2021 Prescription Drug List - UnitedHealthcare & affiliated companies Pharmacy | PDL - UHCprovider.com
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Pharmacy | PDL 2021 Prescription Drug List UnitedHealthcare & affiliated companies
2021 Prescription Drug List
Introduction
The UnitedHealthcare Prescription Drug List (PDL)1 provides a list of the most commonly prescribed
medications in various therapeutic classes. This list is intended for use with UnitedHealthcare health plans
and affiliated companies’ pharmacy benefit plan designs. The PDL applies only to prescription medications
dispensed to outpatients and does not include inpatient medications or medications obtained or administered
in a physician’s office. The PDL does not define benefit coverage. Benefit coverage is decided by the
member’s pharmacy benefit plan.2 This means that there may be medications listed on the PDL that are not
covered under a particular member’s pharmacy benefit plan.
You may also access PDL information by visiting our website at UHCprovider.com.
Prescription Drug List medication overview
Tier decisions are made by our PDL Management Committee based on clinical, economic and other factors.
The PDL Management Committee is compromised of senior UnitedHealth Group physician and business
leaders. The UnitedHealthcare Pharmacy & Therapeutics (P&T) Committee, comprising of physicians and
pharmacists, reviews new and existing medications and provides clinical guidance to the PDL Management
Committee. Guidance is based on similarities and differences compared with other medications that treat the
same disease or condition.
The tier placement of a medication on the PDL may change. While medications change tiers infrequently,
such changes generally occur up to 3 times per calendar year. Additionally, when a brand-name medication
becomes available as a generic, the tier status and coverage of the brand-name medication and its
corresponding generic will be evaluated. When a medication changes tiers, your patient may be required to
pay more or less for that medication. These changes may occur without prior notice to you or your patient.
However, you may visit our website at UHCprovider.com or use the PreCheck MyScript® app for the most
up-to-date information for a particular medication. Your patient can also find the most up-to-date tier status and
cost3,8 information for a particular medication by visiting our member website at myuhc.com® and/or calling
the toll-free member phone number located on their health plan ID card.
Tier designations
Prescription medications are categorized within 3 tiers on the PDL.4 Each tier is assigned a cost,³ which is
determined by the member’s pharmacy benefit plan. You may refer to the PDL as a guide to select the most
appropriate medication with the lowest member cost for your patients.
Drug Tier Includes Helpful Tips
Tier 1 $ Lowest cost Members can maximize their cost savings when you prescribe
Tier 1 medications are your patient’s Tier 1 medications, if you decide they are appropriate for your
lowest cost option. patient’s treatment.
Tier 2 $$ Mid-range cost Consider Tier 2 medications if no Tier 1 medication is
Tier 2 medications are your patient’s appropriate to treat your patient’s condition.
mid-range cost option.
Tier 3 $$$ Highest cost If your patient is currently taking a medication in Tier 3, you may
Tier 3 medications are your patient’s want to determine if there is an appropriate alternative in Tier 1
highest cost option. or Tier 2.
You and your patient make decisions about health care and medication treatments.
If the member has a “closed” pharmacy benefit (such as a 2-tier pharmacy benefit plan that does not cover
medications classified in Tier 3 of this PDL), medications in Tier 3 are generally not covered, except under
certain processes consistent with applicable law.
2Some members have a 4-tier prescription plan, and these medications are noted as T4 throughout the
document. Members with a 4-tier prescription plan should refer to their enrollment materials, check the
Medication Pricing/Coverage information on our member website or call the toll-free member phone number
provided on their ID card for more information about their benefit plan.
Not all medications are represented in this PDL. Only the most commonly prescribed medications
are included.
Over-the-counter and therapeutically equivalent medications
For some conditions, you and your patient may decide that an over-the-counter (OTC) medication is the
most appropriate treatment. According to UnitedHealthcare benefit design, OTC medications are defined
as medications that do not require a prescription by federal or state law to be dispensed. In some instances,
OTC medications are listed on the PDL for reference purposes only. OTC medications may cost less than the
member’s out-of-pocket expense for prescription medications.
Therapeutically Equivalent means that medications can be expected to produce essentially the same
efficacy or adverse event profile. Our benefit designs allow us to exclude a medication if determined to be
Therapeutically Equivalent to another covered product or OTC option.
If the patient or physician requests a medication we have excluded based on determination of Therapeutic
Equivalent, the patient may be required to pay the entire cost of the medication as it may not be covered under
the member’s pharmacy benefit. Please refer to the member’s pharmacy benefit plan.
Symbols
E May be excluded from coverage or subject to Prior Authorization in Connecticut, New Jersey and New York
H May be part of health care reform preventive5
H-PA May be part of health care reform preventive with prior authorization5
MC Multiple copay
PA Prior authorization required6
RS May be eligible for the Refill and Save Program
SL Supply limit
SP Specialty medication
ST Step therapy7
T4 May be covered on Tier 4 in select benefits
Generic medication policy
Many generic medications are included on the PDL in Tier 1; however, generic medications can be placed into
any tier of the PDL. When a generic medication does not offer significant financial savings, it may be placed in
the same tier or a higher tier than the brand medication. Generic medications are noted in italic font.
Note that when a brand-name medication becomes available as a generic, that brand-name product may move
to a higher tier or be excluded from coverage by the member’s plan. Members may be required to pay more for
a prescription when a higher-tier brand-name product is dispensed. The member’s cost share is determined
by the pharmacy benefit plan. When generic substitution conflicts with state regulations or restrictions, the
pharmacist must obtain approval from the prescribing physician or other health care professional to substitute
the generic equivalent.
Specialty medications
Some members may have coverage for self-administered injectable and oral specialty medications through
their pharmacy benefit plan. You will find these medications included in the body of this document within the
appropriate therapeutic categories. UnitedHealthcare has a specialty pharmacy program that requires most
specialty medications to be obtained through a designated specialty pharmacy. These medications are noted
by SP throughout the document. The specialty pharmacy program includes designated specialty pharmacies,
3each selected based on their clinical expertise for the targeted therapeutic classes, quality of services, and cost. Their
pharmacists are trained to help educate patients for these specialty medications, which may help improve treatment adherence.
Participating members should be instructed to call the toll-free member number on their ID card where a representative will
answer questions about our program and then transfer them to a specialty pharmacy based on their particular specialty
medication prescription.
Medications requiring prior authorization and other pharmacy programs
Select medications may require prior authorization to be eligible for coverage under the member’s pharmacy benefit plan.
Such medications are noted with a PA. Depending on your patients’ benefit and/or medication, a coverage review may apply to
determine coverage under the pharmacy benefit. The pharmacy benefit may exclude coverage of medications for certain uses.
Clinical criteria for PA medications are available on our website at UHCprovider.com. The criteria reflect UnitedHealthcare’s
P&T Committee decisions.
Some benefit plans may include our Step Therapy7 program. Step Therapy requires prior authorization and offers a “stepwise”
approach to therapy for certain high-cost medications and requires that a member first try a more cost-effective medication
before another high-cost medication. Step Therapy medications are noted as ST.
Supply limits define the maximum supply of medication per copayment or period of time. Supply limits are based on several
factors that may include FDA-approved dosing guidelines as defined in the product package insert, medical literature,
guidelines or supportive data. Supply limit medications are noted as SL.
The Refill and Save Program encourages members to adhere to their treatment regimens by rewarding them with a discounted
copayment/coinsurance for refilling their prescription within the defined time period. Eligible medications are noted as RS.
How to obtain authorization
Use the PreCheck MyScript app on Link. By using the PreCheck MyScript app, you can now run a pharmacy trial claim and
get real-time prescription coverage detail for your patients who are UnitedHealthcare benefit plan members. This will allow you
to check current prescription coverage and price, including out-of-pocket prescription costs for UnitedHealthcare members at
their selected pharmacy, as well as:
• Get information on lower-cost prescription alternatives, if available, to help save members money.
• See which prescriptions currently require prior authorization, or are non-covered or non-preferred.
• Request prior authorization and receive status and results.
The app is now available to all Link users; to access, sign in to UHCprovider.com, then select the Link Marketplace from your
Link dashboard and search for the PreCheck MyScript app. Add the app to your dashboard and start using it.
Below are also options to obtain authorization:
• Online: Use the online prior authorization tool (available through UHCprovider.com). Most online prior authorizations are
approved in real-time, and an autopopulation feature provides 95% of a member’s information. Prior authorizations can also
be submitted online by signing in to optumrx.com > Healthcare Professionals > Prior Authorizations.
• By Phone: Call the OptumRx prior authorization team at 1-800-711-4555.
1
In certain documents the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This change in descriptive terms does not affect your patient’s benefit coverage.
2
Where differences are noted, the benefit plan documents will govern.
3
UnitedHealthcare operates a wide number of benefit programs and products, and some benefit programs may have alternative benefit designs. Physicians should always check the member’s specific benefit prior
to prescribing medications.
