BLUECROSS BLUESHIELD OF WESTERN NEW YORK FORMULARY 3/ EXCLUSIVE - EXPRESS SCRIPTS
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
BlueCross BlueShield
of Western New York
Formulary 3/
Exclusive
Please bring this guide
with you the next time
you visit your doctor.
If you have questions about your prescription drug benefit, * M G 4 7 9 5 4 G*
visit the Pharmacy Services section of the BlueCross BlueShield web site at
www.bcbswny.com.
MG47954G
(Revise Date 07/01/2018)
A Division of HealthNow New York Inc. An independent licensee of the BlueCross BlueShield Association. The Cross and Shield are
registered trademarks of the BlueCross BlueShield Association.TABLE OF CONTENTS
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Understanding the symbols used
throughout this book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Using this formulary book to help contain costs . iv
Save Money on Your Prescription Drugs. . . . . . . . . . . . . . . . . iv
Finding Medications in the Guide . . . . . . . . . . . . . . . . . . . . . . . . v
Section 1 — Therapeutic Drug Categories . . . . . . . . . . 1
Section II — Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
iiThe BlueCross BlueShield of Western New York Formulary 3/Exclusive is a list of drugs to help guide physi-
cians and pharmacists to select the medication that provides the appropriate treatment for the
best price.
Introduction
BlueCross Blue Shield of Western New York has established an independent committee of practicing physicians
and a pharmacist to help ensure that our formularies are medically sound and that they support your patients’
health. This committee—called the Pharmacy and Therapeutics Committee—reviews and evaluates medications
on the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories.
Understanding the symbols used throughout this book
Throughout this book, you will see certain symbols that indicate a management program is in place for selected
medications. The symbols are as follows:
Key
P = step edit applies to this drug. Step therapy means that in order to receive the medication
A
with a step edit, a preferred medication must be tried first.
z = Specific quantity limits apply. Quantity limits are in place to ensure members receive the
appropriate amount of medication not to exceed the maximum allowable daily dosage of
medication.
= Prior authorization required. Prior authorization (also referred to as coverage review)
means that a healthcare professional must submit clinical documentation to obtain
approval for a member to receive the medication. Prior authorizations ensure medications
are being used appropriately.
u = Included in tablet-splitting program. The medication can be cut in half to obtain the daily
dose of medication (i.e., 20mg daily of simvastatin can be obtained by 1/2 tablet of
simvastatin 40mg). A member will receive a 1-month supply for half their regular 1-month
copay.
+ = Access restricted to specialty pharmacy. Medications must be obtained through a specialty
pharmacy.
o = Customer Home Delivery. The medication should be obtained through the mail service
pharmacy. The medication is subject to a retail refill allowance.
iiiUsing this formulary book to help contain costs
The formulary offers a wide range of outpatient medications.
Because there are over 40,000 Food and Drug Administration (FDA)-approved prescription drugs on the
market, not all tier 3 drugs can be listed in this formulary guide. We have included in this printed for-
mulary guide the drugs that are most commonly prescribed for our members. If you have any questions
regarding coverage of a drug, please call the customer service number on your card.
Save Money on Your Prescription Drugs
Here’s what you can do to save money:
Bring this member guide to your doctor and review the cost-saving information below.
1.
Ask your doctor whether a drug listed in this guide is
2.
right for you.
The amount you pay for a drug is determined by which medication you purchase and to what tier it is
assigned. Some drug plans also exclude certain drugs or classes of drugs from coverage. Please check
your contract or other plan documents if you have a question about your specific drug coverage.
Please refer to your plan documents to confirm your cost share for diabetic drugs and supplies. Cost
share may vary by plan.
Contraceptive Coverage under New York Insurance Law
Contraceptives (for members whose benefits align with contraceptive coverage requirements under
New York Insurance Law): All tier 1 contraceptives are covered at a $0 copayment. Brand-name
contraceptives without a generic equivalent are covered at a $0 copayment. Brand-name contraceptives
with a generic equivalent are covered at the copayment based on your plan design unless deemed
medically necessary by the prescriber. The prescriber must designate “DAW” (Dispense as Written) on
the prescription in order for the brand-name contraceptive with a generic equivalent to be considered
medically necessary and covered at a $0 copayment. Both prescription and over-the-counter (OTC)
products are covered only when prescribed by a licensed health care provider and require a valid
prescription. Please refer to your plan documents to confirm your cost share for contraceptives. Cost
share may vary by plan.
Contraceptives may include implantable rods, intrauterine devices (IUD), shots/injections, oral
contraceptives, patches, vaginal contraceptive rings, diaphragms, sponges, cervical caps, female
condoms, spermicides, and emergency contraceptives. Please see the “Women’s Health” section of this
guide for specific product examples.
* Some plan designs require that you use a Tier 1 generic drug if a generic is available.
Disclaimer: The BlueCross BlueShield of Western New York Medication Guide is subject to change, as we regularly review
medications and existing therapies for inclusion in the BlueCross BlueShield of Western New York Formulary 3/Exclusive.
The tier that a medication is currently in may change during the effective dates of the guides due to generic availability.
ivFinding Medications in the Guide
This guide lists medications two different ways:
Section 1: Alphabetically by drug category (such as Diabetes, Heart or Pain/Arthritis)
Locate a category and drug on the guide and you will see the tier and copayment for that
drug—Tier 1, Tier 2 or Tier 3—which determines your copayment. To determine if a drug is a
generic or brand-name medication, look at the name of the drug. Generic medications are
lower case (e.g., amoxicillin), and brand-name medications are capitalized (e.g., Advair).
Section 2: Alphabetically by drug name. Use this list to find your drug.
Questions? Please call Pharmacy Services at 1 866 237-0333 if you have any questions about the
BlueCross BlueShield of Western New York Formulary 3/Exclusive. For the most up-to-date version of the
Guide, visit the Pharmacy Services section of our web site at www.bcbswny.com.
vSection I — Therapeutic drug categories
TIER TIER TIER TIER
Allergy/Cough & Cold z tolterodine 1 Hormones Diabetes
Antihistamines & Decongestants z tolterodine ER 1 anastrozole 1 Please refer to your plan documents to confirm your
brompheniramine/ phenylephrine 1 z trospium 1 bicalutamide 1
z trospium ER 1 cost share for diabetic drugs. Cost share may vary
exemestane 1
Pz
brompheniramine/ pseudoephedrine 1
o Detrol 3 by plan.
flutamide 1
Pz
cetirizine 1
Detrol LA 3 Antidiabetic Agents, Injectable
Pz
clemastine 1 letrozole 1
Ditropan XL 3 Basaglar 2
Pz
cyproheptadine 1 leuprolide 1
Enablex 3 z Bydureon 2
Pz
dexchlorpheniramine 1 megestrol 1
Gelnique 3 z Byetta 2
Pz
diphenhydramine 1 tamoxifen 1
Myrbetriq 3 Humalog insulin 2
Pz
zo fexofenadine 1 Fareston 2
Oxytrol 3
Pz
zo fexofenadine-D 1 Miscellaneous Humulin (all types) 2
Sanctura 3
Pz
hydroxyzine HCl 1 etoposide 1 Lantus 2
z
Sanctura XR 3
Pz
hydroxyzine pamoate 1 hydroxyurea 1 Symlin 2
Toviaz 3
Pz +z
zo levocetirizine 1 imatinib 1 Toujeo 2
Vesicare 3
loratadine 1
Cholinergic Agents nilutamide 1 z Victoza 2
loratadine-D 1
Urecholine 3 + temozolamide 1 Pz Adlyxin 3
pseudoephedrine 1
Miscellaneous +z Afinitor 2 P Admelog 3
Semprex-D 2
Jynarque 3 +z Arcalyst 2 P Apidra 3
zo Clarinex-D 3
+z Bosulif 2 P Fiasp 3
zo desloratadine 3 Blood P
z +z Cabometyx 2 Levemir 3
P
Grastek 3 Anticoagulants/Antithrombotics
z z Caprelsa 2 Novolin 3
P
Odactra 3 anagrelide 1
+z Oralair 3 o z Cometriq 2 Novolog 3
z
aspirin-dipyridamole 1
+z Pz Ozempic
o
Ragwitek 3 Cotellic 2 3
z
clopidogrel 1
Expectorant & Cough Products o +z Erivedge 2 Soliqua 3
Pz Tanzeum
dipyridamole 1
benzonatate 1 +z Farydak 2 3
P
enoxaparin 1
guaifenesin/codeine 1 fondaparinux sodium 1 z Gilotrif 2 Tresiba 3
hydrocodone/chlorpheniramine 1 heparin 1 + Hycamtin 2 Pz Trulicity 3
hydrocodone/homatropine 1 jantoven 1 +z Ibrance 2 z Xultophy 3
promethazine/codeine 1 o ticlopidine 1 z Iclusig 2 Antidiabetic Agents, Glucose Elevating Agents
promethazine/DM 1 warfarin 1 z Imbruvica 2 acarbose 1
promethazine/phenylephrine/ codeine 1 Coumadin 2 +z Inlyta 2 chlorpropamide 1
+
pseudoephedrine/codeine 1 Eliquis 2 z glimepiride 1
Intron A 2
Cardec/DM 3
Guaifenesin DM 3
Fragmin 2 +z Iressa 2 glipizide 1
+z
Xarelto 2 z glipizide ER 1
Hycodan 3 Jakafi 2
Bevyxxa 3
Rondec DM/TR 3 o Brilinta 3 z Lenvima 2 z glipizide/metformin 1
Vituz 3 zo Durlaza 3 +z Lonsurf 2 glyburide 1
Mucolytic Agents Innohep 3 z Lynparza 2 glyburide micronized 1
acetylcysteine inh soln. 1 o prasugrel 3 Lysodren 2 metformin 1
Nasal Medications z Pradaxa 3 Matulane 2 z metformin ER (generic Glucophage XR) 1
azelastine nasal spray 1 z Savaysa 3 +z Mekinist 2 z metformin/glyburide 1
budesonide nasal spray 1 zo Zontivity 3 Mesnex 2 z nateglinide 1
Clarispray 1 Other Blood Modifiers +z Nexavar 2 z pioglitazone/metformin 1
Flonase Allergy Relief 1 o cilostazol 1 +z Ninlaro 2 z repaglinide 1
Flonase Sensimist 1 pentoxifylline 1 +z Odomzo 2 tolazamide 1
zo fluticasone nasal spray 1 z trientine 1 +z Pomalyst 2 tolbutamide 1
ipratropium nasal spray 1 +z Actimmune 2 +z Sprycel 2 z Avandamet 2
z Nasacort Allergy 24HR 1 + Aranesp 2 + Stivarga 2 z Avandaryl 2
Rhinocort Allergy 1 + Exjade 2 +z Avandia 2
o
Sutent 2 z
+z
triamcinolone nasal spray 1 + Jadenu 2 Duetact 2
+
Sylatron 2 z
Atrovent Nasal Spray 3 Leukine 2
o z
Pzo Beconase AQ Synribo 2 Glucagon 2
3 Miacalcin inj. 2
Dymista 3 Neulasta 2 +z Tafinlar 2 z Invokamet/XR 2
zo flunisolide nasal spray 3 + Neupogen 2 +z Tagrisso 2 z Invokana 2
Pzo mometasone nasal spray 3 + Procrit 2 +z Tarceva 2 z Janumet 2
Pzo Nasacort AQ 3 +z Promacta 2 +z Tasigna 2 z Janumet XR 2
Pzo Omnaris 3 +z Revlimid 2 + Thalomid 2 z Januvia 2
Pzo Qnasl 3 + Alprolix 3 +z Tykerb 2 z Jardiance 2
z Xhance 3 + Eloctate 3 z Valchlor 2 Jentadueto 2
Pzo Zetonna 3 z Endari 3 +z Votrient 2 z Jentadueto XR 2
Alzheimer Agents + Epogen 3 +z Xalkori 2 Juvisync 2
Ferriprox 3 +z Xtandi 2 z Synjardy/XR 2
zo donepezil 1 + Granix 3 +z Zelboraf 2 Tradjenta 2
ergoloid mesylates 1 + Hemlibra 3 +z Zolinza 2 Afrezza 3
zo galantamine 1 Pz
z
Mircera 3 Farxiga 3
galantamine ER 1 Zydelig 2
Pz
zo Omontys 3
zo memantine 1 z +z Zykadia 2 Fortamet 3
Pz
Zarxio 3
zo rivastigmine 1 z Zontivity 3 + Zytiga 2 Glumetza 3
zo rivastigmine patch 1 +z Alecensa 3 z Glyxambi 3
zo memantine ER 3 Cancer Drugs +z Alunbrig 3 P Kazano 3
z Namzaric 3 Alkylating Agents z Calquence 3 P Kombiglyze XR 3
Bladder/Kidney cyclophosphamide 1 +z Erleada 3 Pz metformin ER (except generic
Alkeran 2 +z Idhifa 3 Glucophage XR) 3
Acidifiers CeeNu 2 +z Kisqali 3 miglitol 3
P
K-Phos 3 Emcyt 2 +z Nerlynx 3 Nesina 3
P
Alkalinizers
+z
Hexalen 2
citric acid/sod citrate 1 Rubraca 3 Onglyza 3
P
Leukeran 2
potassium citrate 1 z Rydapt 3 Oseni 3
Myleran 2
Oracit 3 Antimetabolites + Temodar 3 z Qtern 3
Analgesics + capecitabine 1 z Venclexta 3 repaglinide/metformin 3
phenazopyridine 1 mercaptopurine 1 +z Verzenio 3 Riomet solution 3
Anticholinergics methotrexate 1 z Zejula 3 Pz Segluromet 3
z oxybutynin 1 Purixan 2 Rexinoids Pz Steglatro 3
z oxybutynin ER 1 Trexall 3 + bexarotene 1 z Steglujan 3
z Oxytrol for Women 1 z Xatmep 3 + Targretin gel 2 Pz Xigduo XR 3
KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program
z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.
