BlueShield of Northeastern New York Formulary 3/ Exclusive
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BlueShield of
Northeastern
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,
visit the Pharmacy Services section of the BlueShield web site at
www.bsneny.com.
CRP2107_009678.1 MG009678H
(Revise Date 07/01/2021)
A Division of HealthNow New York Inc. An independent licensee of the BlueCross BlueShield Association. The Shield is a registered
trademark 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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
iiThe BlueShield of Northeastern New York Formulary 3/Exclusive is a list of drugs to help guide physicians
and pharmacists to select the medication that provides the appropriate treatment for the best price.
Introduction
Blue Shield of Northeastern 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.
= Affordable Care Act (ACA) Preventive Drug. The medication is included on the ACA
Preventive Drug List.
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.
Affordable Care Act (ACA) Preventive Drug List
The Affordable Care Act (ACA) Preventive Drug List consists of medications that may be covered at $0.
They are not subject to any annual deductibles, coinsurance, or copayments. Please refer to your plan
documents to confirm if the ACA Preventive Drug List applies to you.
We’ve noted any drugs on the ACA Preventive Drug List within this guide. Please consult the key on
page iii. This list is reviewed periodically and is subject to change.
The presence of a drug on this list does not guarantee coverage. Drugs on this list may require prior
authorization, step-edits, and quantity limits. Restrictions may apply to certain brand-name ACA
medications with generic equivalents. Other restrictions may apply according to U.S. Preventive Services
Task Force (USPSTF) recommendations, which define ACA coverage requirements. These restrictions
may be based on age, dose, diagnosis, and others as recommended by USPSTF. Both prescription and
over-the-counter (OTC) products are eligible to be covered when prescribed by a licensed health care
provider and require a valid prescription.
* Some plan designs require that you use a Tier 1 generic drug if a generic is available.
Disclaimer: The BlueShield of Northeastern New York Medication Guide is subject to change, as we regularly review medica-
tions and existing therapies for inclusion in the BlueShield of Northeastern 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.
ivContraceptive 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.
Finding 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
BlueShield of Northeastern 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.bsneny.com.
vSection I — Therapeutic drug categories
TIER TIER TIER TIER
Allergy/Cough & Cold Pz Detrol LA 3 Leukeran 2 +z Idhifa 3
Pz Ditropan XL 3 Myleran 2 +z Inrebic 3
Antihistamines & Decongestants Pz Enablex 3 Antimetabolites +z Kesimpta 3
brompheniramine/ phenylephrine 1
Pz Gelnique 3 + capecitabine 1 +Pz Kisqali 3
brompheniramine/ pseudoephedrine 1
Pz +z
Pz Myrbetriq 3 mercaptopurine 1 Kisqali Femara Co-Pack 3
carbinoxamine 1
Pz Oxytrol 3 methotrexate 1 z Koselugo 3
cetirizine 1
Pz Sanctura 3 Purixan 2 +z Lorbrena 3
clemastine 1
Pz Sanctura XR 3 +z Inqovi 3 z Mektovi 3
cyproheptadine 1
z solifenacin 3 + Onureg 3 +z Nerlynx 3
dexchlorpheniramine 1
Pz Toviaz 3 Trexall 3 z Orgovyx 3
diphenhydramine 1
Pz Vesicare 3 z Xatmep 3 z Pemazyre 3
hydroxyzine HCl 1 +z Piqray 3
z
hydroxyzine pamoate 1 Cholinergic Agents Hormones
Qinlock 3
z levocetirizine 1 Urecholine 3 anastrozole 1 +z Retevmo 3
loratadine 1 Miscellaneous bicalutamide 1 +z
Pz Gemtesa
Rozlytrek 3
loratadine-D 1 3 exemestane 1 +z Rubraca 3
pseudoephedrine 1 z Jynarque 3 flutamide 1 z
Rydapt 3
Semprex-D 2
Blood letrozole 1 +z Tabrecta 3
z Clarinex-D 3 leuprolide 1 +z Talzenna 3
z desloratadine 3 Anticoagulants/Antithrombotics megestrol 1 +z
z
Tarceva 3
Grastek 3 anagrelide 1 tamoxifen 1 z
z
Tazverik 3
Odactra 3 aspirin 325mg OTC 1 Fareston 2 +
z
Temodar 3
Oralair 3 aspirin 81mg OTC 1 +z Nubeqa 3 z
z
Tepmetko 3
z
Palforzia 3 aspirin-dipyridamole 1 Miscellaneous
z
Tibsovo 3
Ragwitek 3 clopidogrel 1 +z abiraterone acetate 1 z Tukysa 3
Expectorant & Cough Products dipyridamole 1 +z erlotinib 1 z Turalio 3
benzonatate 1 enoxaparin 1 etoposide 1 +z Tykerb 3
guaifenesin/codeine 1 fondaparinux sodium 1 +z everolimus (generic Afinitor) 1 Ukoniq 3
hydrocodone/chlorpheniramine 1 heparin 1 hydroxyurea 1 z Venclexta 3
hydrocodone/homatropine 1 jantoven 1 +z imatinib 1 +z Vitrakvi 3
promethazine/codeine 1 ticlopidine 1 +z lapatinib 1 +z Vizimpro 3
promethazine/DM 1 warfarin 1 nilutamide 1 + Xgeva 3
promethazine/phenylephrine/ codeine 1 Coumadin 2 + temozolamide 1 z Xospata 3
pseudoephedrine/codeine 1 Eliquis 2 +z Arcalyst 2 z Xpovio 3
Cardec/DM 3 Fragmin 2 +z Bosulif 2 +z Yonsa 3
Guaifenesin DM 3 Xarelto 2 +z Cabometyx 2 z Zejula 3
Hycodan 3 Bevyxxa 3 z Caprelsa 2 +Pz Zytiga 3
Rondec DM/TR 3 Brilinta 3 +z Cometriq 2 Rexinoids
Vituz 3 Durlaza 3 +z Cotellic 2 + bexarotene 1
+z
z
Mucolytic Agents Innohep 3 Erivedge 2 + Targretin gel 2
acetylcysteine inh soln. 1 prasugrel 3 +z Farydak 2
Pradaxa 3 +z Gilotrif 2 Diabetes
Nasal Medications z
+ Hycamtin capsule 2 Please refer to your plan documents to confirm your
+z
azelastine nasal spray 1 z Savaysa 3
Ibrance 2 cost share for diabetic drugs. Cost share may vary
z
budesonide nasal spray 1 z Zontivity 3 Iclusig 2 by plan.