4
In certain documents Tier 1 was referred to as “generics;” Tier 2 was referred to as “preferred brands” or “brand-name” on the PDL; and Tier 3 was referred to as “non-preferred brands,” “not on the PDL,” or
“brand-name not on the PDL.” These changes in descriptive terms do not affect your patient’s benefit coverage.
5
Health Care Reform drug lists may vary by plan; your patient can find the most up-to-date tier status and cost information for a particular medication by visiting myuhc.com and/or calling the toll-free member
phone number on their health plan ID card.
6
Depending on your patients’ benefit and/or medication, notification or medical necessity criteria will be applied to determine if covered under the pharmacy benefit.
7
For New Jersey fully insured members, this program is referred to as First Start.
8
In accordance with HCR/ACA requirements, providers may request a zero dollar coverage exception review for preventive medications. Please access uhcprovider.com>Drug List and Pharmacy>Additional
Resources > Patient Protection and Affordable Care Act $0 Cost-share Preventive Medications Exemption Requests (Commercial members) or call the toll-free number on the member’s health plan ID card.
4Table of Contents
Analgesics - Drugs for Pain.............................. 6 Genetic or Enzyme Disorder - Drugs for
Analgesics - Drugs for Pain and Inflammation. 8 Replacement, Modification, Treatment.........45
Anti-Addiction / Substance Abuse Treatment Genitourinary Agents - Drugs for Bladder,
Agents............................................................ 9 Genital and Kidney Conditions..................... 45
Antibacterials - Drugs for Infections................10 Genitourinary Agents - Drugs for Prostate
Anticoagulants - Drugs to Treat or Prevent Conditions.................................................... 46
Blood Clots................................................... 10 Hormonal Agents - Hormone Replacement
Anticonvulsants - Drugs for Seizures............. 11 and Birth Control.......................................... 46
Antidementia Agents - Drugs for Alzheimer's Hormonal Agents - Oral Steroids....................51
Disease and Dementia................................. 12 Hormonal Agents - Other................................52
Antidepressants - Drugs for Depression.........13 Hormonal Agents - Testosterone
Antiemetics - Drugs for Nausea and Vomiting 14 Replacement................................................ 52
Antifungals - Drugs for Fungal Infections....... 15 Hormonal Agents - Thyroid.............................53
Antigout Agents - Drugs for Gout................... 16 Immunological Agents - Drugs for Immune
Antimigraine Agents - Drugs for Migraines.....16 System Stimulation or Suppression............. 53
Antimyasthenic Agents - Drugs to Treat Immunological Agents - Drugs for
Myasthenia Gravis........................................17 Vaccination...................................................54
Antimycobacterials - Drugs to Treat Infertility Agents.............................................. 55
Infections...................................................... 17 Inflammatory Bowel Disease Agents..............55
Antineoplastics - Drugs for Cancer.................17 Metabolic Bone Disease Agents - Drugs for
Antiparasitics - Drugs for Parasitic Infections. 18 Osteoporosis................................................ 56
Antiparkinson Agents - Drugs for Parkinson's Metabolic Bone Disease Agents - Other........ 56
Disease ........................................................ 19 Ophthalmic Agents - Drugs for Eye Allergy,
Antiplatelets - Drugs for Heart Attack and Infection and Inflammation........................... 56
Stroke Prevention.........................................19 Ophthalmic Agents - Drugs for Glaucoma......57
Antipsychotics - Drugs for Mood Disorders.... 19 Ophthalmic Agents - Drugs for Miscellaneous
Antivirals - Drugs for Viral Infections.............. 20 Eye Conditions............................................. 58
Anxiolytics - Drugs for Anxiety........................21 Otic Agents - Drugs for Ear Conditions.......... 58
Bipolar Agents - Drugs for Mood Disorders....22 Respiratory - Drugs for Anaphylaxis...............59
Cardiovascular Agents - Drugs for Heart and Respiratory Tract / Pulmonary Agents -
Circulation Conditions.................................. 22 Drugs for Allergies, Cough, Cold..................59
Central Nervous System Agents - Drugs for Respiratory Tract / Pulmonary Agents -
Attention Deficit Disorder..............................27 Drugs for Asthma and COPD....................... 60
Central Nervous System Agents - Drugs for Respiratory Tract / Pulmonary Agents -
Multiple Sclerosis......................................... 28 Drugs for Cystic Fibrosis.............................. 62
Central Nervous System Agents - Respiratory Tract / Pulmonary Agents -
Miscellaneous...............................................29 Drugs for Pulmonary Fibrosis.......................62
Dental and Oral Agents - Drugs for Mouth Respiratory Tract / Pulmonary Agents -
and Throat Conditions.................................. 29 Drugs for Pulmonary Hypertension.............. 62
Dermatological Agents - Drugs for Skin Skeletal Muscle Relaxants - Drugs for
Conditions.................................................... 30 Muscle Pain and Spasm...............................62
Diabetes - Glucose Monitoring....................... 36 Sleep Disorder Agents....................................63
Diabetes - Insulin............................................38 Index of Drugs................................................ 64
Diabetes - Non-Insulin Agents........................39
Drugs for Blood Disorders.............................. 40
Drugs for Sexual Dysfunction......................... 41
Electrolytes / Vitamins.................................... 41
Gastrointestinal Agents - Drugs for Acid
Reflux and Ulcer...........................................43
Gastrointestinal Agents - Drugs for Bowel,
Intestine and Stomach Conditions................43
5Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
Analgesics - Drugs for butalbital-apap-caffeine
Pain oral capsule 50-325-40 1 QL
acetaminophen-codeine 1 mg