= Prior Authorization Required. o = Home Service Delivery.
1Section I — Therapeutic drug categories (cont’d)
TIER TIER TIER TIER
Diabetic Test Strips o Betoptic-S 2 midodrine 1 Hemangeol 3
Please refer to your plan documents to confirm your o Istalol 3 +z Northera 3 Calcium Channel Blockers
Carbonic Anhydrase Inhibitors Anti-Adrenergic Blockers Peripheral o amlodipine 1
o o o
cost share for diabetic supplies. Cost share may vary
dorzolamide 2% eye drops 1 doxazosin 1 cartia XT 1
by plan. Test strips other than OneTouch require o dorzolamide/timolol eye drops 1 o prazosin 1 o diltia XT 1
prior authorization. o Azopt 2 o terazosin 1 o diltiazem 1
OneTouch o o
P
Miotics Cardura XL 3 diltiazem CD/SR/ER/XR 1
Accu-Chek o o
P
pilocarpine 1 Antiarrhythmics felodipine ER 1
Ascensia Breeze
o o
P
Phospholine Iodide 2 amiodarone 1 isradipine 1
Contour o
P
Miscellaneous digoxin 1 nicardipine 1
Freestyle
o o
P
Cystaran 2 disopyramide 1 nifediac CC 1
Precision
o o
P
z Restasis 3 flecainide 1 nifedical XL 1
TRUEtest
Po Rhopressa o o
P
3 mexiletine 1 nifedipine 1
TRUEtrack z Xiidra 3 o procainamide 1 o nifedipine SR 1
Ear Mydriatics o propafenone 1 o nimodipine 1
Anti-infective Agents atropine sulfate ophth 1 o propafenone SR 1 o nisoldipine 1
acetic acid otic 1 homatropine 1 o quinidine gluconate 1 o verapamil/SR 1
acetic acid/aluminum acetate 1 tropicamide 1 o quinidine sulfate SR 1 Dynacirc/CR 3
ciprofloxacin otic 1 NSAIDs o sotalol 1 zo Nymalize 3
ofloxacin otic 1 bromfenac 1 Lanoxin 2 Combination Anti-Hypertensive
Domeboro 3 diclofenac 1 dofetilide 3 zo amlodipine/atorvastatin 1
Xtoro 3 flurbiprofen ophth 1 o Multaq 3 o amlodipine/benazepril 1
Anti-infective/Anti-inflammatory combinations ketorolac tromethamine 1 o Norpace CR 3 o atenolol/chlorthalidone 1
acetic acid HC otic 1 Nevanac 2 Antilipidemics o benazepril/HCTZ 1
neomycin/polymyxin/HC otic 1 Acular PF 3 zuo atorvastatin calcium 1 o bisoprolol/HCTZ 1
Ciprodex 2 Prolensa 3 o cholestyramine 1 Pzo candesartan/HCTZ 1
Cipro HC 3 Prostaglandin Analogues/Prostamines o colestipol 1 o captopril/HCTZ 1
bimatoprost 0.03% 1 o fenofibrate 1 o enalapril/HCTZ 1
Eye o latanoprost 1 o fenofibric acid, tab 1 o fosinopril/HCTZ 1
Antiallergy Agents (Eye) o travoprost 1 o gemfibrozil 1 zo irbesartan/HCTZ 1
azelastine ophth 1 P Izba 3 zuo lovastatin 1 o lisinopril/HCTZ 1
cromolyn ophth 1 Po Lumigan 3 o niacin ER 1 zo losartan/HCTZ 1
olopatadine ophth 1 Po Rescula 3 zo niacin/simvastatin 1 o methyldopa/HCTZ 1
Alomide 3 Po Travatan Z 3 zuo pravastatin 1 o metoprolol/HCTZ 1
Bepreve 3 Po Vyzulta 3 zo rosuvastatin 1 o propranolol/HCTZ 1
ketotifen opthalmic solution 3 Po Xalatan 3 zuo simvastatin 1 o quinapril/HCTZ 1
Pataday 3 Po Zioptan 3 o Advicor 2 zo telmisartan/HCTZ 1
Pazeo 3 Sympathomimetics o Colestid 2 zo valsartan/HCTZ 1
Zaditor 3 o brimonidine 1 +z Kynamro 2 Pzo Tekturna 2
Zerviate 3 o Alphagan P 0.1% 2 Pzo Altoprev 3 Pzo Tekturna HCT 2
Anti-infective Agents Vasoconstrictors Po Antara 3 zo amlodipine/valsartan 3
bacitracin ophth 1 naphazoline 1 Pzuo Crestor 3 zo amlodipine/valsartan/HCTZ 3
bacitracin/polymyxin 1 phenylephrine ophth 1 z Epanova 3 Pzo Amturnide 3
ciprofloxacin ophth 1 Gout zo ezetimibe 3 Pzo Atacand HCT 3
erythromycin ophth 1 zo ezetimibe-simvastatin 3 Pzo Avalide 3
gatifloxacin 1 allopurinol 1 Po Fenoglide 3 Pzo Benicar HCT 3
gentamicin ophth 1 colchicine/probenecid 1 Po Fibricor 3 zo Byvalson 3
neomycin/bacitracin/poly B 1 probenecid 1 zo fenofibric acid, capsule, delayed Pzo Diovan HCT 3
ofloxacin ophth 1 Colcrys 2 release 3 Pzo Edarbyclor 3
polymyxin B/TMP 1 z Duzallo 3 zo fluvastatin 3 Pzo Hyzaar 3
sulfacetamide 10% 1 z Mitigare 3 z Pzo Micardis HCT
1 Pz
Juxtapid 3 3
tobramycin soln Uloric 3 Pzuo Lescol
2 Pz
3 zo olmesartan/amlodipine 3
Tobrex ointment Zurampic 3 Pzo Lescol XL 3 zo olmesartan/amlodipine/HCTZ 3
Vigamox 2 Heart Pzuo Lipitor 3 zo olmesartan/HCT 3
Azasite 3 Angiotensin Converting Enzyme Inhibitors Po Lipofen 3 zo Prestalia 3
Besivance 3 o benazepril 1 Po Livalo 3 zo telmisartan/amlodipine 3
Ciloxan 3 o captopril 1 Pzuo Mevacor 3 o trandolapril/verapamil 3
Tobrex solution 3 o enalapril 1 z omega-3 acid ethyl esters 3 Pzo Valturna 3
Anti-inflammatory o fosinopril 1 Pz Nikita 3 Diuretics
fluorometholone ophth 1 o lisinopril 1 z Omtryg 3 o acetazolamide 1
prednisolone acetate 1 o moexipril 1 +zo Praluent 3 o acetazolamide ER 1
prednisolone sod phosphate 1 o perindopril 1 Pzuo Pravachol 3 o amiloride 1
FML Forte 2 o quinapril 1 +zo Repatha 3 o amiloride/HCTZ 1
FML S.O.P. 2 o ramipril 1 Po Tricor 3 o bumetanide 1
Lotemax 2 o trandolapril 1 Po Triglide 3 o chlorothiazide 1
Pred Mild 2 zo Epaned 3 Vascepa 3 o chlorthalidone 1
Flarex 3 zo Qbrelis 3 o Welchol 3 o furosemide 1
Maxidex 3 Angiotensin II Antagonists Pzuo Zocor 3 o hydrochlorothiazide 1
Anti-inflammatory/Anti-infective combinations zo candesartan 1 Pzo Zypitamag 3 o indapamide 1
dexameth/neomycin/poly B 1 zo eprosartan 600mg 1 Beta Blockers o methazolamide 1
neomycin/bacitracin/poly B/HC 1 zo irbesartan 1 o acebutolol 1 o methyclothiazide 1
sulfacetamide/prednisolone ophth 1 zo losartan 1 o atenolol 1 o metolazone 1
tobramycin/dexameth 1 zo telmisartan 1 betaxolol 1 o spironolactone 1
Tobradex ointment 2 zo valsartan 1 o bisoprolol 1 o spironolactone/HCTZ 1
Maxitrol ophth 3 Pzo Atacand 3 o carvedilol 1 o torsemide 1
Pred-G 3 Pzo Avapro 3 o carvedilol ER 1 o triamterene/HCTZ 1
Zylet 3 Pzo Benicar 3 o labetalol 1 zo Carospir 3
Antiviral Pzo Cozaar 3 o metoprolol 1 Miscellaneous Cardiovascular Agents
z famciclovir ophth 1 Pzo Diovan 3 o metoprolol ER 1 zo eplerenone 1
trifluridine 1 Pzo Edarbi 3 o metoprolol/HCTZ 1 +z Berinert 2
Beta-Blockers (Eye) Pzo Micardis 3 o nadolol 1 +z Cinryze 2
o betaxolol HCl 1 Pz Prexxartan 3 o pindolol 1 +z Firazyr 2
o carteolol 1 Anti-Adrenergic Blockers Centrally acting o propranolol 1 o Ranexa 2
o levobunolol 1 o clonidine, oral, patch 1 o timolol 1 +z Ruconest 2
o metipranolol 1 o guanfacine 1 o Innopran XL 2 +z Samsca 2
o timolol 1 o methyldopa 1 o Bystolic 3 zo Corlanor 3
KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program
z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.