Clarispray 1 Other Blood Modifiers z Imbruvica 2
+z
Flonase Allergy Relief 1 cilostazol 1 Antidiabetic Agents, Injectable
Inlyta 2
+
Flonase Sensimist 1 + deferasirox 1 Basaglar 2
Intron A 2
+z
z fluticasone nasal spray 1 pentoxifylline 1 z Bydureon 2
Iressa 2
ipratropium nasal spray 1 z trientine 1 +z Jakafi 2
z Byetta 2
z Nasacort Allergy 24HR 1 +z Actimmune 2 +z Lenvima 2
Humalog insulin 2
+z
Rhinocort Allergy 1 + Aranesp 2 Humulin (all types) 2
Lonsurf 2
+z
triamcinolone nasal spray 1 + Fulphila 2 Lantus 2
Lynparza 2 Lyumjev 2
Atrovent Nasal Spray 3 + Leukine 2 Lysodren 2
Pz Beconase AQ 3 Miacalcin inj. 2 Matulane 2 z Ozempic 2
Dymista 3 Neulasta 2 +z Mekinist 2 z
z
Soliqua 2
z flunisolide nasal spray 3 +z Promacta 2 Mesnex 2 Symlin 2
Pz mometasone nasal spray 3 + Retacrit 2 +z Nexavar 2 Toujeo 2
Pz Nasacort AQ 3 +z Revlimid 2 +z Ninlaro 2 z Trulicity 2
Pz +z
Zarxio 2 z Victoza 2
Pz
Omnaris 3 z Odomzo 2
Pz +z
+ Alprolix 3 Adlyxin 3
P
Qnasl 3 Pomalyst 2
z z Cablivi 3 +z Admelog 3
P
Xhance 3 Sprycel 2
Pz deferiprone 3 + Apidra 3
P
Zetonna 3 Stivarga 2
+z Doptelet 3 +z Fiasp 3
P
Sutent 2
Alzheimer Agents + Eloctate 3 z Insulin Lispro 3
P
Sylatron 2
+z Endari 3 z Levemir 3
P
z donepezil 1 Synribo 2
+ Epogen 3 +z Novolin 3
P
ergoloid mesylates 1 Tafinlar 2
+ Exjade 3 +z Novolog 3
P
z galantamine 1 Tagrisso 2
Ferriprox 3 +z Semglee 3
Pz
z galantamine ER 1 Tasigna 2
+ Granix 3 Tanzeum 3
P
memantine 1 + Thalomid 2
+
z
z rivastigmine 1 Hemlibra 3 +z Valchlor 2 Tresiba 3
z rivastigmine patch 1 + Jadenu 3 +z Verzenio 2 z Xultophy 3
memantine ER 3 + Jivi 3 +z Votrient 2 Antidiabetic Agents, Glucose Elevating Agents
z
Namzaric 3 Mircera 3 +z Xalkori 2 acarbose 1
+z
z
Mulpleta 3 +z Xtandi 2 chlorpropamide 1
Bladder/Kidney + Neupogen 3 +z Zelboraf 2 z glimepiride 1
Acidifiers + Nivestym 3 +z Zolinza 2 glipizide 1
K-Phos 2 +P Nyvepria 3 +z Zydelig 2 z glipizide ER 1
Omontys 3 +z Zykadia 2 z glipizide/metformin 1
+z +Pz Afinitor
Alkalinizers glyburide 1
Oxbryta 3 3
+
potassium citrate 1
Procrit 3 +z Alecensa 3 glyburide micronized 1
z
Oracit 3 Tavalisse 3 +z Alunbrig 3 metformin 1
Analgesics +P Udenyca 3 z Ayvakit 3 z metformin ER (generic Glucophage XR) 1
phenazopyridine 1 +P Ziextenzo 3 z Balversa 3 z metformin/glyburide 1
Anticholinergics z Zontivity 3 z Braftovi 3 z nateglinide 1
z oxybutynin 1
Cancer Drugs z Brukinsa 3 z pioglitazone/metformin 1
z oxybutynin ER 1 z Calquence 3 z repaglinide 1
z Oxytrol for Women 1 Alkylating Agents z Copiktra 3 tolazamide 1
z tolterodine 1 cyclophosphamide 1 +z Daurismo 3 tolbutamide 1
z tolterodine ER 1 Alkeran 2 +z Erleada 3 z Avandamet 2
z trospium 1 CeeNu 2 Fotivda 3 z Avandaryl 2
z trospium ER 1 Emcyt 2 Gavreto 3 z Avandia 2
Pz Detrol 3 Hexalen 2 +Pz Gleevec 3 z Duetact 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. = ACA Preventive Drug
1Section I — Therapeutic drug categories (cont’d)
TIER TIER TIER TIER
z Farxiga 2 Tobrex ointment 2 colchicine/probenecid 1 Antara 3
Glucagon 2 Azasite 3 probenecid 1 colesevelam 3
z Invokamet/XR 2 Besivance 3 z Mitigare 2 zu Crestor 3