acetaminophen-codeine butalbital-apap-caffeine 1 QL
1 oral tablet
#2
acetaminophen-codeine butalbital-asa-caff- 1
1 codeine
#3
acetaminophen-codeine butalbital-aspirin-caffeine 1
1
#4 butorphanol tartrate 2 QL
ALLZITAL E nasal
apap-caff-dihydrocodeine BUTRANS E PA; ST; QL
4 QL
oral capsule CONZIP ORAL
(generic for
ARYMO ER E PA; ST; QL CAPSULE EXTENDED
E Conzip);
RELEASE 24 HOUR 100 QL
ascomp-codeine 1
MG
BELBUCA 3 PA; QL
CONZIP ORAL
BUPAP 4 CAPSULE EXTENDED E QL
buprenorphine RELEASE 24 HOUR 200
E PA; ST; QL MG, 300 MG
transdermal
butalbital-acetaminophen DILAUDID ORAL 4
E QL
capsule 50-300 mg oral DOLOPHINE 3 PA; QL
BUTALBITAL- DURAGESIC-100 E PA; ST; QL
ACETAMINOPHEN DURAGESIC-12 E PA; ST; QL
E QL
CAPSULE 50-300 MG
ORAL DURAGESIC-25 E PA; ST; QL
butalbital-acetaminophen DURAGESIC-50 E PA; ST; QL
E
oral tablet 25-325 mg DURAGESIC-75 E PA; ST; QL
butalbital-acetaminophen DVORAH E QL
3
oral tablet 50-300 mg endocet 1
butalbital-acetaminophen 1 ESGIC 4 QL
oral tablet 50-325 mg
fentanyl transdermal
butalbital-apap-caff-cod patch 72 hour 100
oral capsule 50-300-40- E QL 2 PA; QL
mcg/hr, 12 mcg/hr, 25
30 mg mcg/hr, 50 mcg/hr, 75
butalbital-apap-caff-cod mcg/hr
oral capsule 50-325-40- 1 QL
fentanyl transdermal
30 mg patch 72 hour 37.5 E PA; ST; QL
butalbital-apap-caffeine mcg/hr, 62.5 mcg/hr,
oral capsule 50-300-40 3 QL 87.5 mcg/hr
mg FIORICET 4 QL
FIORICET/CODEINE E QL
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
6Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
FIORINAL 4 methadone hcl oral tablet
1 QL
FIORINAL/CODEINE #3 4 soluble
hydrocodone- methadose oral 1 QL
acetaminophen oral 1 concentrate 10 mg/ml
solution 10-325 mg/15ml methadose oral tablet 1 QL
hydrocodone- soluble
acetaminophen oral 2 methadose sugar-free 1 QL
solution 7.5-325 mg/15ml morphine sulfate
hydrocodone- (concentrate) oral 1
acetaminophen oral solution 100 mg/5ml, 20
E
tablet 10-300 mg, 5-300 mg/ml
mg, 7.5-300 mg morphine sulfate er oral
hydrocodone- capsule extended E PA; ST; QL
acetaminophen oral 1 release 24 hour
tablet 10-325 mg, 5-325 morphine sulfate er oral
mg, 7.5-325 mg 1 PA; QL
tablet extended release
hydrocodone-ibuprofen 1 1
morphine sulfate oral
hydromorphone hcl oral 1 1
morphine sulfate rectal
hydromorphone hcl rectal 1 3 PA; ST; QL
MS CONTIN
HYSINGLA ER E PA; ST; QL E QL
NALOCET
KADIAN E PA; ST; QL 4
NORCO
lidocaine external 2 QL NUCYNTA 4 QL
ointment
NUCYNTA ER 3 PA; QL
lidocaine external patch 5
3 PA; QL OXAYDO E QL
%
lidocaine hcl external OXYCODONE HCL ER E PA; ST; QL
1
solution oxycodone hcl oral
1
lidocaine hcl capsule
1
urethral/mucosal oxycodone hcl oral 1
lidocaine-prilocaine concentrate 100 mg/5ml
1
external cream oxycodone hcl oral 1
LIDODERM E PA; QL solution
LORTAB 4 oxycodone hcl oral tablet
10 mg, 15 mg, 20 mg, 30 1
methadone hcl intensol 1 QL mg
methadone hcl oral 1 QL oxycodone hcl oral tablet
concentrate 1 QL
5 mg
methadone hcl oral 1 PA; QL OXYCODONE-
solution ACETAMINOPHEN E
methadone hcl oral tablet 1 PA; QL ORAL TABLET 10-300
MG, 5-300 MG
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
7Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
oxycodone- TREZIX 4 QL
acetaminophen oral ULTRACET 4 QL
tablet 10-325 mg, 2.5- 1
325 mg, 5-325 mg, 7.5- ULTRAM 4
325 mg VANATOL LQ 2 PA; QL
OXYCODONE- VANATOL S 2 PA; QL
ACETAMINOPHEN VTOL LQ 2 PA; QL
E QL
ORAL TABLET 2.5-300
XTAMPZA ER 2 PA; QL
MG
E PA; ST; QL ZEBUTAL 4 QL
OXYCONTIN
2 QL ZTLIDO E PA; QL
oxymorphone hcl
4 PA; ST; QL Analgesics - Drugs for
oxymorphone hcl er
Pain and Inflammation
pentazocine-naloxone hcl 1
ARTHROTEC 3
PERCOCET E
CELEBREX E QL
premium lidocaine 2 QL
celecoxib oral 2 QL
PRIMLEV E
DAYPRO 4
PROLATE E
DICLOFENAC E
ROXICODONE ORAL EPOLAMINE
4
TABLET 15 MG, 30 MG
diclofenac potassium 1
ROXICODONE ORAL 4 QL diclofenac sodium er 1
TABLET 5 MG
SUBSYS E PA; QL diclofenac sodium E
external gel 1 %
tencon 1
diclofenac sodium
(generic for E
E external solution
tramadol hcl er (biphasic) Ryzolt); QL
diclofenac sodium oral 1
TRAMADOL HCL ER
(generic for diclofenac-misoprostol 3
ORAL CAPSULE
EXTENDED RELEASE E Conzip); diflunisal oral 1
24 HOUR 100 MG, 200 QL DUEXIS E QL
MG, 300 MG
EC-NAPROSYN 3
tramadol hcl er oral
1 QL ec-naproxen 1
capsule extended
release 24 hour 150 mg etodolac 1
(generic for etodolac er 1
tramadol hcl er oral tablet 2 Ultram FELDENE 4
extended release 24 hour ER); QL
FLECTOR E
tramadol hcl oral tablet
E QL flurbiprofen oral 1
100 mg
hydrocodone bitartrate er 3 PA; ST; QL
tramadol hcl oral tablet
1
50 mg hydromorphone hcl er 4 PA; ST; QL
tramadol-acetaminophen 1 QL ibuprofen 1
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
8Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
ibuprofen oral sulindac oral 1
E
suspension TIVORBEX E
INDOCIN 3 VIVLODEX E QL
indomethacin er 1 VOLTAREN E
INDOMETHACIN ORAL ZIPSOR E
E
CAPSULE 20 MG
ZOHYDRO ER E PA; ST; QL
indomethacin oral 1 ZORVOLEX E
capsule 25 mg, 50 mg
E ST; QL Anti-Addiction /
ketoprofen er
Substance Abuse
ketoprofen oral E ST; QL Treatment Agents
KETOROLAC acamprosate calcium 1
TROMETHAMINE 4 ST; QL
ANTABUSE 4
NASAL
BUNAVAIL E PA; QL
ketorolac tromethamine 1
oral buprenorphine hcl
1 QL
LICART E sublingual
LODINE E buprenorphine hcl-
2 QL
naloxone hcl
mefenamic acid oral 3
bupropion hcl er 1 H
meloxicam oral 1 (smoking det)
MOBIC 4 CHANTIX 4 PA; H
nabumetone oral E CHANTIX CONTINUING 4 PA; H
NAPRELAN E MONTH PAK
NAPROSYN 4 PA CHANTIX STARTING 4 PA; H
naproxen dr 1 MONTH PAK
disulfiram oral 1
naproxen oral 1 PA
suspension naloxone hcl injection 1
naproxen oral tablet 1 solution
naproxen sodium er E NALOXONE HCL
INJECTION SOLUTION
naproxen sodium oral E PA; QL
1 AUTO-INJECTOR 2
tablet 275 mg, 550 mg MG/0.4ML
oxaprozin 1 naloxone hcl injection 1
PENNSAID E solution prefilled syringe
piroxicam oral 1 naltrexone hcl oral 1
QMIIZ ODT E NARCAN 2 QL
RELAFEN E NICOTROL 4 PA; H
RELAFEN DS E NICOTROL NS 4 PA; H
salsalate oral 1 SUBOXONE E PA; QL
SPRIX 4 ST; QL ZUBSOLV 2 QL
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
9Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
Antibacterials - Drugs SILVADENE 4
for Infections
silver sulfadiazine
1
AEMCOLO 3 QL external
BACTRIM 4 SOLOSEC 4 ST; QL
BACTRIM DS 4 ssd 1
CENTANY 4 QL sulfamethoxazole-
1
CENTANY AT E trimethoprim oral
CLEOCIN ORAL sulfatrim pediatric 1