= Prior Authorization Required. o = Home Service Delivery.
2Section I — Therapeutic drug categories (cont’d)
TIER TIER TIER TIER
zo Entresto 3 Prezcobix 2 Ecoza 3 + Tobi 3
+z Haegarda 3 Prezista 2 z Lamisil Oral 3 Vancocin 3
Vecamyl 3 Viracept 2 Luzu 3 z Xifaxan 3
Pulmonary Arterial Hypertension Protease Inhibitors Combinations z Noxafil 3 Men’s Health
+z sildenafil citrate 20mg 1 Kaletra 2 Oravig 3
+z Adcirca 2 Huntington’s Disease Antimalarials Impotence - possible contract exclusion; refer to
+z Letairis 2 atovaquone/proguanil HCl 1 individual contract
+z Tracleer 2 z Austedo 3 chloroquine phosphate 1 z Caverject 3
z
+z Uptravi 2 Ingrezza 3 mefloquine 1 zo Cialis 3
+z Adempas 3 +z tetrabenazine 3 Daraprim 2 z Edex 3
+ epoprostenol 3 Immunosuppressants Primaquine 2 zo Levitra 3
+z Opsumit 3 azathioprine 1 quinine sulfate 3 z MUSE 3
+ Orenitram 3 cyclosporine 1 Antituberculosis zo sildenafil citrate 25mg, 50mg, 100mg 3
+z Tyvaso 3 gengraf 1 o ethambutol 1 zo Staxyn 3
+z veletri 3 mycophenolate mofetil 1 o isoniazid 1 zo Stendra 3
+z Ventavis 3 mycophenolic acid 1 o pyrazinamide 1 zo Viagra 3
Vasodilators sirolimus 1 o rifabutin 1 Male Hormones
o hydralazine 1 tacrolimus 1 o rifampin 1 testosterone cypionate 1
o isosorbide dinitrate 1 Neoral 2 Coartem 2 testosterone enanthate 1
o o z Androgel 2
P
isosorbide mononitrate 1 Rapamune solution 2 Rifater 2
o isosorbide mononitrate SA 1 Sandimmune 2 o Rifamate 3 Androderm patch 3
o isoxsuprine 1 Astagraf XL 3 o Sirturo 3 Android 3
o Cellcept 3 fluoxymesterone 3
Pz
minoxidil oral 1 Antivirals
Envarsus XR 3 Axiron 3
Pz
nitroglycerin pumpspray 1 z z acyclovir oral 1
Prograf 3 o Fortesta 3
Pz
nitroglycerin SR 1 amantadine 1
Zortress 3 Natesto 3
P
nitroglycerin transdermal patch 1 z famciclovir 1
o Striant 3
Pz
Dilatrate SR 2 Infection ganciclovir 1
Testim 3
Pz
Nitrostat SL tabs 2 +z moderiba 1
Antibacterial Agents/Antibiotics Testosterone gel (brand) 3
Pz
Gonitro 3 oseltamivir 1
+
Minitran 3 amoxicillin 1 Vogelxo 3
ribapak 1
NitroDur patches 3 amoxicillin-clavulanate ER 1 + ribasphere 1 Prostate Health
+
ampicillin 1 zo alfuzosin 1
HIV - Antivirals ribavirin 1
azithromycin suspension 1 zo finasteride 5mg 1
o
rimantadine 1
Non-Nucleoside Reverse Transcriptase Inhibitor azithromycin tablets 1 tamsulosin 1
Pzo dutasteride
z valacyclovir 1
efavirenz 1 cefaclor 1 3
o
valganciclovir tablets 1
+Pz Daklinza
Atripla 2 cefadroxil 1 dutasteride/tamsulosin 3
Po Flomax
cefdinir 1 2
Edurant 2 +z 3
Pzo Proscar
cefpodoxime 1 Epclusa 2
Intelence 2 3
Po Rapaflo
cefprozil 1 Epivir-HBV solution 2
Rescriptor 2 +z 3
Pzo Uroxatral
cefuroxime 1 Harvoni 2
Viramune, XR 2 z Hepsera 2 3
cephalexin 1
Nucleoside Analog Reverse Transcriptase Inhibitor
ciprofloxacin 1 +z Mavyret 2 Mental Health
Combination
clarithromycin susp 1 +z Olysio 2 Antidepressants
abacavir/lamivudine/zidovudine 1
clarithromycin tabs 1 + Pegasys 2 amitriptyline 1
lamivudine/zidovudine 1 Relenza 2 amitriptyline/ chlordiazepoxide 1
clindamycin 1
tenofovir 300mg 1
dicloxacillin 1 +z Sovaldi 2 amitriptyline/perphenazine 1
Biktarvy 2 + Victrelis 2 amoxapine 1
+Pz Viekira
Cimduo 2 doxycycline 1
2 bupropion 1
+Pz Viekira XR
Complera 2 erythromycin base 1
erythromycin ethylsuccinate 1 2 bupropion 12HR 1
Descovy 2 Baraclude solution 3 bupropion 24HR 1
Dutrebis 2 erythromycin stearate 1
erythromycin/sulfisoxazole 1 entecavir tablets 3 citalopram 1
+P Peg-Intron
u
Odesfey 2 3 clomipramine 1
levofloxacin 1
Stribild 2
minocycline 1 z Prevymis tablets 3 desipramine 1
Symfi 2
nitrofurantoin 1 + Rebetol 3 desvenlafaxine succinate ER 1
Symfi Lo 2
ofloxacin 1 + Ribatab 3 doxepin 1
Triumeq 2 penicillin VK 1 z Sitavig 3 duloxetine 1
Truvada 2 sulfamethoxazole/trimethoprim 1 +Pz Technivie 3 u escitalopram 1
Viread 150mg, 200mg, 250mg, tetracycline 1 z Tyzeka 3 u fluoxetine 10mg and 20mg tablet 1
40mg/scoop powder 2 Ery-Tab 2 valganciclovir solution 3 fluoxetine capsule 1
Nucleoside Reverse Transcriptase Inhibitors Ketek 2 z Valtrex 3 u fluvoxamine tablet 1
abacavir-lamivudine 1 Zmax 2 z Vemlidy 3 imipramine 1
didanosine 1 Acticlate 3 +z Vosevi 3 maprotiline 1
+Pz Zepatier
z
lamivudine tabs 1 Baxdela 3 3 u mirtazapine 1
stavudine 1 Biaxin XL 3 Other Anti-Infectives nefazodone 1
zidovudine 1 Ceftin 3 atovaquone 1 nortriptyline 1
Emtriva 2 Cleocin 3 dapsone tablets 1 u paroxetine 1
Epivir solution 2 erythromycin estolate 3 z linezolid 1 phenelzine 1
Videx 2 Factive 3 methenamine combination 1 protriptyline 1
Ziagen 2 Minocin 3 metronidazole 1 u sertraline 1
Other moxifloxacin 3 neomycin 1 tranylcypromine 1
+ Fuzeon 2 Noroxin 3 nitrofurantoin 1 trazodone 1
Genvoya 2 PCE 3 paromomycin 1 u venlafaxine 1
Isentress 2 Spectracef 3 tinidazole 1 venlafaxine ER 1
Juluca 2 Suprax 3 + tobramycin ampule/neb 1 Pu Celexa 3
Selzentry 2 Vibramycin 3 trimethoprim 1 P Desvenlafaxine ER 3
Tivicay 2 Antifungals vancomycin caps 1 P Desvenlafaxine fumarate ER 3
Tybost 2 clotrimazole lozenge 1 Firvanq 2 Fetzima 3
Vitekta 2 fluconazole 1 Nebupent 2 P fluoxetine 60mg tablet 3
Protease Inhibitors flucytosine 1 z Sivextro 2 P fluvoxamine ER capsule 3
atazanavir 1 griseofulvin 1 + Tobi Podhaler 2 Forfivo 3
ritonavir tablet 1 z itraconazole 1 + Bethkis 3 P Khedezla 3
Aptivus 2 ketoconazole 1 Cayston 3 Pu Lexapro 3
Crixivan 2 nystatin 1 z Dificid 3 P Luvox CR 3
Evotaz 2 z terbinafine 1 Flagyl/ER 3 zu Oleptro ER 3
Invirase 2 z voriconazole 1 z Impavido 3 Pu Paxil/CR 3
Lexiva 2 z Sporanox suspension 2 + Kitabis Pak 3 P Pexeva 3
Norvir capsule, solution 2 z Cresemba 3 Macrodantin 3 P Pristiq ER 3
KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program
z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.
= Prior Authorization Required. o = Home Service Delivery.