z Invokana 2 Ciloxan 3 z Duzallo 3 z Epanova 3
z Janumet 2 Tobrex solution 3 Pz febuxostat 3 z Ezallor 3
z Janumet XR 2 Anti-inflammatory z Gloperba 3 z ezetimibe-simvastatin 3
z Januvia 2 fluorometholone ophth 1 Pz Uloric 3 Fenofibrate (brand) 3
z Jardiance 2 loteprednol 1 z Zurampic 3 z fenofibric acid, capsule, delayed release 3
Jentadueto 2 loteprednol etabonate susp 1 Fenoglide 3
z Jentadueto XR 2 prednisolone acetate 1 Heart Fibricor 3
Juvisync 2 prednisolone sod phosphate 1 Angiotensin Converting Enzyme Inhibitors z fluvastatin 3
z Rybelsus 2 FML Forte 2 benazepril 1 +z Juxtapid 3
z Synjardy/XR 2 FML S.O.P. 2 captopril 1 zu Lescol 3
Tradjenta 2 Lotemax ointment 2 enalapril 1 z Lescol XL 3
z Trijardy XR 2 Lotemax SM 2 fosinopril 1 zu Lipitor 3
z Xigduo XR 2 Pred Mild 2 lisinopril 1 Lipofen 3
Afrezza 3 Flarex 3 moexipril 1 Livalo 3
Baqsimi 3 Lotemax gel 3 perindopril 1 zu Mevacor 3
Pz Fortamet 3 Maxidex 3 quinapril 1 z Nexletol 3
Pz Glumetza 3 Anti-inflammatory/Anti-infective combinations ramipril 1 z Nexlizet 3
z Glyxambi 3 dexameth/neomycin/poly B 1 trandolapril 1 z Nikita 3
P Kazano 3 neomycin/bacitracin/poly B/HC 1 z Epaned 3 z omega-3 acid ethyl esters 3
P Kombiglyze XR 3 sulfacetamide/prednisolone ophth 1 z Qbrelis 3 z Omtryg 3
Pz metformin ER (except generic tobramycin/dexameth 1 Angiotensin II Antagonists zu Pravachol 3
Glucophage XR) 3 Tobradex ointment 2 z candesartan 1 Tricor 3
miglitol 3 Maxitrol ophth 3 Triglide 3
P
z eprosartan 600mg 1
Nesina 3 Vascepa 3
P
Pred-G 3 z irbesartan 1
Onglyza 3 zu Zocor 3
P
Zylet 3 z losartan 1
Oseni 3 Antiviral z olmesartan 1 z Zypitamag 3
z Qtern 3 z famciclovir ophth 1 z telmisartan 1 Beta Blockers
repaglinide/metformin 3 trifluridine 1 z valsartan 1 acebutolol 1
z Segluromet 3 Pz Atacand 3 atenolol 1
z Steglatro 3 Beta-Blockers (Eye) Pz Avapro 3 betaxolol 1
betaxolol HCl 1
z Steglujan 3
carteolol 1 Pz Benicar 3 bisoprolol 1
Diabetic Test Strips levobunolol 1 Pz Cozaar 3 carvedilol 1
metipranolol 1 Pz Diovan 3 carvedilol ER 1
Pz
Please refer to your plan documents to confirm your labetalol 1
timolol 1 Edarbi 3
cost share for diabetic supplies. Cost share may vary
Betoptic-S 2 Pz Micardis 3 metoprolol 1
by plan. Test strips other than OneTouch require
Istalol 3 Pz Prexxartan 3 metoprolol ER 1
prior authorization. Anti-Adrenergic Blockers Centrally acting metoprolol/HCTZ 1
Carbonic Anhydrase Inhibitors
OneTouch clonidine, oral, patch 1 nadolol 1
P
brinzolamide 1
Accu-Chek guanfacine 1 pindolol 1
P
dorzolamide 2% eye drops 1
Ascensia Breeze methyldopa 1 propranolol 1
P
dorzolamide/timolol eye drops 1
Contour midodrine 1 timolol 1
P
Azopt 3
Freestyle +z droxidopa 3 Innopran XL 2
P
Miotics
Precision +z Northera 3 Bystolic 3
P
pilocarpine 1 Hemangeol 3
TRUEtest Anti-Adrenergic Blockers Peripheral
P
Phospholine Iodide 2
TRUEtrack doxazosin 1 Calcium Channel Blockers
Miscellaneous amlodipine 1
Ear Cystaran 2 prazosin 1
terazosin 1 cartia XT 1
Anti-infective Agents z Restasis 2 diltia XT 1
Cequa 3 Cardura XL 3
acetic acid otic 1 z diltiazem 1
1 +z Oxervate 3 Antiarrhythmics
P
