DESMOPRESSIN
oral 2
ACETATE NASAL
hydrocortisone oral 1
desmopressin acetate
MEDROL ORAL TABLET 1
2 oral
2 MG
desmopressin acetate pf 1
methylprednisolone oral 1
desmopressin acetate
methylprednisolone 1
spray
sodium succ injection
1 leuprolide acetate
solution reconstituted 125 1
injection
mg
LUPRON DEPOT (1-
prednisolone oral solution 1 2
MONTH)
prednisolone sodium LUPRON DEPOT (3-
phosphate oral solution 2
1 MONTH)
15 mg/5ml, 25 mg/5ml,
6.7 (5 base) mg/5ml LUPRON DEPOT (4-
MONTH)
prednisone oral 1 2
INTRAMUSCULAR KIT
SOLU-CORTEF 2 30MG
Hormonal Agents - Men's Health LUPRON DEPOT (6-
MONTH)
danazol oral 1 2
INTRAMUSCULAR KIT
DEPO-TESTOSTERONE 45MG
(brand testosterone 1 PA LUPRON DEPOT-PED
cypionate intramuscular) 2
(1-MONTH)
TESTOSTERONE LUPRON DEPOT-PED
1 PA 2
CYPIONATE INJECTION (3-MONTH)
testosterone cypionate octreotide acetate 1
1 PA
intramuscular
OMNITROPE 4 PA; QL
testosterone enanthate
1 PA SANDOSTATIN LAR
intramuscular 2 QL
DEPOT
STIMATE 2
Effective Date: 09/01/2021
29Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Hormonal Agents - Sex Hormones and Birth DEPO-ESTRADIOL 2
Control
desogestrel-ethinyl
afirmelle 1 estradiol oral tablet 0.15- 1
1 30 mg-mcg
AFTERPILL
drospirenone-ethinyl
altavera 1
estradiol oral tablet 3-0.03 1
alyacen 1/35 1 mg
alyacen 7/7/7 1 elinest 1
apri 1 ELLA 2
aranelle 1 eluryng 1
aubra 1 emoquette 1
aubra eq 1 enpresse-28 1
aurovela 1.5/30 1 enskyce 1
aurovela 1/20 1 errin 1
aurovela fe 1.5/30 1 estarylla 1
aurovela fe 1/20 1 estradiol oral 1
aviane 1 estradiol transdermal
1
patch weekly
ayuna 1
estradiol vaginal 1
balziva 1
estradiol valerate
blisovi fe 1.5/30 1 1
intramuscular
blisovi fe 1/20 1 2
ESTRING
briellyn 1 ethynodiol diac-eth
1
camila 1 estradiol
caziant 1 etonogestrel-ethinyl
1
estradiol
chateal 1
falmina 1
chateal eq 1
FEMRING 2
CLIMARA 1
femynor 1
cryselle-28 1
hailey 1.5/30 1
cyclafem 1/35 1
hailey fe 1.5/30 1
cyclafem 7/7/7 1
hailey fe 1/20 1
cyred 1
heather 1
cyred eq 1
hydroxyprogesterone
dasetta 1/35 1 4
caproate intramuscular oil
dasetta 7/7/7 1 incassia 1
deblitane 1 isibloom 1
DELESTROGEN 2 jencycla 1
delyla 1 juleber 1
Effective Date: 09/01/2021
30Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
junel 1.5/30 1 megestrol acetate oral
1
tablet
junel 1/20 1
microgestin 1.5/30 1
junel fe 1.5/30 1
microgestin 1/20 1
junel fe 1/20 1
microgestin fe 1.5/30 1
kalliga 1
microgestin fe 1/20 1
kelnor 1/35 1
mili 1
kelnor 1/50 1
MIRENA (52 MG) 2
kurvelo 1
mono-linyah 1
larin 1.5/30 1
necon 0.5/35 (28) 1
larin 1/20 1
nora-be 1
larin fe 1.5/30 1
norethin ace-eth estrad-fe
larin fe 1/20 1 1
oral tablet
larissia 1 norethindrone acetate
1
leena 1 oral
lessina 1 norethindrone acet-ethinyl
1
est
levonest 1
norethindrone oral 1
levonorgestrel 1
norgestimate-eth estradiol 1
levonorgestrel-ethinyl
estrad oral tablet 0.1-20 1 norgestimate-ethinyl
1
mg-mcg, 0.15-30 mg-mcg estradiol triphasic
levonorg-eth estrad norlyda 1
1
triphasic norlyroc 1
levora 0.15/30 (28) 1 nortrel 0.5/35 (28) 1