3Section I — Therapeutic drug categories (cont’d)
TIER TIER TIER TIER
Pu Prozac 3 methylphenidate/SR 1 Multiple Sclerosis Agents Oxycontin 3
P Sarafem 3 z modafinil 1 + glatiramer acetate 1 z Roxicet solution 3
Trintellix 3 procentra 1 +z glatopa 1 Pz Subsys 3
Viibryd 3 Pz Adzenys 3 + Avonex 2 z Tylenol/codeine 3
Pu Zoloft 3 P Aptensio XR 3 + Rebif 2 z Vicodin/ES 3
Antimanic Agents Pz armodafinil 3 +z Gilenya 2 Xartemis XR 3
lithium carbonate 1 atomoxetine 3 +z Tecfidera 2 z Xtampza ER 3
Antipsychotic Agents Pz Cotempla XR 3 + Ampyra 3 Zohydro ER 3
aripiprazole 1 Pz Dyanavel XR 3 +z Aubagio 3 Analgesics, Salicylates
chlorpromazine 1 P Focalin XR 3 +P Betaseron 3 o choline mag. trisalicylate 1
clozapine 1 guanfacine ER 3 + Copaxone 3 o diflunisal 1
fluphenazine 1 Pz Mydayis 3 +P Extavia 3 o salsalate 1
haloperidol 1 Pz Quillichew ER 3 +Pz Plegridy 3 zo Yosprala 3
loxapine 1 Quillivant XR 3 Anti-Rheumatic
z olanzapine 1 P Vyvanse 3 Muscle Relaxants o hydroxychloroquine 1
perphenazine 1 Miscellaneous baclofen 1 leflunomide 1
z quetiapine 1 carisoprodol 1 methotrexate 1
z risperidone 1 Antidiuretic Agents carisoprodol/ASA 1 +z Actemra 2
z risperidone m-tab 1 desmopressin solution 1 chlorzoxazone 1 oz Cuprimine 2
thioridazine 1 desmopressin tabs 1 cyclobenzaprine 1 +z Enbrel 2
thiothixene 1 Stimate 2 dantrolene sodium 1 +z Humira 2
trifluoperazine 1 DDAVP nasal spray 3 metaxalone 1 +z Otezla 2
ziprasidone caps 1 DDAVP sol, tab 3 methocarbamol 1 o Ridaura 2
z
z
Pz Abilify 3 Noctiva 3 orphenadrine 1 +z Xeljanz 2
P Fanapt 3 Other CNS tizanidine 1 +z Xeljanz XR 2
Fazaclo 3 acamprosate calcium tablet EC 1 Osteoporosis +Pz Cimzia 3
Pz Geodon 3 buprenorphine 1 oz Depen 3
Pz +zo Kevzara
buprenorphine-naloxone 1 zo alendronate 1
Invega 3 3
Pz z
disulfiram 1 zo calcitonin-salmon 1
Latuda 3 Kineret 3
+Pz Orencia SC
fortical NS 1
+z naltrexone 1 zo
Nuplazid 3 3
riluzole 1 zo ibandronate tabs 1
z olanzapine/fluoxetine 3 Otrexup 3
Pz z Narcan Nasal Spray 2 zo raloxifene 1
+z
paliperidone 3 Rasuvo 3
+Pz Simponi
Suboxone film 2 Forteo 2
+z
z quetiapine fumarate ER 3 3
Pz Bunavail 3 Tymlos 2
Rexulti 3 Pzo Cox-2s
Pz Campral dosepack 3 Actonel 3
Risperdal 3 Pzo zo celecoxib 3
Pz Evzio 3 Atelvia 3
Pzo
Saphris 3 z Migraine (Analgesics, Non-narcotic)
Pz z Gralise 3 Binosto 3
Seroquel 3
Pz Horizant Pzo butalbital/APAP 1
Pz 3 Boniva 3
Seroquel XR 3 Pzo butalbital/APAP/caffeine 1
Pz Savella 3 Fosamax 3
Symbyax 3 Pzo butalbital/aspirin/caffeine 1
P Zubsolv 3 Fosamax D 3
Versacloz 3 z dihydroergotamine mesylate 1
Pz
zo risedronate 150mg 3
Pzo
Vraylar 3 Other Endocrine z eletriptan 1
Pz danazol 1 risedronate DR 3
Zyprexa 3 ergotamine/caffeine 1
Pz Zyprexa Zydis 3 fludrocortisone 1 Pain/Arthritis isometh/dichloralphen/APAP 1
Anxiolytics, Sedatives, and Hypnotics + octreotide 1 Analgesics, Narcotic z naratriptan 1
alprazolam/ER 1 +z Cerdelga 2 z acetaminophen w/codeine 1 z rizatriptan 1
buspirone 1 +z Egrifta 2 z belladonna & opium supp 1 z sumatriptan 1
chloral hydrate 1 +z HP Acthar Gel 2 z butalbital/APAP/codeine 1 tramadol/ER tablet 1
chlordiazepoxide 1 + Norditropin 2 z butalbital/aspirin/codeine 1 tramadol/acetaminopen 1
clorazepate 1 +o Sensipar 2 butorphanol NS 1 zolmitriptan 1
P
z z
diazepam 1 Synarel 2 z codeine sulfate 1 Ergomar 2
estazolam 1 Zavesca 2 endocet 1 Pz Amerge 3
+P Genotropin
z
flurazepam 1 3 z fentanyl lozenge 1 Pz Axert 3
lorazepam 1 +P Humatrope 3 fentanyl patch 1 Cafergot 3
meprobamate 1 + Increlex 3 z hydrocodone/APAP 1 z Cambia 3
oxazepam 1 z Myalept 3 z hydrocodone/ibuprofen 1 Pz Frova 3
temazepam 1 +z Natpara 3 hydromorphone 1 Pz Imitrex 3
+P Nutropin/AQ
z
triazolam 1 3 meperidine 1 Pz Maxalt 3
+P Omnitrope
z
z zaleplon 1 3 methadone 1 Pz Maxalt MLT 3
z zolpidem 1 +P Saizen 3 morphine SR 1 Pz Onzetra 3
z zolpidem ER 1 + Sandostatin 3 z morphine sulfate ER 1 Pz Relpax 3
z Xyrem 2 + Sandostatin LAR 3 morphine tab, soln, supp 1 z Sumavel 3
Pz Ambien 3 +P Serostim 3 z oxycodone 1 tramadol ER capsule 3
Pz Ambien CR 3 + Somatuline Depot 3 z oxycodone/acetaminophen 1 Pz Treximet 3
Ativan 3 +z Somavert 3 oxycodone/aspirin 1 +Pz Zecuity 3
+P Tev-Tropin
z
Pz Belsomra 3 3 oxycodone/ibuprofen 1 Pz Zembrace 3
+P Zorbtive
z
Pz Edluar 3 3 oxymorphone/ER 1 Pz Zomig 3
Pz eszopiclone 3 Other Miscellaneous z pentazocine/naloxone 1 Pz Zomig Nasal 3
z Hetlioz 3 +z Keveyis 2 Pz Abstral 3 Pz Zomig ZMT 3
Pz Intermezzo 3 z Signifor 2 Pz Actiq 3 Nonsteroidal Anti-Inflammatory/Combination
Librium 3 Carbaglu 3 z Belbuca 3 Products
P Rozerem 3 Cystadane 3 Buprenorphine TD patch 3 o diclofenac potassium 1
Pz Silenor 3 + Cystagon 3 Butrans 3 o diclofenac sodium 1
Somnote 3 z Korlym 3 z Demerol 3 z diclofenac sodium gel 1% 1
Pz Sonata 3 Procysbi 3 Embeda 3 o etodolac 1
Pz zolpidem ER sublingual tablet 3 + Ravicti 3 fentanyl patch 37.5mcg/hr, 62.5mcg/hr, o etodolac SA 1
Pz Zolpimist 3 + sodium phenylbutyrate 3 and 87.5mcg/hr 3 o fenoprofen 1
Cerebral Stimulants Strensiq 3 Pz Fentora 3 o flurbiprofen 1
dexmethylphenidate 1 z Veltassa 3 Fioricet/codeine 3 o ibuprofen 1
dexmethylphenidate XR 1 z Xuriden 3 Fiorinal/codeine 3 o indomethacin 1
dextroamphetamine tabs 1 Miscellaneous Immunologicals hydromorphone ER 3 o ketoprofen 1
generic Adderall 1 Cuvitru 3 Hysingla ER 3 ketorolac inj. 1
generic Adderall XR 1 + Gammagard Liquid 3 Kadian 3 z ketorolac tab 1
generic Concerta 1 + Gammaked 3 Pz Lazanda 3 o meclofenamate 1
generic Dexedrine spansules 1 + Gamunex-C 3 MorphaBond 3 o meloxicam 1
metadate ER 1 + Hizentra 3 Nucynta/ER 3 o nabumetone 1
methylphenidate CD 1 + HyQvia 3 Oxycodone ER 3 o naproxen/EC 1
KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program
z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.
= Prior Authorization Required. o = Home Service Delivery.
4Section I — Therapeutic drug categories (cont’d)
TIER TIER TIER TIER
o oxaprozin 1 z Spiriva Respimat 2 Skin econazole 1
o piroxicam 1 z Stiolto Respimat 2 ketoconazole 1
o
Acne/Rosacea
sulindac 1 z Symbicort 2 nystatin 1
o
adapalene cream/gel 1
tolmetin 1 z Symdeko 2 amnesteem 1 nystatin/triamcinolone 1
diclofenac sodium 3% gel 3 z Trelegy Ellipta 2 nystop 1
o
avita cream 1
diclofenac sodium/misoprostol 3 Pz Advair diskus 3 oxiconazole 1
Pz
benzoyl peroxide 1
diclofenac sodium topical solution 3 P Advair HFA 3 Exelderm 2
Pz
claravis 1
Duexis 3 Pz AirDuo 3 Oxistat lotion 2
Pz
clindamycin/benzoyl peroxide 1
Flector 3 Anoro Ellipta 3 Jublia 3
o
clindamycin phospate 1 z
mefenamic acid 3 Bevespi 3 Kerydin 3
Pz
z erythromycin/benz peroxide 1 z
Pennsaid 3 P Breo Ellipta 3 minocycline 1 Naftin 3
z Sprix 3 o Daliresp 3 Miscellaneous
o
prascion RA 1
Tivorbex 3 Glassia 3
Pzo Vimovo
+ sodium sulfacetamide 1 aluminum chloride 20% 1
3 Incruse Ellipta 3
Pzo Vivlodex
z sod. sulfacetamide/sulfur emulsion fluorouracil 5% cr/sol 1
3
o
z Lonhala Magnair 3 cleanser 1 fluorouracil 2% sol 1
Zorvolex 3 z Seebri 3 sod. sulfacetamide/sulfur lot 1 imiquimod 5% cream 1
Parkinson’s Disease Tudorza 3 sotret 1 podofilox 1
o benztropine 1 z Utibron 3 tretinoin cr/gel 1 sodium chloride irrigating soln 1
o bromocriptine 1 Sympathomimetics Absorica 3 Carac 2
o carbidopa/levodopa 1 o albuterol sulfate ER 1 P Acanya 3 Panretin 2
o carbidopa/levodopa SA 1 o albuterol tab, syr 1 P Aczone 3 Phisohex 2
o entacapone 1 metaproterenol syr 1 P Adapalene lotion 3 Picato 2
o pramipexole 1 terbutaline tab 1 P Avar 3 Regranex 2
o ropinirole 1 Foradil 2 P Avita gel 3 +z Benlysta SC 3
P
z
selegiline 1 Azelex 3 +z Dupixent 3
P
zo z Maxair Autohaler 2
o trihexyphenidyl 1 Benzaclin 3 Eucrisa 3
P
z ProAir HFA/RespiClick 2
+z Apokyn 3 Benzamycin 3
P
z Serevent Diskus 2 Fluoroplex 3
o carbidopa 3 Arcapta 3 Cleocin T 3 Fluorouracil 0.5% cr 3
z Duopa 3 P
dapsone 5% 3
P
Levalbuterol Tartrate HFA 3 Regenecare 3
z Gocovri 3 Pz
Differin 3
pergolide 3
Proventil HFA 3 P Doryx 3 Psoralens
o
z Striverdi Respimat 3 P methoxsalen capsule 1
Pz
pramipexole ER 3 doxycycline hyclate DR 3
Ventolin HFA 3 P 8-MOP 2
P
rasagiline 3 Doxycycline IR-DR 3
P
zo Xopenex HFA 3
o Duac 3 Scabicides & Pediculicides
ropinirole ER 3
o
Xanthine Derivatives P Duac CS 3 acticin 1
Rytary 3 o aminophylline 1 P Epiduo 3 permethrin 1
o
Tasmar 3
theochron 1 P Evoclin 3 spinosad 1
o
Xadago 3
P
zo
theophylline/SR tabs, liquid 1 Fabior 3 Lindane 2
Potassium o Theo-24 2 P Finacea 3 Ulesfia 2
Potassium agents o Elixophyllin 3 P Metrogel topical 1% 3 Eurax 3
o potassium bicarb/potassium chloride 1 Seizures P minocycline HCl ER 3 Sklice 3
o potassium bicarbonate 1 P Mirvaso 3 Topical Anti-Inflammatory Agents
o potassium citrate ER 1 Barbiturates P Noritate 3 alclometasone 1
o potassium chloride 1 mephobarbital 1 P Onexton 3 amcinonide 1
Potassium Removing agent phenobarbital 1 P Oracea 3 aug. betamethasone diprop 1