acetic acid/aluminum acetate amiodarone 1 diltiazem CD/SR/ER/XR 1
Rhopressa 3 felodipine ER 1
z
ciprofloxacin otic 1 digoxin 1
Rocklatan 3 isradipine 1
ofloxacin otic 1 disopyramide 1
z Xiidra 3 nicardipine 1
Domeboro 3 dofetilide 1
Xtoro 3 Mydriatics flecainide 1 nifediac CC 1
atropine sulfate ophth 1 nifedical XL 1
Anti-infective/Anti-inflammatory combinations homatropine 1 mexiletine 1
acetic acid HC otic 1 procainamide 1 nifedipine 1
tropicamide 1 nifedipine SR 1
ciprofloxacin/dexamethasone 1 NSAIDs propafenone 1
neomycin/polymyxin/HC otic 1 propafenone SR 1 nimodipine 1
bromfenac 1 quinidine gluconate 1 nisoldipine 1
Cipro HC 3 diclofenac 1 verapamil/SR 1
Pz
quinidine sulfate SR 1
Eye flurbiprofen ophth 1 sotalol 1 Conjupri 3
Antiallergy Agents (Eye) Nevanac 2 Dynacirc/CR 3
P
Lanoxin 2
azelastine ophth 1 Acular PF 3 Multaq 3 Katerzia 3
Prolensa 3 Norpace CR 3 z Nymalize 3
cromolyn ophth 1
olopatadine ophth 1 Prostaglandin Analogues/Prostamines Antilipidemics Combination Anti-Hypertensive
Alomide 3 bimatoprost 0.03% 1 aliskiren 1
latanoprost 1 zu atorvastatin calcium 1
Bepreve 3 cholestyramine 1 z amlodipine/atorvastatin 1
Xelpros 2 amlodipine/benazepril 1
ketotifen opthalmic solution 3 P Izba 3 colestipol 1
olopatadine 0.2% drop 3 P z amlodipine/valsartan 1
Lumigan 3 z ezetimibe 1 atenolol/chlorthalidone 1
Pazeo 3 P Rescula 3 fenofibrate (generic) 1
benazepril/HCTZ 1
Cystadrops 3 P Travatan Z 3 fenofibric acid, tab 1 bisoprolol/HCTZ 1
Zaditor 3 travoprost (generic Travatan Z) 3 gemfibrozil 1 Pz candesartan/HCTZ 1
Zerviate 3 P Vyzulta 3 zu lovastatin 1 captopril/HCTZ 1
Anti-infective Agents P Xalatan 3 niacin ER 1 enalapril/HCTZ 1
bacitracin ophth 1 P Zioptan 3 P niacin IR 500mg tablet 1 fosinopril/HCTZ 1
bacitracin/polymyxin 1 Sympathomimetics niacin (OTC) 1 z irbesartan/HCTZ 1
ciprofloxacin ophth 1 brimonidine 1 z niacin/simvastatin 1 lisinopril/HCTZ 1
erythromycin ophth 1 Alphagan P 0.1% 2 zu pravastatin 1 z losartan/HCTZ 1
gatifloxacin 1 Upneeq 3 z rosuvastatin 1 methyldopa/HCTZ 1
gentamicin ophth 1 Vasoconstrictors zu simvastatin 1 metoprolol/HCTZ 1
moxifloxacin 0.5% (generic Vigamox) 1 naphazoline 1 Advicor 2 z olmesartan/HCTZ 1
neomycin/bacitracin/poly B 1 phenylephrine ophth 1 Colestid 2 propranolol/HCTZ 1
ofloxacin ophth 1 +z Kynamro 2 quinapril/HCTZ 1
polymyxin B/TMP 1 Gout z Praluent 2 z telmisartan/HCTZ 1
sulfacetamide 10% 1 allopurinol 1 z Repatha 2 z valsartan/HCTZ 1
tobramycin soln 1 colchicine (generic Colcrys) 1 z Altoprev 3 Pz Tekturna HCT 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. = ACA Preventive Drug
2Section I — Therapeutic drug categories (cont’d)
TIER TIER TIER TIER
z amlodipine/valsartan/HCTZ 3 HIV - Antivirals azithromycin tablets 1 ganciclovir 1
Pz Amturnide 3 cefaclor 1 +z moderiba 1
Pz Atacand HCT 3 Non-Nucleoside Reverse Transcriptase Inhibitor cefadroxil 1 oseltamivir 1
Pz Avalide 3 efavirenz 1 cefdinir 1 + ribapak 1
Pz Benicar HCT 3 efavirenz/emtricit/tenofovr df 1 cefpodoxime 1 + ribasphere 1
Edurant 2
z Byvalson 3 cefprozil 1 +
Pz Intelence 2 ribavirin 1
Diovan HCT 3 cefuroxime 1