CAPSULE 150 MG, 300 4 tinidazole oral 3
MG trimethoprim oral 1
CLEOCIN ORAL 2 VANCOCIN 4 QL
CAPSULE 75 MG
VANCOCIN HCL 4 QL
CLEOCIN ORAL
SOLUTION 4 vancomycin hcl oral
1 QL
RECONSTITUTED capsule
CLEOCIN VAGINAL vancomycin hcl oral 3
4 solution reconstituted
CREAM
CLEOCIN VAGINAL vandazole 2
2
SUPPOSITORY XEPI 3 QL
clindamycin hcl oral 1 XIFAXAN 3 PA; QL
clindamycin palmitate hcl 2 ZYVOX ORAL
clindamycin phosphate SUSPENSION 4 QL
2 RECONSTITUTED
vaginal
CLINDESSE 2 ZYVOX ORAL TABLET E QL
colistimethate sodium Anticoagulants - Drugs
1 to Treat or Prevent
(cba)
Blood Clots
COLY-MYCIN M 4
ARIXTRA 4 QL
DIFICID 3 QL
ELIQUIS 2 QL
FIRVANQ 1
enoxaparin sodium 2 QL
FLAGYL 4
fondaparinux sodium 2 QL
gentamicin sulfate
1 QL heparin sodium (porcine) 1
external
linezolid oral 2 QL heparin sodium (porcine) 1
pf
metronidazole oral 1
jantoven 1
metronidazole vaginal 2
LOVENOX E QL
mupirocin calcium 3 QL
PRADAXA 2 QL
mupirocin external 1 QL
SAVAYSA 4 QL
NUVESSA E
warfarin sodium oral 1
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
10Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
XARELTO 2 QL epitol 1
XARELTO STARTER ethosuximide oral 1
2 QL
PACK felbamate 1
Anticonvulsants - 4 PA; ST
FELBATOL
Drugs for Seizures
FYCOMPA ORAL
APTIOM 3 PA 4 PA
SUSPENSION
BANZEL ORAL 3 FYCOMPA ORAL
SUSPENSION 3 PA
TABLET
BANZEL ORAL TABLET 3 PA 1
gabapentin oral capsule
BRIVIACT ORAL 4 PA gabapentin oral solution
SOLUTION 1
250 mg/5ml
BRIVIACT ORAL 3 PA gabapentin oral tablet 1
TABLET
KEPPRA ORAL 4 PA; ST
carbamazepine er oral
capsule extended 2 KEPPRA XR 4 PA; ST
release 12 hour LAMICTAL 4 PA; ST
carbamazepine er oral LAMICTAL ODT ORAL
tablet extended release 3 KIT 21 X 25 MG & 7 X 50 3 PA; ST
12 hour MG, 42 X 50 MG &
carbamazepine oral 1 14X100 MG
CARBATROL 4 LAMICTAL ODT ORAL 4 PA; ST
KIT 25 & 50 & 100 MG
clobazam oral 3 PA
suspension LAMICTAL ODT ORAL
4 PA; ST
TABLET DISPERSIBLE
clobazam oral tablet 2 PA
LAMICTAL STARTER 4 PA; ST
DEPAKOTE 4 PA
LAMICTAL XR 3 PA; ST
DEPAKOTE ER 4 PA; ST
lamotrigine er 3 PA; ST
DEPAKOTE SPRINKLES 4 PA; ST
lamotrigine oral kit 3 PA; ST
DIASTAT ACUDIAL 4 QL
lamotrigine oral tablet 1
DIASTAT PEDIATRIC 2 QL
lamotrigine oral tablet
diazepam rectal 1 QL 1
chewable
DILANTIN 3
lamotrigine oral tablet
3 PA; ST
DILANTIN INFATABS 3 dispersible
divalproex sodium er 2 lamotrigine starter kit-
1
divalproex sodium oral blue
capsule delayed release 2 lamotrigine starter kit- 1
sprinkle green
divalproex sodium oral 1 lamotrigine starter kit- 1
tablet delayed release orange
EPIDIOLEX 3 PA; SP levetiracetam er 2
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
11Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
levetiracetam oral 1 TROKENDI XR E PA; ST
MYSOLINE 2 PA; ST valproic acid oral 1
NAYZILAM 3 PA; QL VALTOCO 10 MG DOSE 3 PA; QL
NEURONTIN 4 PA; ST VALTOCO 15 MG DOSE 3 PA; QL
ONFI 4 PA; ST VALTOCO 20 MG DOSE 3 PA; QL
oxcarbazepine 1 VALTOCO 5 MG DOSE 3 PA; QL
OXTELLAR XR E PA; ST VIMPAT ORAL 3 PA
phenobarbital oral 1 XCOPRI 3 PA
phenobarbital oral 1 XCOPRI (250 MG DAILY 3 PA
solution 20 mg/5ml DOSE)
PHENYTEK 4 XCOPRI (350 MG DAILY
3 PA
phenytoin infatabs 1 DOSE)
phenytoin oral ZARONTIN 4
1
suspension 125 mg/5ml ZONEGRAN 4 PA; ST
phenytoin oral tablet zonisamide oral 1
1
chewable Antidementia Agents -
phenytoin sodium Drugs for Alzheimer's
1
extended Disease and Dementia
primidone oral 1 ARICEPT ORAL 3
QUDEXY XR E PA; ST TABLET 10 MG, 5 MG
roweepra 1 ARICEPT ORAL E
TABLET 23 MG
roweepra xr 2
donepezil hcl oral tablet 1
SPRITAM E PA; ST 10 mg, 5 mg
subvenite 1 donepezil hcl oral tablet E
subvenite starter kit-blue 1 23 mg
subvenite starter kit- donepezil hcl oral tablet
1 1
green dispersible
subvenite starter kit- EXELON E
1
orange memantine hcl er E
SYMPAZAN E PA memantine hcl oral
3
TEGRETOL 3 solution 2 mg/ml
TEGRETOL-XR 4 memantine hcl oral tablet 2
TOPAMAX 4 PA; ST NAMENDA 4
TOPAMAX SPRINKLE 4 PA; ST NAMENDA TITRATION
4
topiramate er E PA; ST PAK
1 NAMENDA XR E
topiramate oral
TRILEPTAL 4 PA; ST NAMENDA XR
E
TITRATION PACK
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
12Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
rivastigmine 3 escitalopram oxalate oral
3
rivastigmine tartrate 1 solution
Antidepressants - escitalopram oxalate oral 1
Drugs for Depression tablet
amitriptyline hcl oral 1 FETZIMA 4 ST; QL
ANAFRANIL E FETZIMA TITRATION 4 ST; QL
APLENZIN E QL fluoxetine hcl (pmdd) E
BRISDELLE E QL fluoxetine hcl oral 1
capsule
bupropion hcl er (sr) 1
fluoxetine hcl oral 3 QL
bupropion hcl er (xl) oral capsule delayed release
tablet extended release 1
24 hour 150 mg, 300 mg fluoxetine hcl oral 1
solution
BUPROPION HCL ER
(XL) ORAL TABLET fluoxetine hcl oral tablet 3 QL
E QL 10 mg
EXTENDED RELEASE
24 HOUR 450 MG fluoxetine hcl oral tablet
3
bupropion hcl oral 1 20 mg
CELEXA E fluoxetine hcl oral tablet
E
60 mg
citalopram hydrobromide 1
fluvoxamine maleate 1
clomipramine hcl oral 4
fluvoxamine maleate er 3 QL
CYMBALTA E QL
FORFIVO XL E QL
desipramine hcl oral 1
imipramine hcl oral 1
DESVENLAFAXINE ER E QL
LEXAPRO E
desvenlafaxine succinate 3 QL
er mirtazapine oral 1
doxepin hcl oral capsule 1 NARDIL 4
doxepin hcl oral nefazodone hcl 1
1
concentrate NORPRAMIN 4
DRIZALMA SPRINKLE 4 PA; QL nortriptyline hcl oral 1
duloxetine hcl oral olanzapine-fluoxetine hcl 2 QL
capsule delayed release PAMELOR 4
2 QL
particles 20 mg, 30 mg,
60 mg PARNATE 4
duloxetine hcl oral paroxetine hcl 1
capsule delayed release E paroxetine hcl er 3 QL
particles 40 mg paroxetine mesylate E QL
EFFEXOR XR E 4 QL
PAXIL CR
EMSAM 3
PAXIL ORAL 3
SUSPENSION
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
13Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
PAXIL ORAL TABLET 4 EMEND ORAL
4 QL
phenelzine sulfate oral 1 CAPSULE 80 MG
PRISTIQ E QL EMEND ORAL
SUSPENSION 2 QL
protriptyline hcl 1 RECONSTITUTED
PROZAC E EMEND TRI-PACK 4 QL
REMERON 4 GIMOTI E
REMERON SOLTAB 4 2
granisetron hcl oral
SARAFEM E 4
MARINOL
sertraline hcl oral 1
meclizine hcl oral tablet E
SPRAVATO (56 MG 4 PA; QL 12.5 mg, 25 mg
DOSE) metoclopramide hcl oral 1
SPRAVATO (84 MG solution
4 PA; QL
DOSE) metoclopramide hcl oral 1
SYMBYAX 4 QL tablet
tranylcypromine sulfate 1 metoclopramide hcl oral
E
trazodone hcl oral 1 tablet dispersible
TRINTELLIX 4 ST; QL ondansetron hcl oral 1