sod. polystyrene sulfonate 1 Hydantoins P Retin-A/Micro 3 betamethasone dipropionate 1
o phenytoin 1 P Rhofade 3 betamethasone valerate 1
Respiratory/Asthma o Dilantin 3 P Rosula 3 clobetasol emol/emuls 1
Adrenergic o Peganone 3 P Solodyn 3 clobetasol proprionate
Epinephrine (Impax) 2 Miscellaneous Soolantra 3 foam/gel/oint/cr/sol 1
Epinephrine (Mylan) 2 o carbamazepine 1 P tazarotene cream 3
P
desonide 1
Adrenaclick 3 o carbamazepine XR 200mg, 400mg 1 P Tazorac 3
P
desoximetasone 1
Auvi-Q 3 clonazepam 1 P tretinoin microsphere gel 3
P
diflorasone 1
Epipen/Jr. 3 o divalproex sodium/ER 1 P Veltin gel 3 fluocinolone acetonide 1
Symjepi 3 felbamate 1 P Ziana gel 3 fluocinonide 1
Corticosteroids o gabapentin 1 Antibiotics (Topical)
o
fluticasone propionate 1
budesonide inh. o lamotrigine/ODT 1 clindamycin sol/swabs/gel/lotion 1 halobetasol 1
(0.25mg/2ml, 0.5mg/2ml) 1 o levetiracetam 1 erythromycin sol/swabs/gel 1 halobetasol propionate 1
zo Asmanex 2 o oxcarbazepine 1 gentamicin cr/oint 1 hydrocortisone 2.5% 1
zo Pulmicort flexhaler/powder 2 o metronidazole cream/lotion/ 0.75% gel 1
o
primidone 1 hydrocortisone valerate 1
Pulmicort respules (1mg/2ml) 2 o topiramate 1 mupirocin 1 hydrocortisone/iodoquinol 1
zo Qvar 2 o valproic acid 1 Bactroban cream 3 mometasone cr/oint 1
o
z Aerobid/M 3 Centany 3
Pzo Alvesco P
zonisamide 1 prednicarbate 1
o
3 Xepi 3
Pzo ArmonAir
Tegretol 2 triamcinolone acetonide 1
o
3 Antipsoriatics
Pzo Arnuity Ellipta Aptiom 3 Cordran tape 2
o
3 acitretin 1
Pzo Flovent HFA/Diskus 3 Banzel 3
calcipotriene 1
betamethasone valerate foam 3
z Briviact 3 Capex Shampoo 3
Leukotrienes tacrolimus 1
o z Fycompa 3
+z clobetasol propionate
o
montelukast 1 Cosentyx 2
o zafirlukast 1 lamotrigine ER 3 Dritho-Scalp 2 lotion/shampoo/spray 3
Lyrica 3 Cordran ointment 3
P
zo zileuton ER 3 Elidel 2
Zyflo 3 Lyrica CR 3 Soriatane CK 2 fluocinonide cream (generic Vanos) 3
z
zo
Nuedexta 3 +z Stelara 2 flurandrenolide cream 3
o
Other Agents
cromolyn inh. soln. 1 Oxtellar XR 3 +Pz Tremfya 2 Halog 3
Potiga 3 P calcipotriene-betamethasone ointment 3 hydrocortisone butyrate/emoll cream 3
P
ipratropium inh. soln. 1
ipratropium/albuterol 1 o Qudexy XR 3 calcitriol ointment 3 Impoyz 3
Atrovent HFA 2 + Sabril 3 P Enstilar 3 Kenalog/aerosol 3
o
z
Combivent Respimat 2 Tegretol XR 100mg 3 +Pz Siliq 3 Topical Antipruritics/Anesthetics
o
z
Dulera 2 tiagabine 3 P Taclonex 3 lidocaine 1
o
z
+z Esbriet 2 topiramate ER 3 +Pz Taltz 3 z lidocaine patch 1
z Fluticasone-Salmeterol 2 o Trokendi XR 3 Burn preparation selenium sulf 2.5% suspension 1
z Kalydeco 2 + vigabatrin oral powder 3 silver sulfadiazine 1 Rectiv 3
+z Ofev 2 Vimpat 3 Fungicides Topical Antivirals
z Orkambi 2 Succinimides betamethasone/clotrimazole 1 acyclovir ointment 1
+ Pulmozyme 2 o ethosuximide 1 ciclopirox cream 1 Zovirax Cream 2
z Spiriva 2 o Celontin 3 ciclopirox soln 1 Denavir 3
KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program
z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.
= Prior Authorization Required. o = Home Service Delivery.
5Section I — Therapeutic drug categories (cont’d)
TIER TIER TIER TIER
Smoking Cessation Gallstone Solubilizing Agents o folic acid Rx 1mg tab 1 Prempro 2
o ursodiol 1 leucovorin 1 zo Alora 3
Members coverage varies by plan. Patient should be +z Ocaliva 3 levocarnitine 1 Cenestin 3
in a smoking cessation program. H2 Antagonists o multivitamin + fluoride 1 zo Climara Pro 3
bupropion 1 o cimetidine 1 potassium aminobenzoate 1 o Crinone 3
Nicorelief gum 1 o famotidine 1 o pre-natal vitamins 1 Duavee 3
Nicorelief lozenge 1 o nizatidine 1 sevelamer 1 o Enjuvia 3
Nicotine Gum 1 o ranitidine (all) 1 o sodium fluoride chewable tab & drops 1 zo Estraderm 3
Nicotine lozenges 1 o vit A,D,C + fluoride 1 o estradiol 0.01% cream 3
1 Other Antiulcer o
2 o
Nicotine patches various vit A,D,C + fluoride and iron 1 Estrasorb packet 3
Chantix misoprostol 1 zo
propantheline bromide 1 Galzin 2 zo Estring 3
o
2 o
Commit 2 Mephyton 2 Estrogel 3
sucralfate 1 zo
Nicotrol Inhaler
Helidac 3 o Nascobal 2 o Evamist 3
Nicotrol NS 2 Orfadin 2 Femring 3
lansoprazole/amox/clarith 3 zo
Zyban 3
Other GI Products o phytonadione 2 z Intrarosa 3
Steroids alosetron 1 o Prenate Elite 2 o Menest 3
cortisone acetate 1 balsalazide 1 Renagel 2 zo Menostar 3
dexamethasone oral 1 budesonide EC 1 Auryxia 3 Ortho-Est 3
hydrocortisone oral 1 o cromolyn sodium 1 Fosrenol oral powder 3 Osphena 3
methylprednisolone 4mg, 8mg, 16mg, enulose 1 lanthanum carbonate tablet 3 zo Prefest 3
32mg 1 lactulose 1 paricalcitol 3 o Premarin 3
prednisolone oral 1 mesalamine enema 1 o Poly-Vi-Flor + Iron 3 o Premarin vag cream 3
o
z
prednisone oral 1 o sulfasalazine 1 z Rayaldee 3 progesterone, micronized 3
Medrol 2mg 2 o sulfasalazine EC 1 o Tri-Vi-Flor 3 o yuvafem 3
z Emflaza 3 Cholbam 2 Velphoro 3 Miscellaneous
Rayos 3 + Kuvan 2 Weight Loss - possible contract exclusion; paroxetine 7.5mg 1
Amitiza 3 refer to individual contract z Addyi 3
Stomach/Ulcer z
Oral Contraceptives
Apriso 3 benzphetamine 1 o
Anorectal amethia 1
Asacol HD 3 1 o
hydrocortisone rectal cr. & supp. 1 o diethylpropion amethyst 1
Azulfidine 3 phendimetrazine 1 o
hydrocortisone rectal enema 1 apri 1
Canasa supp. 3 phentermine 1 o
pramoxine/HC acetate 2.5% 1 aranelle 1
Delzicol 3 Belviq 3 o
Analpram-HC 1-1% 3 aviane 1
z
Dipentum 3 Belviq XR 3 o
Analpram-HC 2.5% cr/lot 3 + balziva 1
z
Gattex 3 Contrave 3 o
Cortifoam 3 camila 1
z
Giazo 3 Qsymia 3 o
Proctofoam-HC 3 camrese 1
z
Linzess 3 Saxenda 3 o
Anticholinergics/Antispasmodic/GI Motility cryselle 1
mesalamine DR tablet 1.2g 3 Suprenza ODT 3 o
belladonna/phenobarbital 1 z enpresse 1
Movantik 3 Xenical 3 o
chlordiazepoxide/clindinium 1 Pentasa 3 errin 1
dicyclomine 1 Relistor 3 Women’s Health o jolessa 1
glycopyrrolate 1 z Symproic 3 o jolivette 1
o
Please refer to your plan documents to confirm your
hyoscyamine/CR 1 z Trulance 3 junel/FE 1
cost share for contraceptives. Cost share may vary o kariva 1
metoclopramide 1 Uceris 3
Donnatal tablet 2 z Xermelo 3
by plan. o lessina 1
Contraceptives - Other o levora 1
o
Antidiarrheal
diphenoxylate/atropine
Proton Pump Inhibitors
1 zo xulane 1 o low-ogestrel 1
lansoprazole 1 + Mirena 2 o lutera 1
o
paregoric 1 z
Alinia 2 zo
Nexium 24HR 1 NuvaRing 2 o microgestin/FE 1
3 o
z omeprazole 1
Fulyzaq 2 zo Caya Contoured Diaphragm mononessa 1
pantoprazole 1 Conceptrol 3 my choice 1
Antiemetic/Antivertigo z Prevacid 24HR 1 o
z
Depo-SubQ Provera 3 my way 1
aprepitant 1 z Prilosec-OTC 1 3 o
z
FC2 Female Condom necon 1
granisetron 1 z Zegerid OTC 1 Femcap 3 next choice one dose 1
meclizine 1 zo Nexium susp 2 3 o
z
Kyleena
1 Pzo Aciphex
+ nora-BE 1
ondansetron 3 Liletta 3 o
prochlorperazine 1 Pzo Dexilant 3 Nexplanon 3
norethindrone a-e estradiol/ ferrous
1 Pzo esomeprazole magnesium
+ fumarate 1
promethazine 3 Paragard 3 o
scopolamine patch 1 Pzo Nexium 3 Skyla 3 o
nortrel 1
1 Pzo omeprazole/sodium bicarbonate
+ ocella 1
trimethobenzamide 3 Today Contraceptive Sponge 3 o
2 Pzo Prevacid ogestrel 1
o
Antivert 50mg 3
z 2 Pzo Prilosec Fertility Induction Agents - possible contract portia 1
o
Anzemet 3
z 2 Pzo Protonix exclusion; refer to individual contract previfem 1
1 o
Emend 3
Pz Akynzeo 3 Pzo rabeprazole clomiphene quasense 1
1 o
3
3 Pzo Zegerid progesterone in oil sprintec 1
1 o
z Bonjesta 3 tri-sprintec 1
serophene
2 o
Diclegis 3
z
Thyroid Bravelle trinessa 1
z Granisol 3
o trivora 1
z Cetrotide 2
2 o
Sancuso 3 Antithyroid
3 o Follistim AQ velivet 1
2 o
Syndros methimazole 1
z
3 o
zarah 1
z Novarel
2 o
Varubi propylthiouracil 1
z Ovidrel zenchent 1
2 o
Zuplenz 3 Thyroid
Bowel Evacuants levothroid 1 Repronex zovia 1
peg 3350/electrolyte 1 o levothyroxine 1 Chorionic gonadotropin 3 Ella 3
1 o levoxyl 1 Ganirelix 3 mibelas 24 Fe 3
P
Trilyte
2 o Gonal F 3 Plan B One-Step 3
3 o
Halflytely liothyronine 1
3 o Menopur Quartette 3
3 o
Nulytely thyroid 1
3 o Pregnyl Safyral 3
Prepopik unithroid 1 o
o Hormones Tydemy 3
Suclear 3 Synthroid 2
o zo estradiol/noreth ac 1 Oxytocic Agents
Suprep 3 Thyroid (Armour) 2
o zo estradiol oral 1 methylergonovine maleate 1
Digestants Thyrolar 2 Methergine 3
o Zenpep 2 Vitamins zo estradiol patches 1
Po Creon 3 o zo estropipate 1 Vaginal Preparations
miconazole vag supp 1
Po Pancreaze
calcitriol 1 zo estrogen/methyltesterone 1
3 o nystatin vag tab 1
Po Pertzye
calcitriol inj 1 zo jinteli 1
o
3 terconazole 1
Po Ultresa
calcium acetate 1 medroxyprogesterone 1
o
3 vandazole vag 1
o
cholecalciferol 1 norethindrone 1
Viokace 3 o cyanocobalamin inj. 1 Cleocin Vag/Ovules 3
zo Combipatch 2
o ergocalciferol capsule 1 o Premphase 2 Clindesse 3
o etidronate 1 Gynazole-1 3
KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program
z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.