Pz Edarbyclor 3 Rescriptor 2 cephalexin 1
rimantadine 1
Pz Hyzaar 3 Viramune, XR 2 ciprofloxacin 1 z valacyclovir 1
Pz Micardis HCT 3 Atripla 3 clarithromycin susp 1 valganciclovir tablets 1
z olmesartan/amlodipine 3 Nucleoside Analog Reverse Transcriptase Inhibitor clarithromycin tabs 1 +z Epclusa 2
z olmesartan/amlodipine/HCTZ 3 Combination clindamycin 1 Epivir-HBV solution 2
z Prestalia 3 abacavir/lamivudine/zidovudine 1 dicloxacillin 1 +z Harvoni 2
Pz Tekturna 3 efavirenz/lamivu/tenofovr diop 1 doxycycline 1 z Hepsera 2
z telmisartan/amlodipine 3 emtricitabine/tenofovir disop 1 ery-tab 250mg, 333mg 1 +z Mavyret 2
trandolapril/verapamil 3 lamivudine/zidovudine 1 erythromycin base 1 + Pegasys 2
Pz Valturna 3 tenofovir 300mg 1 erythromycin DR 1 Relenza 2
Diuretics Biktarvy 2 erythromycin ethylsuccinate 1 +z Sovaldi 2
acetazolamide 1 Cimduo 2 erythromycin stearate 1 + Victrelis 2
acetazolamide ER 1 Complera 2 erythromycin/sulfisoxazole 1 +Pz Viekira
2
amiloride 1 Descovy 2 levofloxacin 1
Dutrebis 2 Baraclude solution 3
amiloride/HCTZ 1 minocycline 1 entecavir tablets 3
+Pz Ledipasvir/Sofosbuvir
bumetanide 1 Odesfey 2 nitrofurantoin 1
Stribild 2 3
+P Peg-Intron
chlorothiazide 1 ofloxacin 1
chlorthalidone 1 Triumeq 2 penicillin VK 1 3
furosemide 1 Viread 150mg, 200mg, 250mg, sulfamethoxazole/trimethoprim 1 z Prevymis tablets 3
hydrochlorothiazide 1 40mg/scoop powder 2 tetracycline 1 + Rebetol 3
indapamide 1 Symfi 3 Ketek 2 + Ribatab 3
methazolamide 1 Symfi Lo 3 Zmax 2 Pz Sitavig 3
methyclothiazide 1 Truvada 3 Baxdela 3 +Pz Sofosbuvir/Velpatasvir 3
metolazone 1 Nucleoside Reverse Transcriptase Inhibitors Biaxin XL 3 z Tyzeka 3
spironolactone 1 abacavir-lamivudine 1 cefixime 3 valganciclovir solution 3
spironolactone/HCTZ 1 didanosine 1 Ceftin 3 z Valtrex 3
torsemide 1 emtricitabine 1 Cleocin 3 z Vemlidy 3
triamterene/HCTZ 1 lamivudine tabs 1 z doxycycline hyclate 50mg, 75mg, 150mg tab 3 +z Vosevi 3
z Carospir 3 stavudine 1 erythromycin estolate 3 z Xofluza 3
Miscellaneous Cardiovascular Agents zidovudine
Emtriva solution
1
2
erythromycin suspension 3 +Pz Zepatier 3
z eplerenone 1 Factive 3 Other Anti-Infectives
+z icatibant 1 Epivir solution 2 z Lymepak 3 atovaquone 1
ranolazine ER 1 Videx 2 Minocin 3
dapsone tablets 1
+z tolvaptan 1 Ziagen 2 moxifloxacin 3
linezolid 1
+z Other Noroxin 3 z
Berinert 2
+z Fuzeon 2 PCE 3 methenamine combination 1
Cinryze 2 metronidazole 1
z Entresto 2 Genvoya 2 Spectracef 3
+z Isentress 2 Vibramycin 3 neomycin 1
Ruconest 2
+z Juluca 2 nitrofurantoin 1
Samsca 15mg 2 Antifungals
Pz Selzentry 2 pentamidine inhal powder 1
Consensi 3 clotrimazole lozenge 1
z Tivicay 2 paromomycin 1
Corlanor 3 fluconazole 1
+z Tybost 2 tinidazole 1
Firazyr 3 flucytosine 1
+z Vitekta 2 + tobramycin ampule/neb 1
Haegarda 3 griseofulvin 1
z Protease Inhibitors trimethoprim 1
Orladeyo 3 z itraconazole 1 vancomycin caps 1
Ranexa 3 atazanavir 1
ketoconazole 1
+z ritonavir tablet 1 Firvanq 2
Samsca 30mg 3 nystatin 1
+z Aptivus 2 z Sivextro 2
Takhzyro 3
Crixivan 2 Pz oxiconazole 1 + Tobi Podhaler 2
Vecamyl 3 terbinafine 1