lillow 1 nortrel 1/35 (21) 1
low-ogestrel 1 nortrel 1/35 (28) 1
lutera 1 nortrel 7/7/7 1
lyleq 1 nylia 7/7/7 1
lyza 1 nymyo 1
MAKENA ocella 1
4 QL
SUBCUTANEOUS
orsythia 1
marlissa 1
PARAGARD
medroxyprogesterone INTRAUTERINE 2
1
acetate intramuscular COPPER
medroxyprogesterone 1
1 philith
acetate oral
pirmella 1/35 1
megestrol acetate oral
suspension 40 mg/ml, 1 pirmella 7/7/7 1
400 mg/10ml 1
portia-28
PREMARIN VAGINAL 2
Effective Date: 09/01/2021
31Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
preventeza 1 zafemy 1
previfem 1 zarah 1
progesterone zovia 1/35 (28) 1
1
intramuscular
zovia 1/35e (28) 1
progesterone oral 1
zumandimine 1
reclipsen 1
Hormonal Agents - Thyroid
sharobel 1
levothyroxine sodium oral
1
SKYLA 2 tablet
sprintec 28 1 liothyronine sodium oral 1
sronyx 1 methimazole oral 1
syeda 1 propylthiouracil oral 1
tarina fe 1/20 1 Immunological Agents - Drugs for Immune
System Stimulation or Suppression
tarina fe 1/20 eq 1
azathioprine oral 1
tri femynor 1
BERINERT 4 PA; QL
tri-estarylla 1
COSENTYX (300 MG
tri-linyah 1 4 PA; QL
DOSE)
tri-lo-estarylla 1 COSENTYX 150 MG/ML 4 PA; QL
tri-lo-marzia 1 COSENTYX
4 PA; QL
tri-lo-mili 1 SENSOREADY (300 MG)
1 COSENTYX
tri-lo-sprintec 4 PA; QL
SENSOREADY PEN
tri-mili 1
CUVITRU 4 PA; QL
tri-nymyo 1
cyclosporine modified 1
tri-previfem 1
cyclosporine oral 1
tri-sprintec 1 ENBREL 4 PA; QL
trivora (28) 1 ENBREL MINI 4 PA; QL
tri-vylibra 1 ENBREL SURECLICK 4 PA; QL
tri-vylibra lo 1 gengraf 1
tulana 1 HIZENTRA 4 PA; QL
tyblume 1 HUMIRA 4 PA; QL
velivet 1 HUMIRA PEDIATRIC
4 PA; QL
CROHNS START
vienva 1
HUMIRA PEN 4 PA; QL
vyfemla 1
HUMIRA PEN-CD/UC/HS
vylibra 1 4 PA; QL
STARTER
wera 1 HUMIRA PEN-
4 PA; QL
xulane 1 PEDIATRIC UC START
yuvafem 1 HUMIRA PEN-
4 PA; QL
PS/UV/ADOL HS START
Effective Date: 09/01/2021
32Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
HUMIRA PEN- DIPHTHERIA-TETANUS
4 PA; QL 2
PSOR/UVEIT STARTER TOXOIDS DT
HYPERHEP B 2 ENGERIX-B 2
HYQVIA 4 PA; QL FLUARIX
1
icatibant acetate 4 PA; QL QUADRIVALENT
1 FLUBLOK
leflunomide oral 1
QUADRIVALENT
methotrexate oral 1
FLUCELVAX
1 1
methotrexate sodium QUADRIVALENT
methotrexate sodium (pf) 1 FLULAVAL
1
mycophenolate mofetil QUADRIVALENT
1 FLUMIST
oral 1
QUADRIVALENT
mycophenolate sodium 1
FLUZONE HIGH-DOSE
NABI-HB 2 1
QUADRIVALENT
ORENCIA CLICKJECT 4 PA; QL FLUZONE
1
ORENCIA QUADRIVALENT
4 PA; QL
SUBCUTANEOUS 2
GARDASIL 9
OTEZLA 4 PA; QL
HAVRIX 2
RASUVO 2
HEPLISAV-B 2
RIDAURA 4 QL
HIBERIX 2
sirolimus oral tablet 1
INFANRIX 2
SKYRIZI 4 PA; QL
IPOL 2
SKYRIZI (150 MG DOSE) 4 PA; QL
KINRIX 2
SKYRIZI PEN 4 PA; QL
MENACTRA 2
STELARA
4 PA; QL
SUBCUTANEOUS MENQUADFI 2
tacrolimus oral 1 MENVEO 2
TREMFYA 4 PA; QL M-M-R II 2
XELJANZ ORAL TABLET 4 PA; QL PEDIARIX 2
XELJANZ XR 4 PA; QL PEDVAX HIB 2
Immunological Agents - Drugs for PENTACEL 2
Vaccination
PNEUMOVAX 23 2
ACTHIB 2
PREVNAR 13 2
ADACEL 2
PROQUAD 2
AFLURIA
1 QUADRACEL 2
QUADRIVALENT
BEXSERO 2 RECOMBIVAX HB 2
BOOSTRIX 2 ROTARIX 2
DAPTACEL 2 ROTATEQ 2
SHINGRIX 2
Effective Date: 09/01/2021
33Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
TDVAX 2 Miscellaneous Therapeutic Agents
TENIVAC 2 ALCOHOL PREP PADS
1
PAD
TETANUS-DIPHTHERIA
2 ALCOHOL PREP PADS
TOXOIDS TD 1
PAD 70 %
TRUMENBA 2
ALCOHOL PREP PADS
VAQTA 1
SHEET 70 %
INTRAMUSCULAR
2 BREATHE EASE LARGE 2
SUSPENSION 50
UNIT/ML BREATHE EASE
2
VARIVAX 2 MEDIUM
VAXELIS 2 BREATHE EASE SMALL 2
Inflammatory Bowel Disease Agents CAYA 2
APRISO 1 ST CLEVER CHOICE
2
HOLDING CHAMBER
balsalazide disodium 1
COMPACT SPACE
CORTIFOAM 2 2
CHAMBER/LG MASK
hydrocortisone (perianal) COMPACT SPACE
1 2
external cream 2.5 % CHAMBER/MED MASK
hydrocortisone rectal 1 COMPACT SPACE
2
LIALDA 1 CHAMBER/SM MASK
mesalamine er oral deferoxamine mesylate
1 ST injection solution 1
capsule 0.375 gm
reconstituted 500 mg
mesalamine oral capsule
1 ST EASIVENT 2
delayed release 400 mg
mesalamine oral tablet FEMCAP 2
1
delayed release 1.2 gm FLEXICHAMBER ADULT
2
mesalamine rectal 1 MASK/SMALL
PENTASA 2 PA FLEXICHAMBER CHILD
2
MASK/LARGE
PROCTOFOAM HC 2
FLEXICHAMBER CHILD
procto-med hc 1 2
MASK/SMALL
proctozone-hc 1 GLUCAGEN
2
sulfasalazine oral 1 DIAGNOSTIC
Metabolic Bone Disease Agents - Drugs for GLUCAGON HCL
2
Osteoporosis (DIAGNOSTIC)
alendronate sodium 1 methergine 1
ibandronate sodium oral 1 methylergonovine
1
maleate
risedronate sodium oral
1 MICROCHAMBER 2
tablet
Metabolic Bone Disease Agents - Other NOZIN NASAL
1
SANITIZER POPSWAB
calcitriol oral 1
PANDA MASK LARGE 2
cinacalcet hcl 1 PA
Effective Date: 09/01/2021
34Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
PANDA MASK MEDIUM 2 cromolyn sodium
1
ophthalmic
PANDA MASK SMALL 2
dexamethasone sodium
PEDIATRIC PANDA 1
2 phosphate ophthalmic
MASK
diclofenac sodium
pocket spacer 2 1
ophthalmic
PRO COMFORT 2
2 DUREZOL
SPACER ADULT
erythromycin ophthalmic 1
PRO COMFORT
2
SPACER CHILD fluorometholone 1
PRO COMFORT flurbiprofen sodium 1
2
SPACER INFANT
FML 2
PROCARE
2 FML FORTE 2
SPACER/ADULT MASK
PROCARE gatifloxacin ophthalmic 1
2
SPACER/CHILD MASK gentak 1
WIDE-SEAL gentamicin sulfate
2 1
DIAPHRAGM 60 ophthalmic
WIDE-SEAL ketorolac tromethamine
2 1
DIAPHRAGM 65 ophthalmic
WIDE-SEAL moxifloxacin hcl (2x day) 1
2
DIAPHRAGM 70
moxifloxacin hcl
WIDE-SEAL 1
2 ophthalmic solution
DIAPHRAGM 75
NATACYN 2
WIDE-SEAL
2 ofloxacin ophthalmic 1
DIAPHRAGM 80
WIDE-SEAL olopatadine hcl
2 1
DIAPHRAGM 85 ophthalmic solution 0.1 %
WIDE-SEAL PRED MILD 2
2
DIAPHRAGM 90 prednisolone acetate
1
WIDE-SEAL ophthalmic
2
DIAPHRAGM 95 prednisolone acetate p-f 1
ZEVRX STERILE sulfacetamide sodium
1 1
ALCOHOL PREP PAD ophthalmic
Ophthalmic Agents - Drugs for Eye Allergy, tobramycin ophthalmic 1
Infection and Inflammation
TOBREX OPHTHALMIC
ACULAR 2 2
OINTMENT
ALOMIDE 2 trifluridine 1
azelastine hcl ophthalmic 1 VIGAMOX 2
bacitracin ophthalmic 1 Ophthalmic Agents - Drugs for Glaucoma
CILOXAN OPHTHALMIC acetazolamide er 1
2
OINTMENT
acetazolamide oral 1
ciprofloxacin hcl
1 1
ophthalmic betaxolol hcl ophthalmic
Effective Date: 09/01/2021
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