venlafaxine hcl 1 ondansetron odt 1
venlafaxine hcl er oral perphenazine oral 1
capsule extended 1 prochlorperazine 1
release 24 hour prochlorperazine maleate
1
venlafaxine hcl er oral oral
tablet extended release E QL promethazine hcl oral 1
24 hour
promethazine hcl rectal 1
VIIBRYD 4 QL
promethegan 1
VIIBRYD STARTER 4
PACK REGLAN 4
E scopolamine 3
WELLBUTRIN SR
E SYNDROS 4 PA; QL
WELLBUTRIN XL
E TIGAN ORAL 4
ZOLOFT
Antiemetics - Drugs for TRANSDERM-SCOP
4
Nausea and Vomiting (1.5 MG)
aprepitant 2 QL trimethobenzamide hcl
1
oral
BONJESTA E PA
VARUBI (180 MG DOSE) 2 QL
compro 1
ZOFRAN 4
DICLEGIS E PA
ZUPLENZ E QL
doxylamine-pyridoxine E PA
dronabinol 1
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
14Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
Antifungals - Drugs for ketoconazole external
1 QL
Fungal Infections cream
BIO-STATIN ORAL ketoconazole external
3 3 ST; QL
CAPSULE foam
bio-statin oral powder 1 ketoconazole external 1
ciclodan 1 shampoo
ciclopirox external gel 1 ketoconazole oral 1
ciclopirox external ketodan external foam 3 ST; QL
2
shampoo LOPROX EXTERNAL E
ciclopirox external CREAM
1
solution LOPROX EXTERNAL E
ciclopirox olamine SHAMPOO
1
external LOPROX EXTERNAL
E
ciclopirox treatment E SUSPENSION
clotrimazole external E NOXAFIL ORAL
2
SUSPENSION
clotrimazole mouth/throat 1
NOXAFIL ORAL TABLET
CRESEMBA ORAL 3 E
DELAYED RELEASE
DIFLUCAN ORAL nyamyc 1 QL
SUSPENSION 4
RECONSTITUTED nystatin external 1 QL
DIFLUCAN ORAL nystatin mouth/throat 1
TABLET 100 MG, 150 4 nystatin oral 1
MG, 200 MG nystatin-triamcinolone E
DIFLUCAN ORAL 3 nystop 1 QL
TABLET 50 MG
posaconazole 2
econazole nitrate 2 QL
external SPORANOX 4 QL
ECOZA E SPORANOX PULSEPAK 4 QL
EXELDERM 3 SULCONAZOLE
3
NITRATE
EXTINA 4 ST; QL
terbinafine hcl oral 1 QL
fluconazole oral 1
terconazole 1
griseofulvin microsize 1
oral TOLSURA E
griseofulvin VFEND ORAL
1 SUSPENSION 4
ultramicrosize
RECONSTITUTED
GYNAZOLE-1 3
VFEND ORAL TABLET 4 QL
itraconazole oral capsule 1 QL
200 MG
itraconazole oral solution 2 QL
VFEND ORAL TABLET 3 QL
JUBLIA 4 PA; ST; QL 50 MG
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
15Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
voriconazole oral IMITREX ORAL E QL
1
suspension reconstituted IMITREX STATDOSE
E QL
voriconazole oral tablet 1 QL SYSTEM
XOLEGEL 3 IMITREX
E QL
Antigout Agents - SUBCUTANEOUS
Drugs for Gout MAXALT E QL
allopurinol oral 1 MAXALT-MLT E QL
COLCHICINE ORAL MIGRANAL E PA; QL
E
CAPSULE naratriptan hcl 1 QL
colchicine oral tablet E E PA; ST; QL
NURTEC
colchicine-probenecid 1 E QL
ONZETRA XSAIL
COLCRYS E E QL
RELPAX
febuxostat 3 ST; QL 2 PA; ST; QL
REYVOW
GLOPERBA 4 PA 1 QL
rizatriptan benzoate
MITIGARE 2 2 QL
sumatriptan nasal
probenecid 1
sumatriptan succinate
1 QL
ULORIC E ST; QL oral
ZYLOPRIM 4 sumatriptan succinate
1 QL
Antimigraine Agents - subcutaneous
Drugs for Migraines sumatriptan-naproxen E QL
AIMOVIG 2 PA; ST; QL sodium
AJOVY E PA; ST; QL TOSYMRA E QL
almotriptan malate 3 QL TREXIMET E QL
AMERGE 4 QL UBRELVY 2 PA; ST; QL
CAMBIA E QL ZEMBRACE E QL
SYMTOUCH
D.H.E. 45 E
zolmitriptan oral tablet 2 QL
dihydroergotamine
1 zolmitriptan oral tablet
mesylate injection 3 QL
dispersible
dihydroergotamine
4 PA; QL ZOMIG NASAL
mesylate nasal 3 ST; QL
SOLUTION 2.5 MG
eletriptan hydrobromide 2 QL
ZOMIG NASAL 4 ST; QL
EMGALITY 2 PA; ST; QL
SOLUTION 5 MG
EMGALITY (300 MG ZOMIG ORAL 4 QL
2 PA; ST; QL
DOSE)
ZOMIG ZMT 4 QL
FROVA 4 QL
frovatriptan succinate 3 QL
IMITREX NASAL 4 QL
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
16Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
Antimyasthenic Agents CASODEX 4
- Drugs to Treat
COMETRIQ (100 MG
Myasthenia Gravis 2 PA; QL; SP
DAILY DOSE)
MESTINON ORAL 4 COMETRIQ (140 MG
SOLUTION 2 PA; QL; SP
DAILY DOSE)
MESTINON ORAL E COMETRIQ (60 MG
TABLET 2 PA; QL; SP
DAILY DOSE)
MESTINON ORAL cyclophosphamide oral 2
TABLET EXTENDED 3
RELEASE ERLEADA 2 PA; QL; SP
pyridostigmine bromide everolimus oral tablet 2.5 2 PA; QL; SP
1 mg, 5 mg, 7.5 mg
er
pyridostigmine bromide exemestane 2
3
oral solution FEMARA E
pyridostigmine bromide GLEEVEC E PA; QL; SP
E
oral tablet 30 mg GLEOSTINE 2 SP
pyridostigmine bromide 1 HYDREA 4
oral tablet 60 mg
hydroxyurea oral 1
Antimycobacterials -
Drugs to Treat IBRANCE 2 PA; QL; SP
Infections ICLUSIG 3 PA; QL; SP
dapsone oral 2 IDHIFA 2 PA; QL; SP
Antineoplastics - Drugs imatinib mesylate 1 PA; QL; SP
for Cancer 2 PA; QL; SP
IMBRUVICA
abiraterone acetate oral INLYTA 3 PA; QL; SP
2 PA; QL; SP
tablet 250 mg
JAKAFI 2 PA; QL; SP
AFINITOR DISPERZ 2 PA; QL; SP
LENVIMA (10 MG DAILY
AFINITOR ORAL 3 PA; QL; SP
2 PA; QL; SP DOSE)
TABLET 10 MG
LENVIMA (12 MG DAILY
AFINITOR ORAL 3 PA; QL; SP
DOSE)
TABLET 2.5 MG, 5 MG, E PA; QL; SP
7.5 MG LENVIMA (14 MG DAILY 3 PA; QL; SP
DOSE)
ALECENSA 2 PA; QL
LENVIMA (18 MG DAILY 3 PA; QL; SP
anastrozole oral 1
DOSE)
ARIMIDEX E
LENVIMA (20 MG DAILY 3 PA; QL; SP
AROMASIN 4 DOSE)
bexarotene E SP LENVIMA (24 MG DAILY
3 PA; QL; SP
bicalutamide 1 DOSE)
CABOMETYX 2 PA; QL; SP LENVIMA (4 MG DAILY
3 PA; QL; SP
DOSE)
capecitabine E QL; SP
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
17Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
LENVIMA (8 MG DAILY ZEJULA 2 PA; QL; SP
3 PA; QL; SP
DOSE) ZYTIGA ORAL TABLET
E PA; QL; SP
letrozole oral 1 250 MG
leucovorin calcium oral 1 ZYTIGA ORAL TABLET
E PA; SP
LYNPARZA 2 PA; QL; SP 500 MG
3 PA; QL; SP Antiparasitics - Drugs
MEKINIST
for Parasitic Infections
mercaptopurine oral 1
albendazole oral 3 PA; QL
NERLYNX 2 PA; QL; SP
ALBENZA 4 PA; QL
NINLARO 2 PA; QL; SP
ALINIA 2 QL
NUBEQA 2 PA; QL; SP
ARAKODA 4 QL
POMALYST 3 PA; QL; SP
atovaquone oral 2
PURIXAN 4 PA; SP
atovaquone-proguanil hcl 2
REVLIMID 2 PA; QL; SP
chloroquine phosphate
SOLTAMOX E 1
oral
PA; ST; ELIMITE 4
4
SPRYCEL QL; SP
EMVERM 4 PA; QL
TAFINLAR 3 PA; QL; SP
hydroxychloroquine 1
TAGRISSO 3 PA; QL; SP sulfate oral
tamoxifen citrate oral ivermectin oral 1
1
tablet 10 mg
KRINTAFEL 1 QL
tamoxifen citrate oral
1 H-PA MALARONE 4
tablet 20 mg
3 QL; SP malathion 1
TARGRETIN EXTERNAL
2 SP mefloquine hcl 1
TARGRETIN ORAL
PA; ST; MEPRON E
2
TASIGNA QL; SP NATROBA E
TEMODAR ORAL 4 PA; SP OVIDE 4
temozolomide 1 PA; SP permethrin external 1
VENCLEXTA 2 PA; QL; SP PLAQUENIL E
VENCLEXTA STARTING QUALAQUIN 4
2 PA; QL; SP
PACK quinine sulfate oral 1