z Evotaz 2 z + Bethkis 3
Verquvo 3
+z Invirase 2 z voriconazole 1 + Cayston 3
Pz
Vyndamax 3
+z Lexiva 2 Oxistat lotion 2 z Dificid 3
Vyndaqel 3 Flagyl/ER 3
Norvir capsule, solution 2 z Posaconazole 2
Pulmonary Arterial Hypertension Prezcobix 2 Impavido 3
z Sporanox suspension 2
z z
alyq 1 Prezista 2 Kitabis Pak 3
+z z Cresemba 3 +
ambrisentan 1 Viracept 2 Macrodantin 3
+z bosentan 1 Ecoza 3
+z sildenafil 20 mg tab 1 Protease Inhibitors Combinations Pz Ertaczo 3 + Tobi 3
+z Kaletra 2 Lamisil Oral 3 Vancocin 3
z
tadalafil (generic Adcirca) 1 z
+z Tracleer tab for susp 2 Huntington’s Disease Luzu 3 Xifaxan 3
+z Tyvaso 2 +z Austedo 3 z Noxafil 3 Men’s Health
+z Uptravi 2 z Ingrezza 3 Oravig 3
+z
Impotence
Adempas 3 +z Pz Oxistat cream 3
+
tetrabenazine 3 Caverject 3
Pz Tolsura
epoprostenol 3 z
3
+Pz Letairis 3 Immunosuppressants z Cialis 3
+z
Antimalarials z Edex 3
Opsumit 3 azathioprine 1
+ Orenitram 3 cyclosporine 1
atovaquone/proguanil HCl 1 z Levitra 3
+Pz Revatio 3 gengraf 1
chloroquine phosphate 1 z MUSE 3
+Pz sildenafil suspension 3 mycophenolate mofetil 1
mefloquine 1 z sildenafil citrate 25mg, 50mg, 100mg 3
+Pz Tracleer tab 3 mycophenolic acid 1 pyrimethamine 1 z Staxyn 3
+z veletri 3 sirolimus 1 Primaquine 2 z Stendra 3
+Pz Ventavis 3 tacrolimus 1 quinine sulfate 3 z tadalafil (generic Cialis) 3
Vasodilators Neoral 2 Antituberculosis z vardenafil 3
hydralazine 1 Sandimmune 2 ethambutol 1 z vardenafil ODT 3
isosorbide dinitrate 1 Astagraf XL 3 isoniazid 1 z Viagra 3
isosorbide mononitrate 1 Cellcept 3 pyrazinamide 1 Male Hormones
isosorbide mononitrate SA 1 Envarsus XR 3 rifabutin 1 testosterone cypionate 1
isoxsuprine 1 z Lupkynis 3 rifampin 1 testosterone enanthate 1
minoxidil oral 1 Prograf 3 Coartem 2
nitroglycerin pumpspray 1 Zortress 3 z testosterone gel 1
nitroglycerin SR 1 Rifater 2 z testosterone pump 1
nitroglycerin transdermal patch 1 Infection Rifamate 3 P Androderm patch 3
Dilatrate SR 2 Antibacterial Agents/Antibiotics Sirturo 3 Android 3
Nitrostat SL tabs 2 amoxicillin 1 Antivirals fluoxymesterone 3
Gonitro 3 amoxicillin-clavulanate ER 1 z acyclovir oral 1 Pz Axiron 3
Minitran 3 ampicillin 1 amantadine 1 Pz Fortesta 3
NitroDur patches 3 azithromycin suspension 1 z famciclovir 1 Pz Jatenzo 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. = ACA Preventive Drug
3Section I — Therapeutic drug categories (cont’d)
TIER TIER TIER TIER
Pz Natesto 3 Pz Caplyta 3 Miscellaneous Multiple Sclerosis Agents
P Striant 3 P Fanapt 3 +z dimethyl fumarate 1
Pz
Antidiuretic Agents
Testim 3 Fazaclo 3 + glatiramer acetate 1
Pz Pz
desmopressin solution 1
Testosterone gel (brand) 3 Geodon 3 +z glatopa 1
Pz Pz
desmopressin tabs 1
Vogelxo 3 Invega 3 + Avonex 2
Pz Pz
Stimate 2
Xyosted 3 Latuda 3 DDAVP nasal spray 3 +z Gilenya 2
Prostate Health +z Nuplazid 3 DDAVP sol, tab 3 +z Mayzent 2
z alfuzosin 1 z olanzapine/fluoxetine 3 z Nocdurna 3 +z Plegridy 2
z finasteride 5mg 1 Pz paliperidone 3 z Noctiva 3 + Rebif 2
tamsulosin 1 z quetiapine fumarate ER 3 +z Vumerity 2
Pz
Other CNS