= Prior Authorization Required. o = Home Service Delivery.
6Section II — Index
DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE
A amoxapine 1 3 zBelbuca 3 4 calcium acetate 1 6 zoClimara Pro 3 6 desvenlafaxine
amoxicillin 1 3 zbelladonna & opium supp 1 4 zCalquence 3 1 clindamycin 1 3 succinate ER 1 3
zCambia
abacavir-lamivudine 1 3
abacavir/lamivudine/ amoxicillin-clavulanate ER 1 3 belladonna/phenobarbital 1 6 3 4 clindamycin phospate 1 5 PzDetrol 3 1
zidovudine 1 3 ampicillin 1 3 PzBelsomra 3 4 ocamila 1 6 clindamycin PzDetrol LA 3 1
PzAbilify 3 4 +Ampyra 3 4 Belviq 3 6 Campral dosepack 3 4 sol/swabs/gel/lotion 1 5 dexameth/neomycin/poly B 1 2
Absorica 3 5 PzoAmturnide 3 2 zBelviq XR 3 6 ocamrese 1 6 clindamycin/ dexamethasone oral 1 6
PzAbstral 3 4 anagrelide 1 1 obenazepril 1 2 Canasa supp. 3 6 benzoyl peroxide 1 5 dexchlorpheniramine 1 1
acamprosate Analpram-HC 1-1% 3 6 obenazepril/HCTZ 1 2 zocandesartan 1 2 Clindesse 3 6 PzoDexilant 3 6
calcium tablet EC 1 4 Analpram-HC 2.5% cr/lot 3 6 PzoBenicar 3 2 Pzocandesartan/HCTZ 1 2 clobetasol emol/emuls 1 5 dexmethylphenidate 1 4
PAcanya 3 5 anastrozole 1 1 PzoBenicar HCT 3 2 +capecitabine 1 1 clobetasol propionate l dexmethylphenidate XR 1 4
acarbose 1 1 PAndroderm patch 3 3 +zBenlysta SC 3 5 Capex Shampoo 3 5 otion/shampoo/spray 3 5 dextroamphetamine tabs 1 4
PAccu-Chek 2 zAndrogel 2 3 PBenzaclin 3 5 zCaprelsa 2 1 clobetasol proprionate diazepam 1 4
oacebutolol 1 2 Android 3 3 PBenzamycin 3 5 ocaptopril 1 2 foam/gel/oint/cr/sol 1 5 zDiclegis 3 6
zacetaminophen Anoro Ellipta 3 5 benzonatate 1 1 ocaptopril/HCTZ 1 2 clomiphene 1 6 diclofenac 1 2
w/codeine 1 4 PoAntara 3 2 benzoyl peroxide 1 5 Carac 2 5 clomipramine 1 3 odiclofenac potassium 1 4
oacetazolamide 1 2 Antivert 50mg 2 6 benzphetamine 1 6 Carbaglu 3 4 clonazepam 1 5 odiclofenac sodium 1 4
oacetazolamide ER 1 2 zAnzemet 2 6 obenztropine 1 5 ocarbamazepine 1 5 oclonidine, oral, patch 1 2 diclofenac sodium 3% gel 3 5
acetic acid HC otic 1 2 PApidra 3 1 Bepreve 3 2 ocarbamazepine XR oclopidogrel 1 1 zdiclofenac sodium gel 1%1 4
acetic acid otic 1 2 +zApokyn 3 5 +zBerinert 2 2 200mg, 400mg 1 5 clorazepate 1 4 Pzdiclofenac sodium
acetic acid/aluminum acetate 1 2 zaprepitant 1 6 Besivance 3 2 ocarbidopa 3 5 clotrimazole lozenge 1 3 topical solution 3 5
acetylcysteine inh soln. 1 1 oapri 1 6 betamethasone ocarbidopa/levodopa 1 5 clozapine 1 4 odiclofenac sodium/
PzoAciphex 3 6 Apriso 3 6 dipropionate 1 5 ocarbidopa/levodopa SA 1 5 Coartem 2 3 misoprostol 3 5
acitretin 1 5 PAptensio XR 3 4 betamethasone valerate 1 5 Cardec/DM 3 1 zcodeine sulfate 1 4 dicloxacillin 1 3
+zActemra 2 4 oAptiom 3 5 betamethasone valerate oCardura XL 3 2 colchicine/probenecid 1 2 dicyclomine 1 6
acticin 1 5 Aptivus 2 3 foam 3 5 carisoprodol 1 4 Colcrys 2 2 didanosine 1 3
zActiclate 3 3 oaranelle 1 6 betamethasone/ carisoprodol/ASA 1 4 oColestid 2 2 diethylpropion 1 6
+zActimmune 2 1 +Aranesp 2 1 clotrimazole 1 5 zoCarospir 3 2 ocolestipol 1 2 PDifferin 3 5
PzActiq 3 4 +zArcalyst 2 1 +PBetaseron 3 4 ocarteolol 1 2 zoCombipatch 2 6 zDificid 3 3
PzoActonel 3 4 Arcapta 3 5 betaxolol 1 2 ocartia XT 1 2 zCombivent Respimat 2 5 diflorasone 1 5
Acular PF 3 2 aripiprazole 1 4 obetaxolol HCl 1 2 ocarvedilol 1 2 zCometriq 2 1 odiflunisal 1 4
acyclovir ointment 1 5 Pzarmodafinil 3 4 +Bethkis 3 3 ocarvedilol ER 1 2 Commit 2 6 digoxin 1 2
zacyclovir oral 1 3 PzoArmonAir 3 5 oBetoptic-S 2 2 zCaverject 3 3 Complera 2 3 zdihydroergotamine mesylate 1 4
PAczone 3 5 PzoArnuity Ellipta 3 5 zBevespi 3 5 Caya Contoured Diaphragm 3 6 Conceptrol 3 6 oDilantin 3 5
adapalene cream/gel 1 5 Asacol HD 3 6 Bevyxxa 3 1 Cayston 3 3 PContour 2 oDilatrate SR 2 3
PAdapalene lotion 3 5 PAscensia Breeze 2 +bexarotene 1 1 CeeNu 2 1 zContrave 3 6 odiltia XT 1 2
+zAdcirca 2 3 zoAsmanex 2 5 Biaxin XL 3 3 cefaclor 1 3
+Copaxone 3 4 odiltiazem 1 2
zAddyi 3 6 oaspirin-dipyridamole 1 1 bicalutamide 1 1 cefadroxil 1 3
Cordran ointment 3 5 odiltiazem CD/SR/ER/XR 1 2
+zAdempas 3 3 Astagraf XL 3 3 Biktarvy 2 3 cefdinir 1 3 PzoDiovan 3 2
PzAdlyxin
Cordran tape 2 5
3 1 PzoAtacand 3 2 bimatoprost 0.03% 1 2 cefpodoxime 1 3
zoCorlanor 3 2 PzoDiovan HCT 3 2
PAdmelog 3 1 PzoAtacand HCT 3 2 PzoBinosto 3 4 cefprozil 1 3
Cortifoam 3 6 Dipentum 3 6
PAdrenaclick 3 5 atazanavir 1 3 obisoprolol 1 2 Ceftin 3 3
cortisone acetate 1 6 diphenhydramine 1 1
PzAdvair diskus 3 5 PzoAtelvia 3 4 obisoprolol/HCTZ 1 2 cefuroxime 1 3
+zCosentyx diphenoxylate/atropine 1 6
PAdvair HFA oatenolol PzoBoniva zocelecoxib 2 5
odipyridamole
+zCotellic
3 5 1 2 3 4 3 4 1 1
PuCelexa odisopyramide
2 1
oAdvicor 2 2 oatenolol/chlorthalidone 1 2 zBonjesta 3 6 3 3
PzCotempla XR
1 2
+zBosulif
3 4
PzAdzenys 3 4 Ativan 3 4 2 1 Cellcept 3 3 disulfiram 1 4
Bravelle oCelontin 3 5 Coumadin 2 1
PzDitropan XL
PzoCozaar
zAerobid/M 3 5 atomoxetine 3 4 2 6 3 1
+zAfinitor zuoatorvastatin calcium 1 odivalproex sodium/ER 1
3 2
2 1 2 PBreo Ellipta 3 5 Cenestin 3 6
PoCreon
5
Afrezza
3 6
3 1 atovaquone 1 3 oBrilinta 3 1 Centany 3 5
zCresemba
dofetilide 3 2
PzAirDuo
3 3
3 5 atovaquone/proguanil HCl 1 3 obrimonidine 1 2 cephalexin 1 3
PzuoCrestor
Domeboro 3 2
PzAkynzeo +zCerdelga 2 4 3 2
zodonepezil
oCrinone
3 6 Atripla 2 3 zBriviact 3 5 1 1
oalbuterol sulfate ER 1 5 atropine sulfate ophth 1 2 bromfenac 1 2 ocetirizine 1 1 3 6
Donnatal tablet 2 6
oalbuterol tab, syr 1 5 zAtrovent HFA 2 5 obromocriptine 1 5 Cetrotide 2 6 Crixivan 2 3
PDoryx 3 5
odorzolamide 2%
Chantix 2 6 cromolyn inh. soln. 1 5
alclometasone 1 5 Atrovent Nasal Spray 3 1 brompheniramine/
+zAlecensa +zAubagio chloral hydrate 1 4 cromolyn ophth 1 2 eye drops 1 2
ocromolyn sodium
3 1 3 4 phenylephrine 1 1
zoalendronate 1 4 chlordiazepoxide 1 4 1 6 odorzolamide/timolol
ocryselle
aug. betamethasone diprop 1 5 brompheniramine/
zoalfuzosin chlordiazepoxide/clindinium 1 6 1 6 eye drops 1 2
ozCuprimine
1 3 Auryxia 3 6 pseudoephedrine 1 1
zAustedo chloroquine phosphate 1 3 2 4 odoxazosin 1 2
Cuvitru
zAlinia 2 6 3 3 budesonide EC 1 6
Alkeran 2 1 PAuvi-Q 3 5 obudesonide inh. ochlorothiazide 1 2 3 4 doxepin 1 3
allopurinol 1 2 PzoAvalide 3 2 (0.25mg/2ml, 0.5mg/2ml) 1 5 chlorpromazine 1 4 ocyanocobalamin inj. 1 6 doxycycline 1 3
Alomide 3 2 zAvandamet 2 1 budesonide nasal spray 1 1 chlorpropamide 1 1 cyclobenzaprine 1 4 Pdoxycycline hyclate DR 3 5
zoAlora 3 6 zAvandaryl 2 1 obumetanide 1 2 ochlorthalidone 1 2 cyclophosphamide 1 1 PDoxycycline IR-DR 3 5