VERZENIO 2 PA; QL; SP SKLICE 4 QL
VOTRIENT 2 PA; QL; SP spinosad 3
XELODA 1 QL; SP STROMECTOL 4
PA; ST;
4
XTANDI QL; SP
PA; ST;
E
YONSA QL; SP
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
18Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
Antiparkinson Agents - Antiplatelets - Drugs
Drugs for Parkinson's for Heart Attack and
Disease Stroke Prevention
amantadine hcl oral 1 AGGRENOX ORAL
AZILECT E CAPSULE EXTENDED 4
RELEASE 12 HOUR 25-
benztropine mesylate 1 200 MG
oral
aspirin-dipyridamole er 3
bromocriptine mesylate 1
oral BRILINTA 4 QL
1 cilostazol 1
carbidopa-levodopa
1 clopidogrel bisulfate oral 1
carbidopa-levodopa er
4 EFFIENT E QL
COMTAN
4 PA PLAVIX E
DUOPA
1 prasugrel hcl 3 QL
entacapone
E QL ZONTIVITY 4 QL
GOCOVRI
3 PA; QL; SP Antipsychotics - Drugs
INBRIJA
for Mood Disorders
MIRAPEX 4
ABILIFY E QL
MIRAPEX ER E
aripiprazole oral solution 3
NEUPRO 3
aripiprazole oral tablet 2 QL
NOURIANZ 3 PA; QL
aripiprazole oral tablet 2 QL
OSMOLEX ER E dispersible
PARLODEL E chlorpromazine hcl oral 1
pramipexole clozapine 1
1
dihydrochloride
CLOZARIL 4
pramipexole E fluphenazine hcl oral 1
dihydrochloride er
3 GEODON ORAL E QL
rasagiline mesylate oral
haloperidol oral 1
REQUIP XL ORAL
TABLET EXTENDED INVEGA E QL
E
RELEASE 24 HOUR 12 LATUDA 4 QL
MG, 6 MG
olanzapine oral tablet 1 QL
ropinirole hcl 1
olanzapine oral tablet 2 QL
ropinirole hcl er E dispersible
RYTARY E paliperidone er 3 QL
selegiline hcl oral 1 pimozide 2
SINEMET 4 quetiapine fumarate 1
trihexyphenidyl hcl 1 quetiapine fumarate er 3 QL
ZELAPAR 3 REXULTI 4 PA; ST; QL
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
19Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
RISPERDAL E entecavir 1 SP
risperidone 1 EPCLUSA ORAL
2 PA; QL; SP
SAPHRIS 3 QL TABLET 400-100 MG
SEROQUEL E EPIVIR 4
SEROQUEL XR E QL EPZICOM E QL
VERSACLOZ E famciclovir oral tablet 125
2
mg, 500 mg
VRAYLAR 4 ST; QL
famciclovir oral tablet 250 2 QL
ziprasidone hcl 2 QL
mg
ZYPREXA ORAL E QL 4 QL
GENVOYA
ZYPREXA ZYDIS E QL
HARVONI ORAL 2 QL
Antivirals - Drugs for PACKET
Viral Infections PA; ST;
HARVONI ORAL 2
abacavir sulfate- TABLET QL; SP
2 QL
lamivudine INTELENCE 2
acyclovir external cream E QL 2
ISENTRESS
acyclovir external ISENTRESS HD 2
4 PA; ST; QL
ointment
JULUCA 2 QL
acyclovir oral 1
KALETRA ORAL 4
atazanavir sulfate 2
SOLUTION
ATRIPLA E ST; QL
KALETRA ORAL 2
BARACLUDE ORAL TABLET
2 SP
SOLUTION lamivudine oral solution 1
BARACLUDE ORAL lamivudine oral tablet
E SP 1
TABLET 150 mg, 300 mg
BIKTARVY 4 QL PA; ST;
LEDIPASVIR-
2
CIMDUO 2 QL SOFOSBUVIR QL; SP
COMPLERA 4 QL lopinavir-ritonavir 2
DENAVIR E MAVYRET 2 PA; QL; SP
DESCOVY E PA; ST; QL nevirapine 1
DOVATO 2 QL nevirapine er E
EDURANT 2 NORVIR ORAL PACKET 2
efavirenz 2 NORVIR ORAL
2
efavirenz-emtricitab- SOLUTION
E ST; QL
tenofovir NORVIR ORAL TABLET E
efavirenz-lamivudine- ODEFSEY 4 QL
2 QL
tenofovir oseltamivir phosphate
2
emtricitabine-tenofovir df 1 QL; H oral capsule
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
20Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
oseltamivir phosphate valganciclovir hcl oral
1
oral suspension 2 QL solution reconstituted
reconstituted valganciclovir hcl oral 1 QL
PIFELTRO 3 tablet
PREZCOBIX 2 VALTREX E QL
PREZISTA 2 VEMLIDY 4 ST; SP
REYATAZ ORAL E VIRAMUNE ORAL 4
CAPSULE SUSPENSION
REYATAZ ORAL 2 VIRAMUNE ORAL E
PACKET TABLET 200 MG
ritonavir 2 VIRAMUNE XR E
RUKOBIA 4 PA VIREAD ORAL 3
SELZENTRY 2 PA POWDER
SITAVIG E QL VIREAD ORAL TABLET
150 MG, 200 MG, 250 2
SOFOSBUVIR- 2 PA; QL; SP MG
VELPATASVIR
VIREAD ORAL TABLET
STRIBILD 4 QL E
300 MG
SUSTIVA 4 2 PA; QL; SP
VOSEVI
SYMFI 2 QL
XOFLUZA (40 MG 3 QL
SYMFI LO 2 QL DOSE)
SYMTUZA E QL XOFLUZA (80 MG 3 QL
TAMIFLU ORAL DOSE)
E
CAPSULE ZEPATIER 2 PA; QL; SP
TAMIFLU ORAL ZOVIRAX EXTERNAL E QL
SUSPENSION E QL CREAM
RECONSTITUTED ZOVIRAX EXTERNAL E PA; ST; QL
TEMIXYS E QL OINTMENT
tenofovir disoproxil ZOVIRAX ORAL 4
2 H-PA
fumarate Anxiolytics - Drugs for
TIVICAY 3 Anxiety
TIVICAY PD 3 alprazolam er 1
TRIUMEQ 2 QL alprazolam intensol 1
TRUVADA E QL alprazolam oral 1
valacyclovir hcl oral 1 QL alprazolam xr 1
VALCYTE ORAL ATIVAN ORAL E
SOLUTION 4 buspirone hcl oral 1
RECONSTITUTED
chlordiazepoxide hcl 1
VALCYTE ORAL
E QL clonazepam oral 1
TABLET
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
21Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
clorazepate dipotassium 1 ALDACTAZIDE ORAL
4
diazepam intensol 1 TABLET 25-25 MG
diazepam oral 1 ALDACTAZIDE ORAL 2
TABLET 50-50 MG
estazolam 1
ALDACTONE 4
HALCION 4
aliskiren fumarate 3
hydroxyzine hcl oral 1
ALTACE 4
hydroxyzine pamoate
1 ALTOPREV E
oral
KLONOPIN E amiloride hcl oral 1
lorazepam intensol 1 amiloride-
1
hydrochlorothiazide
lorazepam oral
1 amiodarone hcl oral 1
concentrate 2 mg/ml
lorazepam oral tablet 1 amlodipine besylate oral 1
oxazepam 1 amlodipine besylate- 1
benazepril hcl
TRANXENE-T 4
amlodipine besylate- 2
triazolam 1 valsartan
VALIUM E
amlodipine-atorvastatin
VISTARIL 4 oral tablet 10-10 mg, 10-
XANAX E 20 mg, 10-40 mg, 10-80 E
mg, 5-10 mg, 5-20 mg, 5-
XANAX XR E
40 mg, 5-80 mg
Bipolar Agents - Drugs
amlodipine-atorvastatin
for Mood Disorders E QL
oral tablet 2.5-10 mg,
EQUETRO 3 2.5-20 mg, 2.5-40 mg
lithium carbonate er 1 amlodipine-olmesartan E
lithium carbonate oral 1 amlodipine-valsartan- E
LITHOBID 4 hctz
Cardiovascular Agents ANTARA E
- Drugs for Heart and ATACAND 4
Circulation Conditions 4
ATACAND HCT
ACCUPRIL 4 1
atenolol oral
ACCURETIC 4 1
atenolol-chlorthalidone
acebutolol hcl oral 1
atorvastatin calcium oral 1 QL; H-PA
acetazolamide er 1 tablet 10 mg, 20 mg
acetazolamide oral 1 atorvastatin calcium oral 1 QL
ADALAT CC ORAL tablet 40 mg, 80 mg
TABLET EXTENDED AVALIDE 4
4
RELEASE 24 HOUR 60 AVAPRO 4
MG
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
22Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
AZOR E clonidine hcl oral 1
benazepril hcl oral 1 colesevelam hcl E
benazepril- COLESTID FLAVORED
1 3
hydrochlorothiazide ORAL GRANULES
BENICAR E COLESTID FLAVORED
4
BENICAR HCT E ORAL PACKET
BETAPACE E COLESTID ORAL 3
GRANULES
BETAPACE AF 4
COLESTID ORAL 4
BIDIL 2 PACKET
bisoprolol fumarate 1 COLESTID ORAL 4
bisoprolol- TABLET
1
hydrochlorothiazide colestipol hcl 1
bumetanide oral 1 COREG 4
BUMEX 3 COREG CR E
BYSTOLIC E CORGARD 4
CADUET E CORLANOR 3 PA; QL
CALAN SR 4 4