Pz dutasteride 3 Rexulti 3 acamprosate calcium tablet EC 1 +z Zeposia 2
dutasteride/tamsulosin 3 Pz Risperdal 3 +z Aubagio 3
+z
buprenorphine 1
P Flomax 3 Pz Saphris 3 Bafiertam 3
+P
buprenorphine-naloxone 1
Pz Proscar 3 Pz Secuado 3 Betaseron 3
+
buprenorphine/naloxone film 1
P Rapaflo 3 Pz Seroquel 3 Copaxone 3
silodosin 3 Pz Seroquel XR 3
disulfiram 1 +z dalfampridine ER 3
Pz Uroxatral 3 Pz Symbyax 3
naltrexone 1 +P Extavia 3
P Versacloz 3
riluzole 1 +z Mavenclad 3
Mental Health
Pz Vraylar 3
z Narcan Nasal Spray 2 Ponvory 3
Antidepressants Pz Zyprexa 3
Bunavail 3 +z Tecfidera 3
Campral dosepack 3
amitriptyline 1 Pz Zyprexa Zydis 3 z Evzio 3 Muscle Relaxants
amitriptyline/ chlordiazepoxide 1 Anxiolytics, Sedatives, and Hypnotics Exservan 3 baclofen 1
z
amitriptyline/perphenazine 1 alprazolam/ER 1 Gralise 3
amoxapine 1 carisoprodol 1
buspirone 1 Lucemyra 3 carisoprodol/ASA 1
Pz Horizant Pz
bupropion 1 chloral hydrate 1
bupropion 12HR 1 3 chlorzoxazone 1
chlordiazepoxide 1 Savella 3 cyclobenzaprine 1
+z Pz
bupropion 24HR 1 clorazepate 1 Tegsedi 3 cyclobenzaprine 7.5mg 1
Pz
u citalopram 1 diazepam 1
clomipramine 1 Tiglutik 3 dantrolene sodium 1
estazolam 1 Zubsolv 3 metaxalone 1
desipramine 1 eszopiclone 1
desvenlafaxine succinate ER 1
z Other Endocrine methocarbamol 1
flurazepam 1 cinacalcet 1 orphenadrine 1
doxepin 1 lorazepam 1
duloxetine 1 danazol 1 orphenadrine/aspirin/caffeine 1
meprobamate 1 fludrocortisone 1 tizanidine 1
u escitalopram 1 oxazepam 1 + miglustat 1 cyclobenzaprine ER 3
u fluoxetine 10mg and 20mg tablet 1 temazepam 1 octreotide 1 Lorzone 3
Pz
fluoxetine capsule 1 +
u fluvoxamine tablet 1 triazolam 1 +z Cerdelga 2 Ozobax 3
imipramine 1 z zaleplon 1 +z Egrifta 2 Osteoporosis
maprotiline 1 z zolpidem 1 +z HP Acthar Gel 2 alendronate 1
+
z zolpidem ER 1 z
Norditropin 2
+z
u mirtazapine 1 z calcitonin-salmon 1
Xyrem 2
Pz
nefazodone 1 + Sensipar 2 fortical NS 1
z
Ambien 3 z
Pz
nortriptyline 1 Synarel 2 z ibandronate tabs 1
u paroxetine 1 Ambien CR 3 + Zavesca 2 raloxifene 1
+P Genotropin
Ativan 3 z
phenelzine 1
Pz
3 +z Forteo 2
Belsomra 3 +P Humatrope +z
z
protriptyline 1 3 Tymlos 2
+
Dayvigo 3
u sertraline 1
Pz Increlex 3 Pz Actonel 3
+z
Edluar 3
tranylcypromine 1
+z Myalept 3 Pz Atelvia 3
z
Hetlioz 3
trazodone 1
Pz Intermezzo 3 Mycapssa 3 Pz Binosto 3
u venlafaxine 1 +z Natpara 3 Pz Boniva 3
+P Nutropin/AQ
Librium 3
venlafaxine ER 1
P 3 Pz Fosamax 3
Pu Celexa ramelteon 3
+P Omnitrope Pz
P
3 3 Fosamax D 3
P Rozerem 3
+P Saizen
Pz
Desvenlafaxine ER 3 3 risedronate 150mg 3
P Silenor 3 z
Desvenlafaxine fumarate ER 3 + Sandostatin 3 Pz risedronate DR 3
P Somnote 3
+P Serostim
Pz
Drizalma Sprinkle 3 3
Fetzima 3 Sonata 3 Pain/Arthritis
P +z Xywav 3 + Somatuline Depot 3
fluoxetine 60mg tablet 3
Pz +z Somavert 3 Analgesics, Opioid - Medications listed under this
P zolpidem ER sublingual tablet 3
+P Tev-Tropin
Pz
fluvoxamine ER capsule 3 3 category may require additional review for coverage
Zolpimist 3
Forfivo 3 +P Zorbtive 3 based on recommendations from the Centers for
P Khedezla 3 Cerebral Stimulants Disease Control and Prevention (CDC).