alosetron 1 6 zAvandia 2 1 Bunavail 3 4 chlorzoxazone 1 4 cyclosporine 1 3 Dritho-Scalp 2 5
oAlphagan P 0.1% 2 2 PzoAvapro 3 2 buprenorphine 1 4 Cholbam 2 6 cyproheptadine 1 1 PDuac 3 5
alprazolam/ER 1 4 PAvar 3 5 Buprenorphine TD patch 3 4 cholecalciferol 1 6 Cystadane 3 4 PDuac CS 3 5
+Alprolix 3 1 oaviane 1 6 buprenorphine-naloxone 1 4 ocholestyramine 1 2 +Cystagon 3 4 Duavee 3 6
PzoAltoprev 3 2 avita cream 1 5 bupropion 1 3 ocholine mag. trisalicylate 1 4 Cystaran 2 2 zDuetact 2 1
aluminum chloride 20% 1 5 PAvita gel 3 5 bupropion 1 6 Chorionic gonadotropin 3 6
D PzDuexis 3 5
+zAlunbrig +Avonex zoCialis
+PzDaklinza
3 1 2 4 bupropion 12HR 1 3 3 3 zDulera 2 5
PzoAlvesco PzAxert ciclopirox cream 1 5 2 3
oDaliresp
3 5 3 4 bupropion 24HR 1 3 duloxetine 1 3
oamantadine 1 3 PzAxiron 3 3 buspirone 1 4 ciclopirox soln 1 5 3 5 zDuopa 3 5
PzAmbien 3 4 Azasite 3 2 butalbital/APAP 1 4 ocilostazol 1 1 danazol 1 4 +zDupixent 3 5
PzAmbien CR 3 4 azathioprine 1 3 butalbital/APAP/caffeine 1 4 Ciloxan 3 2 dantrolene sodium 1 4 zoDurlaza 3 1
amcinonide 1 5 azelastine nasal spray 1 1 zbutalbital/APAP/codeine 1 4 Cimduo 2 3 dapsone 5% 3 5 Pzodutasteride 3 3
PzAmerge 3 4 azelastine ophth 1 2 butalbital/aspirin/caffeine 1 4 ocimetidine 1 6 dapsone tablets 1 3 odutasteride/tamsulosin 3 3
oamethia 1 6 PAzelex 3 5 zbutalbital/aspirin/codeine 1 4 +PzCimzia 3 4 Daraprim 2 3 Dutrebis 2 3
oamethyst 1 6 azithromycin suspension 1 3 zbutorphanol NS 1 4 +zCinryze 2 2 DDAVP nasal spray 3 4 zDuzallo 3 2
oamiloride 1 2 azithromycin tablets 1 3 Butrans 3 4 Cipro HC 3 2 DDAVP sol, tab 3 4 PzDyanavel XR 3 4
oamiloride/HCTZ 1 2 oAzopt 2 2 zBydureon 2 1 Ciprodex 2 2 Delzicol 3 6 Dymista 3 1
oaminophylline 1 5 oAzulfidine 3 6 zByetta 2 1 ciprofloxacin 1 3 zDemerol 3 4 Dynacirc/CR 3 2
oamiodarone 1 2 oBystolic ciprofloxacin ophth 1 2 Denavir 3 5
ozDepen
3 2
B E
zAmitiza 3 6 zoByvalson 3 2 ciprofloxacin otic 1 2 3 4
amitriptyline 1 3 bacitracin ophth 1 2 ucitalopram 1 3 oDepo-SubQ Provera 3 6 econazole 1 5
amitriptyline/ bacitracin/polymyxin 1 2 C citric acid/sod citrate 1 1 Descovy 2 3 Ecoza 3 3
chlordiazepoxide 1 3 baclofen 1 4 +zCabometyx 2 1 claravis 1 5 desipramine 1 3 PzoEdarbi 3 2
amitriptyline/perphenazine 1 3 Bactroban cream 3 5 Cafergot 3 4 zoClarinex-D 3 1 zodesloratadine 3 1 PzoEdarbyclor 3 2
oamlodipine 1 2 balsalazide 1 6 calcipotriene 1 5 Clarispray 1 1 desmopressin solution 1 4 zEdex 3 3
zoamlodipine/atorvastatin 1 2 obalziva 1 6 Pcalcipotriene- clarithromycin susp 1 3 desmopressin tabs 1 4 PzEdluar 3 4
oamlodipine/benazepril 1 2 oBanzel 3 5 betamethasone ointment 3 5 clarithromycin tabs 1 3 desonide 1 5 Edurant 2 3
zoamlodipine/valsartan 3 2 Baraclude solution 3 3 zocalcitonin-salmon 1 4 clemastine 1 1 desoximetasone 1 5 efavirenz 1 3
zoamlodipine/ Basaglar 2 1 ocalcitriol 1 6 Cleocin 3 3 PDesvenlafaxine ER 3 3 +zEgrifta 2 4
valsartan/HCTZ 3 2 Baxdela 3 3 ocalcitriol inj 1 6 PCleocin T 3 5 PDesvenlafaxine 8-MOP 2 5
amnesteem 1 5 PzoBeconase AQ 3 1 calcitriol ointment 3 5 Cleocin Vag/Ovules 3 6 fumarate ER 3 3 zeletriptan 1 4
KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program
z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.
= Prior Authorization Required. o = Home Service Delivery.
7Section II — Index (cont’d)
DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE DRUG NAME TIER PAGE
Elidel 2 5 F ofosinopril 1 2 ohydralazine 1 3 Juvisync 2 1 loratadine 1 1
Eliquis 2 1 PFabior ofosinopril/HCTZ 1 2 ohydrochlorothiazide 1 2 zJuxtapid 3 2 loratadine-D 1 1
4 Jynarque
3 5
oElixophyllin 3 5 Factive 3 3 Fosrenol oral powder 3 6 zhydrocodone/APAP 1 3 1 lorazepam 1 4
Ella 3 6 zfamciclovir 1 3 Fragmin 2 1 hydrocodone/ zolosartan 1 2
PFreestyle 2 chlorpheniramine 1 1 K zolosartan/HCTZ 1 2
+Eloctate 3 1
Embeda
zfamciclovir ophth 1 2
3 4 ofamotidine PzFrova 3 4 hydrocodone/homatropine 1 1 K-Phos 3 1 Lotemax 2 2
4 Kadian
1 6 3 4 zuolovastatin
Emcyt 2 1 PFanapt Fulyzaq 2 6 zhydrocodone/ibuprofen 1 1 2
zEmend
3 4 3 olow-ogestrel
ofurosemide 1 2 hydrocortisone 2.5% 1 5 Kaletra 2 1 6
zKalydeco
2 6 Fareston 2 1
zEmflaza 3 6 PzFarxiga +Fuzeon 2 3 hydrocortisone 2 5 loxapine 1 4
5 okariva
3 1 6 PoLumigan
+zFarydak
Emtriva 2 3 zFycompa 3 5 butyrate/emoll cream 3 1 3 2
6 PKazano
2 1 1 olutera
PzEnablex 3 1 Fazaclo 3 4
hydrocortisone oral 1 3 1 6
G 5 PLuvox CR
oenalapril 1 2 hydrocortisone Kenalog/aerosol 3 3 3
oenalapril/HCTZ 1 2
FC2 Female Condom 3 6 ogabapentin 1 5 rectal cr. & supp. 1 6 zKerydin 3 5 Luzu 3 3
+zEnbrel
felbamate 1 5 zogalantamine 1 1 6 Ketek 2 3 zLynparza
ofelodipine ER
2 4 hydrocortisone rectal enema 1 2 1
zEndari 3 1
1 2 zogalantamine ER 1 1 hydrocortisone valerate 1 5 ketoconazole 1 3 Lyrica 3 5
Femcap 3 6 Galzin 2 6 5 ketoconazole 1 5 PLyrica CR
zoFemring
hydrocortisone/iodoquinol 1 3 5
+Gammagard Liquid
zendocet 1 4
4 oketoprofen
3 6
oEnjuvia ofenofibrate
3 4 zhydromorphone 1 1 4 Lysodren 2 1
+Gammaked
3 6 1 2 3 4 hydromorphone ER 4 ketorolac inj. 1 4
zofenofibric acid,
3
+Gamunex-C
enoxaparin 1 1
oenpresse 1 6 3 4 ohydroxychloroquine 1 4 zketorolac tab 1 4 M
capsule, delayed release 3 2
PEnstilar ofenofibric acid, tab
ganciclovir 1 3 hydroxyurea 1 1 ketorolac tromethamine 1 2 Macrodantin 3 3
Ganirelix
3 5 1 2
oentacapone 1 5 PoFenoglide 3 2
3 6 hydroxyzine HCl 1 1 ketotifen maprotiline 1 3
gatifloxacin 1 2 1 opthalmic solution 3 2 Matulane 2 1
ofenoprofen
hydroxyzine pamoate 1
+Gattex 6 +zKeveyis 4 +zMavyret
entecavir tablets 3 3 1 4
zoEntresto zfentanyl lozenge
3 6 hyoscyamine/CR 1 2 2 3
PzGelnique +HyQvia 4 +zoKevzara
3 3 1 4
fentanyl patch
3 1 3 3 4 zMaxair Autohaler 2 5
ogemfibrozil Hysingla ER 4 PKhedezla 3 PzMaxalt
enulose 1 6 1 4
fentanyl patch 37.5mcg/hr,
1 2 3 3 3 4
2 zKineret 4 PzMaxalt MLT
zEnvarsus XR 3 3
zoEpaned generic Adderall 1 4 PzoHyzaar 3 3 3 4
+zKisqali
3 2 62.5mcg/hr, and 87.5mcg/hr 3 4
PzFentora
generic Adderall XR 1 4 3 1 Maxidex 3 2
zEpanova 3 2 3 4 I
+zEpclusa Ferriprox
generic Concerta 1 4 +Kitabis Pak 3 3 Maxitrol ophth 3 2
2 3 3 1 zoibandronate tabs 1 4 PKombiglyze XR
PEpiduo
generic Dexedrine 3 1 meclizine 1 6
4 +zIbrance 1 zKorlym 4 omeclofenamate
3 5 Fetzima 3 3 2
spansules 1 3 1 4
Epinephrine (Impax) 2 5 zofexofenadine 1 1 gengraf 1 3 oibuprofen 1 4 +Kuvan 2 6 Medrol 2mg 2 6
Epinephrine (Mylan) 2 5 zofexofenadine-D 1 1 +PGenotropin zIclusig 2 1 +Kyleena 6 omedroxyprogesterone 1
PEpipen/Jr.