COZAAR
candesartan cilexetil 3 E QL
CRESTOR
candesartan cilexetil-hctz 3 1
digitek
captopril oral 1 1
digox
CARDIZEM E 1
digoxin oral
CARDIZEM CD E 3
DILATRATE-SR
CARDIZEM LA E 1
diltiazem hcl er
CARDURA 4 2
diltiazem hcl er beads
CAROSPIR 4 PA
diltiazem hcl er coated
cartia xt 2 beads oral capsule 2
carvedilol 1 extended release 24 hour
carvedilol phosphate er E diltiazem hcl er coated
beads oral tablet
CATAPRES 4 extended release 24 hour 2
CATAPRES-TTS-1 4 180 mg, 240 mg, 300
CATAPRES-TTS-2 4 mg, 360 mg
4 diltiazem hcl oral 1
CATAPRES-TTS-3
1 dilt-xr 1
chlorthalidone
cholestyramine light 1 DIOVAN E
cholestyramine oral 1 DIOVAN HCT E
clonidine 3 (Patch) dofetilide 2
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
23Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
doxazosin mesylate oral 1 fosinopril sodium 1
DUTOPROL ORAL fosinopril sodium-hctz 1
TABLET EXTENDED furosemide oral 1
RELEASE 24 HOUR E QL
100-12.5 MG, 50-12.5 gemfibrozil oral 1
MG GONITRO E QL
DUTOPROL ORAL guanfacine hcl 1
TABLET EXTENDED HEMANGEOL E
E
RELEASE 24 HOUR 25-
hydralazine hcl oral 1
12.5 MG
4 hydrochlorothiazide oral 1
DYAZIDE
3 HYZAAR 4
EDARBI
3 indapamide 1
EDARBYCLOR
1 INDERAL LA E
enalapril maleate oral
enalapril- INSPRA 4
1
hydrochlorothiazide irbesartan 1
ENTRESTO 4 PA; QL irbesartan- 1
EPANED 4 PA hydrochlorothiazide
2 ISORDIL TITRADOSE 4
eplerenone
EXFORGE E isosorbide dinitrate oral
tablet 10 mg, 20 mg, 30 1
EXFORGE HCT E mg, 5 mg
EZALLOR SPRINKLE 3 PA isosorbide dinitrate oral
2
ezetimibe 2 tablet 40 mg
ezetimibe-simvastatin 3 isosorbide mononitrate 1
felodipine er 1 isosorbide mononitrate er 1
fenofibrate micronized E KAPSPARGO
4
fenofibrate oral capsule E SPRINKLE
fenofibrate oral tablet 120 labetalol hcl oral 1
E
mg, 40 mg, 48 mg LANOXIN ORAL 3
fenofibrate oral tablet 145 LASIX 4
2
mg, 160 mg, 54 mg LESCOL XL E ST
fenofibric acid oral E LIPITOR E QL
capsule delayed release
LIPOFEN E
FENOGLIDE E
lisinopril oral 1
flecainide acetate 1
lisinopril-
FLOLIPID 4 PA 1
hydrochlorothiazide
fluvastatin sodium 1 LIVALO E ST; QL
fluvastatin sodium er 3 ST LOPID 4
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
24Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
LOPRESSOR 4 nadolol oral 1
LOPRESSOR HCT 4 NEXLETOL 2 PA; ST; QL
losartan potassium oral 1 NEXLIZET 2 PA; ST; QL
losartan potassium-hctz 1 niacin
2
LOTENSIN 4 (antihyperlipidemic)
LOTENSIN HCT 4 niacin er
4
(antihyperlipidemic)
LOTREL 4
niacor 2
lovastatin 1 H
NIASPAN 2
LOVAZA E
nifedipine er 1
matzim la 2
nifedipine er osmotic
MAXZIDE 4 1
release
MAXZIDE-25 4 1
nifedipine oral
methazolamide oral 1 2
nisoldipine er
methyldopa 1 2
NITRO-BID
metolazone 1 NITRO-DUR 3
metoprolol succinate er nitroglycerin sublingual 1
oral tablet extended 2
release 24 hour 100 mg, nitroglycerin transdermal 1
200 mg, 50 mg nitroglycerin translingual E QL
metoprolol succinate er NITROLINGUAL E QL
oral tablet extended 1 NITROMIST 4 QL
release 24 hour 25 mg
NITROSTAT 4
metoprolol tartrate oral
1 nitro-time 1
tablet 100 mg, 25 mg, 50
mg NORVASC E
metoprolol tartrate oral E olmesartan medoxomil 2
tablet 37.5 mg, 75 mg oral
metoprolol- olmesartan medoxomil-
1 2
hydrochlorothiazide hctz
mexiletine hcl oral 1 olmesartan-amlodipine-
E
MICARDIS E hctz
MICARDIS HCT E omega-3-acid ethyl 2
esters
midodrine hcl 1
PACERONE ORAL
MINIPRESS 4 TABLET 100 MG, 400 3
minitran 1 MG
minoxidil oral 1 pacerone oral tablet 200
1
moexipril hcl 1 mg
MULTAQ 4 PA pentoxifylline er 1
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
25Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
perindopril erbumine 2 spironolactone-hctz 1
pindolol 1 SULAR 4
PRALUENT 2 PA; ST; QL TARKA 4
PRAVACHOL 4 taztia xt 2
pravastatin sodium 1 TEKTURNA 3
prazosin hcl oral 1 TEKTURNA HCT 3
prevalite 1 telmisartan 2
PRINIVIL 4 telmisartan-hctz 2
PROCARDIA 4 TENORETIC 100 E
PROCARDIA XL 4 TENORETIC 50 E
propafenone hcl 1 TENORMIN E
propafenone hcl er 3 tiadylt er 2
propranolol hcl er 2 TIAZAC 4
propranolol hcl oral 1 TIKOSYN 4
QBRELIS 4 PA TOPROL XL 4
QUESTRAN 4 torsemide 1
QUESTRAN LIGHT 4 trandolapril 1
quinapril hcl 1 trandolapril-verapamil hcl 3
quinapril- er
2
hydrochlorothiazide triamterene-hctz 1
ramipril 1 TRIBENZOR E
RANEXA E TRICOR E
ranolazine er 2 TRILIPIX E
RECTIV 3 QL valsartan 2
REPATHA 2 PA; ST; QL valsartan- 1
REPATHA SURECLICK 2 PA; ST; QL hydrochlorothiazide
rosuvastatin calcium 2 QL VASCEPA ORAL 4 PA
CAPSULE 0.5 GM
RYTHMOL SR 4
VASCEPA ORAL 3 PA
simvastatin oral tablet 10 CAPSULE 1 GM
1 H-PA
mg, 20 mg, 40 mg, 5 mg
VASERETIC E
simvastatin oral tablet 80 1 VASOTEC E
mg
sotalol hcl (af) 1 verapamil hcl er oral
capsule extended
sotalol hcl oral 1 3
release 24 hour 100 mg,
SOTYLIZE 4 PA 200 mg, 300 mg
spironolactone oral 1
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
26Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
verapamil hcl er oral COTEMPLA XR-ODT E PA; QL
capsule extended 1 DAYTRANA E PA; QL
release 24 hour 120 mg,
180 mg, 240 mg, 360 mg DEXEDRINE E PA
verapamil hcl er oral dexmethylphenidate hcl 1 PA
1
tablet extended release dexmethylphenidate hcl
3 PA; QL
verapamil hcl oral 1 er
VERELAN 4 dextroamphetamine
3 PA
sulfate er
VERELAN PM 4
dextroamphetamine 1 PA
VYTORIN E
sulfate oral solution
WELCHOL 2
dextroamphetamine 3 PA
ZESTORETIC E sulfate oral tablet
ZESTRIL E DYANAVEL XR E PA; QL
ZETIA E EVEKEO E PA
ZIAC ORAL TABLET 10- EVEKEO ODT E PA; QL
3
6.25 MG, 2.5-6.25 MG FOCALIN 4 PA
ZIAC ORAL TABLET 5- 4 FOCALIN XR E PA; QL
6.25 MG
guanfacine hcl er 2 QL
ZOCOR 4
INTUNIV E QL
Central Nervous
System Agents - Drugs JORNAY PM E PA; QL
for Attention Deficit KAPVAY E
Disorder 4 PA; QL
metadate er
ADDERALL E PA 4 PA
METHYLIN
ADDERALL XR 2 QL
methylphenidate hcl er
2 PA; QL
ADHANSIA XR E PA; QL (cd)
ADZENYS ER E PA; QL methylphenidate hcl er
ADZENYS XR-ODT E PA; QL (la) oral capsule
extended release 24 hour 2 PA; QL
AMPHETAMINE ER 4 PA; QL
10 mg, 20 mg, 30 mg, 40
amphetamine sulfate E PA mg
amphetamine- methylphenidate hcl er
1 PA
dextroamphetamine (la) oral capsule 2 PA
amphetamine- extended release 24 hour
E QL 60 mg
dextroamphetamine er
APTENSIO XR E PA; QL methylphenidate hcl er
(xr) capsule extended E PA; QL
atomoxetine hcl 3 QL
release 24 hour 10 mg
clonidine hcl er E oral
CONCERTA 2 PA; QL
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
27Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
METHYLPHENIDATE methylphenidate hcl er
HCL ER (XR) CAPSULE E PA; QL (xr) capsule extended E PA; QL
EXTENDED RELEASE release 24 hour 60 mg
24 HOUR 10 MG ORAL oral
methylphenidate hcl er METHYLPHENIDATE
(xr) capsule extended HCL ER (XR) CAPSULE
E PA; QL E PA; QL
release 24 hour 15 mg EXTENDED RELEASE
oral 24 HOUR 60 MG ORAL
METHYLPHENIDATE methylphenidate hcl er
HCL ER (XR) CAPSULE oral tablet extended 4 PA; QL
E PA; QL
EXTENDED RELEASE release 10 mg, 20 mg
24 HOUR 15 MG ORAL methylphenidate hcl er
methylphenidate hcl er oral tablet extended E PA; QL
(xr) capsule extended release 18 mg, 27 mg, 36
E PA; QL
release 24 hour 20 mg mg, 54 mg, 72 mg
oral methylphenidate hcl er
METHYLPHENIDATE oral tablet extended E PA; QL
HCL ER (XR) CAPSULE E PA; QL release 24 hour
EXTENDED RELEASE methylphenidate hcl oral
24 HOUR 20 MG ORAL 1 PA
solution
methylphenidate hcl er methylphenidate hcl oral
(xr) capsule extended 1 PA
E PA; QL tablet
release 24 hour 30 mg
oral methylphenidate hcl oral
3 PA
tablet chewable
METHYLPHENIDATE
HCL ER (XR) CAPSULE MYDAYIS E PA; QL
E PA; QL
EXTENDED RELEASE PROCENTRA 3 PA
24 HOUR 30 MG ORAL QUILLICHEW ER E PA; QL
methylphenidate hcl er QUILLIVANT XR E PA; QL
(xr) capsule extended E PA; QL relexxii E PA; QL
release 24 hour 40 mg
oral RITALIN 4 PA
METHYLPHENIDATE RITALIN LA E PA; QL
HCL ER (XR) CAPSULE STRATTERA E QL
E PA; QL
EXTENDED RELEASE
VYVANSE 3 PA; QL
24 HOUR 40 MG ORAL
methylphenidate hcl er ZENZEDI E PA
(xr) capsule extended Central Nervous
E PA; QL
release 24 hour 50 mg System Agents - Drugs
oral for Multiple Sclerosis
METHYLPHENIDATE AMPYRA E PA; QL; SP
HCL ER (XR) CAPSULE AUBAGIO 3 PA; QL; SP
E PA; QL
EXTENDED RELEASE
AVONEX PEN 2 PA; QL; SP
24 HOUR 50 MG ORAL
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
28Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
AVONEX PREFILLED 2 PA; QL; SP REBIF TITRATION PA; ST;
4
BAFIERTAM 4 PA; QL; SP PACK QL; SP
BETASERON 2 PA; QL; SP TECFIDERA E PA; QL; SP
E PA; QL; SP Central Nervous
COPAXONE
System Agents -
dalfampridine er 2 PA; QL; SP Miscellaneous
dimethyl fumarate oral 2 PA; QL; SP AUSTEDO 2 PA; QL; SP
dimethyl fumarate starter GRALISE E QL
2 PA; QL; SP
pack
HORIZANT E QL
PA; ST;
E LYRICA 4 PA; ST; QL
EXTAVIA QL; SP
3 PA; QL; SP LYRICA CR E ST; QL
GILENYA
2 PA; QL; SP NUEDEXTA 2 PA
glatiramer acetate
2 PA; QL; SP pregabalin oral capsule 2 QL
glatopa
PA; ST; pregabalin oral solution 3 QL
3
MAVENCLAD (10 TABS) QL; SP RILUTEK 4 SP
PA; ST; riluzole 1 SP
3
MAVENCLAD (4 TABS) QL; SP SAVELLA 4 QL
PA; ST; SAVELLA TITRATION
3 4 QL
MAVENCLAD (5 TABS) QL; SP PACK
PA; ST; TIGLUTIK 4 PA
3
MAVENCLAD (6 TABS) QL; SP
Dental and Oral Agents
PA; ST; - Drugs for Mouth and
3
MAVENCLAD (7 TABS) QL; SP Throat Conditions
PA; ST; cavarest 1
3
MAVENCLAD (8 TABS) QL; SP
cevimeline hcl 1
PA; ST;
3 chlorhexidine gluconate
MAVENCLAD (9 TABS) QL; SP 1
mouth/throat
MAYZENT 3 PA; QL; SP
clinpro 5000 1
MAYZENT STARTER
3 PA; QL; SP denta 5000 plus 1
PACK
3 PA; QL; SP dentagel 1
PLEGRIDY
EVOXAC 4
PLEGRIDY STARTER 3 PA; QL; SP
PACK fluoridex 1
PA; ST; fluoridex enhanced
4 1
REBIF QL; SP whitening
PA; ST; fluoridex sensitivity relief 1
4
REBIF REBIDOSE QL; SP lidocaine hcl 1
REBIF REBIDOSE PA; ST; mouth/throat
4
TITRATION PACK QL; SP lidocaine viscous hcl 1
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
29Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
NAFRINSE acitretin 1
2
DAILY/NEUTRAL ACZONE EXTERNAL
4 QL
NAFRINSE WEEKLY 4 GEL 5 %
oralone 1 ACZONE EXTERNAL
3 QL
paroex 1 GEL 7.5 %
PERIDEX 4 adapalene external E PA; QL
cream
periogard 1
adapalene external gel E PA; QL
pilocarpine hcl oral 1
ADAPALENE E PA
PREVIDENT 5000 EXTERNAL PAD
3
BOOSTER PLUS
ADAPALENE E PA
PREVIDENT 5000 DRY EXTERNAL SOLUTION
4
MOUTH
adapalene-benzoyl
PREVIDENT 5000 E QL
3 peroxide
ENAMEL PROTECT
AKLIEF E PA; QL
PREVIDENT 5000 3
ORTHO DEFENSE ALA SCALP 4
PREVIDENT 5000 PLUS 4 ala-cort external cream 1
E
%
PREVIDENT 5000 3
SENSITIVE ala-cort external cream
1
2.5 %
PREVIDENT DENTAL 4
alclometasone 1
PREVIDENT 3 dipropionate
MOUTH/THROAT
ALDARA 4 QL
SALAGEN 4
ALEVAMAX 4
sf 1
ALTRENO E PA; QL
sf 5000 plus 1
AMELUZ 3
sodium fluoride 5000 1
plus amnesteem 2
sodium fluoride 5000 AMZEEQ 4 PA; QL
1
ppm ARAZLO E QL
sodium fluoride 5000 ATRALIN E PA; QL
1
sensitive avar cleanser 1
sodium fluoride dental 1 AVAR LS CLEANSER E
triamcinolone acetonide AVAR-E EMOLLIENT 3
1
mouth/throat
AVAR-E GREEN 3
Dermatological Agents
- Drugs for Skin AVAR-E LS 3
Conditions avita E PA; QL
ABSORICA E PA azelaic acid external 3
ACANYA E QL AZELEX 3 QL
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
30Requirem Requirem
Drug Drug
Drug Name ents & Drug Name ents &
Tier Tier
Limits Limits
BENZACLIN E QL CALCIPOTRIENE
E QL
BENZACLIN WITH EXTERNAL FOAM
E QL
PUMP calcipotriene external 2
BENZAMYCIN 2 QL ointment
benzoyl peroxide- calcipotriene external 1 QL
1 QL solution
erythromycin
beser external lotion 3 ST; QL calcipotriene-betameth 3 QL
diprop external ointment
betamethasone
dipropionate aug external 1 calcipotriene-betameth
cream diprop external E QL
suspension
betamethasone
dipropionate aug external 1 CALCITRENE 3
gel calcitriol external 1 QL
betamethasone CAPEX 2
dipropionate aug external 3 CARAC 2
lotion
CERACADE E
betamethasone
3 cerovel 1
dipropionate aug external
ointment claravis 2
betamethasone CLEOCIN-T EXTERNAL 4 QL
dipropionate external 2 GEL 1 %
cream CLEOCIN-T EXTERNAL
4
betamethasone LOTION
dipropionate external 1 clindacin etz external
lotion 1
swab
betamethasone clindacin-p 1
dipropionate external 2
ointment CLINDAGEL E QL
betamethasone valerate clindamycin phos-
1 benzoyl perox external 3 QL
external cream
gel 1.2-5 %
betamethasone valerate
E QL clindamycin phos-
external foam
benzoyl perox external E QL
betamethasone valerate gel 1-5 %, 1.2-2.5 %
1
external lotion
clindamycin phosphate
betamethasone valerate 3
1 external foam
external ointment
clindamycin phosphate
bp 10-1 1 3
external lotion
BRYHALI E ST; QL clindamycin phosphate
1 QL
calcipotriene external 2 QL external solution
cream clindamycin phosphate 1
external swab
See page 8 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT,
NJ and NY.
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