3 4 3 6
3 5 PFiasp 3 1 gentamicin cr/oint 1 5 +zIdhifa 3 1 +zKynamro 2 2 omefenamic acid 3 5
Epivir solution 2 3 PoFibricor 3 2 gentamicin ophth 1 2 +zimatinib 1 1 mefloquine 1 3
Epivir-HBV solution 2 3 PFinacea 3 5 Genvoya 2 3 zImbruvica 2 1 L
zoeplerenone
megestrol 1 1
1 2 zofinasteride 5mg 1 3 PzGeodon 3 olabetalol 1 2 +zMekinist
+Epogen Fioricet/codeine
3 4 imipramine 1 2 1
3 1 3 4 5 lactulose 1 6 omeloxicam
+epoprostenol Fiorinal/codeine
Giazo 3 6 imiquimod 5% cream 1 1 4
3 3 3 4 +zGilenya PzImitrex 4 zLamisil Oral 3 3 zomemantine
+zFirazyr
2 4 3
zoeprosartan 600mg
1 1
1 2 2 2 zGilotrif 2 1 zImpavido 3 3 lamivudine tabs 1 3 zomemantine ER
oergocalciferol capsule
3 1
1 6 Firvanq 2 3 +Glassia 3 5 PImpoyz 3 5 lamivudine/zidovudine 1 3 oMenest 3 6
ergoloid mesylates 1 1 Flagyl/ER 3 3 +glatiramer acetate 1 4 +Increlex 3 4 olamotrigine ER 3 5 Menopur 3 6
Ergomar 2 4 Flarex 3 2 +zglatopa 1 4 zIncruse Ellipta 3 5 olamotrigine/ODT 1 5 zoMenostar 3 6
ergotamine/caffeine 1 4 oflecainide 1 2 oindapamide 2 Lanoxin 2 2 zmeperidine
+zErivedge
zglimepiride 1 1 1 1 4
2 1 PzFlector 3 5 oindomethacin 4 zolansoprazole 1 6 mephobarbital
+zErleada
glipizide 1 1 1 1 5
3 1 PoFlomax 3 3 zglipizide ER 1 1 zIngrezza 3 3 lansoprazole/amox/clarith 3 6 oMephyton 2 6
oerrin 1 6 Flonase Allergy Relief 1 1 zglipizide/metformin 1 1 +zInlyta 2 1 lanthanum carbonate tablet 3 6 meprobamate 1 4
Ery-Tab 2 3 Flonase Sensimist 1 1 Glucagon 2 1 Innohep 3 1 Lantus 2 1 mercaptopurine 1 1
erythromycin base 1 3 PzoFlovent HFA/Diskus 3 5 PzGlumetza 3 1 oInnopran XL 2 2 olatanoprost 1 2 mesalamine DR tablet 1.2g 3 6
erythromycin estolate 3 3 fluconazole 1 3 glyburide 1 1 Intelence 2 3 PzLatuda 3 4 mesalamine enema 1 6
erythromycin ethylsuccinate 1 3 flucytosine 1 3 glyburide micronized 1 1 PzIntermezzo 3 4 PzLazanda 3 4 Mesnex 2 1
erythromycin ophth 1 2 fludrocortisone 1 4 glycopyrrolate 1 6 zIntrarosa 3 6 leflunomide 1 4 metadate ER 1 4
erythromycin zoflunisolide nasal spray 3 1 zGlyxambi 3 1 +Intron A 2 1 zLenvima 2 1 metaproterenol syr 1 5
sol/swabs/gel 1 5 fluocinolone acetonide 1 5 zGocovri 3 5 PzInvega 3 4 PzuoLescol 3 2 metaxalone 1 4
erythromycin stearate 1 3 fluocinonide 1 5 PGonal F 3 6 Invirase 2 3 PzoLescol XL 3 2 metformin 1 1
erythromycin/ fluocinonide cream Gonitro 3 3 zInvokamet/XR 2 1 olessina 1 6 Pzmetformin ER (except
benz peroxide 1 5 (generic Vanos) 3 5 zGralise 3 4 zInvokana 2 1 +zLetairis 2 3 generic Glucophage XR) 3 1
erythromycin/ fluorometholone ophth 1 2 zgranisetron 1 6 ipratropium inh. soln. 1 5 letrozole 1 1 zmetformin ER
sulfisoxazole 1 3 Fluoroplex 3 5 1 leucovorin 1 6 (generic Glucophage XR) 1
+zEsbriet
zGranisol 3 6 ipratropium nasal spray 1 1
+Granix
2 5 Fluorouracil 0.5% cr 3 5 3 1 ipratropium/albuterol 1 5 Leukeran 2 1 zmetformin/glyburide 1 1
zGrastek zoirbesartan 2 +Leukine
uescitalopram 1 3 fluorouracil 2% sol 1 5 2 1 methadone 1 4
Pzoesomeprazole
3 1 1
fluorouracil 5% cr/sol 1 5 griseofulvin 1 3 zoirbesartan/HCTZ 1 2 leuprolide 1 1 omethazolamide 1 2
+zIressa 1 PLevalbuterol
magnesium 3 6 ufluoxetine 10mg and methenamine combination 1 3
Guaifenesin DM 3 1 2
estazolam 1 4 20mg tablet 1 3
3 Tartrate HFA 3 5 Methergine 3 6
zoEstraderm
guaifenesin/codeine 1 1
Pfluoxetine 60mg tablet 3
Isentress 2
3 6 3 oguanfacine PLevemir 3 1 omethimazole 1 6
oestradiol 0.01% cream
1 2 isometh/dichloralphen/
4 olevetiracetam
3 6 fluoxetine capsule 1 3 1 5 methocarbamol 1 4
zoestradiol oral
guanfacine ER 3 4 APAP 1
oisoniazid 3 zoLevitra
1 6 fluoxymesterone 3 3 3 3 methotrexate 1 1
zoestradiol patches
Gynazole-1 3 6 1
oisosorbide dinitrate 3 olevobunolol
1 6 fluphenazine 1 4 1 2 methotrexate 1 4
zoestradiol/noreth ac
1
1 6 flurandrenolide cream 3 5 H oisosorbide mononitrate 3 levocarnitine 1 6 methoxsalen capsule 1 5
zoEstrasorb packet
1
3 6 flurazepam 1 4 +zHaegarda 3 3 oisosorbide zolevocetirizine 1 1 omethyclothiazide 1 2
zoEstring 3 6 oflurbiprofen 1 4 Halflytely 2 6 mononitrate SA 1 3 levofloxacin 1 3 omethyldopa 1 2
zoEstrogel 3 6 flurbiprofen ophth 1 2 halobetasol 1 5 oisoxsuprine 1 3 olevora 1 6 omethyldopa/HCTZ 1 2
zoestrogen/methyltesterone 1 6 flutamide 1 1 halobetasol propionate 1 5 oisradipine 1 2 levothroid 1 6 methylergonovine maleate 1 6
zoestropipate 1 6 zofluticasone nasal spray 1 1 Halog 3 5 oIstalol 3 2 olevothyroxine 1 6 methylphenidate CD 1 4
Pzeszopiclone 3 4 fluticasone propionate 1 5 haloperidol 1 4 zitraconazole 1 3 olevoxyl 1 6 methylphenidate/SR 1 4
oethambutol 1 3 zFluticasone-Salmeterol 2 5 +zHarvoni 2 3 PIzba 3 2 PuLexapro 3 3 methylprednisolone
oethosuximide 1 5 zofluvastatin 3 2 Helidac 3 6 Lexiva 2 3 4mg, 8mg, 16mg, 32mg 1 6
oetidronate 1 6 Pfluvoxamine ER capsule 3 3 Hemangeol 3 2 J Librium 3 4 ometipranolol 1 2
oetodolac 1 4 ufluvoxamine tablet 1 3 +Hemlibra 3 1 +Jadenu 2 1 lidocaine 1 5 metoclopramide 1 6
oetodolac SA 1 4 FML Forte 2 2 heparin 1 1 +zJakafi 2 1 zlidocaine patch 1 5 ometolazone 1 2
etoposide 1 1 FML S.O.P. 2 2 zHepsera 2 3 jantoven 1 1 Liletta 3 6 ometoprolol 1 2
Eucrisa 3 5 PFocalin XR 3 4 zHetlioz 3 4 zJanumet 2 1 Lindane 2 5 ometoprolol ER 1 2
Eurax 3 5 ofolic acid Rx 1mg tab 1 6 Hexalen 2 1 zJanumet XR 2 1 zlinezolid 1 3 ometoprolol/HCTZ 1 2
oEvamist 3 6 Follistim AQ 2 6 +Hizentra 3 4 zJanuvia 2 1 Linzess 3 6 ometoprolol/HCTZ 1 2
PEvoclin 3 5 fondaparinux sodium 1 1 homatropine 1 2 zJardiance 2 1 oliothyronine 1 6 PMetrogel topical 1% 3 5
Evotaz 2 3 zForadil 2 5 PzHorizant 3 4 Jentadueto 2 1 PzuoLipitor 3 2 metronidazole 1 3
zEvzio 3 4 Forfivo 3 3 +zHP Acthar Gel 2 4 zJentadueto XR 2 1 PoLipofen 3 2 metronidazole
Exelderm 2 5 PzFortamet 3 1 Humalog insulin 2 1 zojinteli 1 6 olisinopril 1 2 cream/lotion/ 0.75% gel 1 5
exemestane 1 1 +zForteo 2 4 +PHumatrope 3 4 ojolessa 1 6 olisinopril/HCTZ 1 2 PzuoMevacor 3 2
+Exjade 2 1 PzFortesta 3 3 +zHumira 2 4 ojolivette 1 6 lithium carbonate 1 4 omexiletine 1 2
+PExtavia 3 4 zofortical NS 1 4 Humulin (all types) 2 1 zJublia 3 5 PoLivalo 3 2 oMiacalcin inj. 2 1
zoezetimibe 3 2 PzoFosamax 3 4 +Hycamtin 2 1 Juluca 2 3 zLonhala Magnair 3 5 mibelas 24 Fe 3 6
zoezetimibe-simvastatin 3 2 PzoFosamax D 3 4 Hycodan 3 1 ojunel/FE 1 6 +zLonsurf 2 1 PzoMicardis 3 2
KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program
z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.
= Prior Authorization Required. o = Home Service Delivery.
8You can also read