Pu Lexapro armodafinil 1 Other Miscellaneous
+z
3 z z acetaminophen w/codeine 1
P dexmethylphenidate 1 Keveyis 2 belladonna & opium supp 1
Luvox CR 3 +z
z
dexmethylphenidate XR 1 Signifor 2 butalbital/APAP/codeine 1
Oleptro ER 3 +
zu z
Pu Paxil/CR dextroamphetamine tabs 1 Carbaglu 3 butalbital/aspirin/codeine 1
3 z
P Pexeva 3 generic Adderall 1 Cystadane 3 z butorphanol NS 1
P Pristiq ER 3 generic Adderall XR 1 Cystagon 3 z codeine sulfate 1
Pu Prozac 3 generic Concerta 1 + Dojolvi 3 z endocet 1
P Sarafem 3 +z Enspryng 3 z fentanyl lozenge 1
+z
generic Dexedrine spansules 1
Trintellix 3 Evrysdi 3 fentanyl patch 1
z
metadate ER 1
Viibryd 3 Firdapse 3 z hydrocodone/APAP 1
Pu Zoloft 3
methylphenidate CD 1 +z Galafold 3 z hydrocodone/ibuprofen 1
methylphenidate/SR 1 z Isturisa 3 z hydromorphone 1
Antimanic Agents z modafinil 1 z Korlym 3 z meperidine 1
+
lithium carbonate 1 procentra 1 methadone 1
Pz
Procysbi 3
Antipsychotic Agents Adhansia XR 3 + Ravicti 3 morphine SR 1
aripiprazole 1 Pz Adzenys 3 Revcovi 3 z morphine sulfate ER 1
chlorpromazine 1 P Aptensio XR 3 +z Ruzurgi 3 morphine tab, soln, supp 1
clozapine 1 atomoxetine 3 z oxycodone 1
sodium phenylbutyrate 3
fluphenazine 1 Pz Cotempla XR 3 Strensiq 3 z oxycodone/acetaminophen 1
haloperidol 1 Pz Dyanavel XR 3 Veltassa 3 z oxycodone/aspirin 1
P
loxapine 1 z
Focalin XR 3 z z oxycodone/ibuprofen 1
olanzapine 1 Xuriden 3
z
z guanfacine ER 3 oxymorphone/ER 1
Zokinvy 3
Pz
perphenazine 1 z pentazocine/naloxone 1
Pz Abstral
quetiapine 1 Jornay PM 3 Miscellaneous Immunologicals
z 3
Methylphenidate ER (brand) 3 + Cutaquig 3 Pz Actiq
Pz
z risperidone 1 3
risperidone m-tab 1 Mydayis 3 + Cuvitru 3
Pz
z z Belbuca 3
thioridazine 1 Quillichew ER 3 + Gammagard Liquid 3 Buprenorphine 7.5mg TD patch 3
thiothixene 1 Quillivant XR 3 + Gammaked 3 buprenorphine TD patch (generic) 3
trifluoperazine 1 P Vyvanse 3 + Gamunex-C 3 Butrans 3
z ziprasidone caps 1 Miscellaneous + Hizentra 3 z Demerol 3
Pz Abilify 3 z Sunosi 3 + HyQvia 3 Embeda 3
z Abilify Mycite 3 +z Wakix 3 + Xembify 3 z Fentanyl buccal tablet 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. = ACA Preventive Drug
4Section I — Therapeutic drug categories (cont’d)
TIER TIER TIER TIER
fentanyl patch 37.5mcg/hr, 62.5mcg/hr, tramadol ER capsule 3 Respiratory/Asthma theophylline/SR tabs, liquid 1
and 87.5mcg/hr 3 Pz Treximet 3 Theo-24 2
Pz Fentora
Adrenergic
3 +Pz Zecuity 3 Elixophyllin 3
epinephrine auto-injector 1
Fioricet/codeine 3 Pz Zembrace 3 Seizures
Epinephrine (Impax) 2
Fiorinal/codeine 3 Pz Zomig 3
Epinephrine 0.15mg/0.3ml (Mylan) 2
Pz
Barbiturates
P
hydromorphone ER 3 Zomig Nasal 3
Adrenaclick 3
Pz
mephobarbital 1
Hysingla ER 3 Zomig ZMT 3 P Auvi-Q 3
phenobarbital 1
Kadian 3 P
Pz Lazanda
Nonsteroidal Anti-Inflammatory/Combination Epipen/Jr. 3 Hydantoins
3 P Symjepi 3
MorphaBond 3 Products phenytoin 1
Nucynta/ER 3 diclofenac potassium 1 Corticosteroids Dilantin 3
diclofenac sodium 1 budesonide inh. Peganone 3
Oxycodone ER 3 (0.25mg/2ml, 0.5mg/2ml) 1
Oxycontin 3 z diclofenac sodium gel 1% 1
z Asmanex 2
Miscellaneous
z Roxicet solution 3 etodolac 1 carbamazepine 1
Pulmicort flexhaler/powder 2
Pz Subsys etodolac SA 1 z carbamazepine XR 200mg, 400mg 1
3
Pz
Pulmicort respules (1mg/2ml) 2 clobazam 1
z Tylenol/codeine 3 fenoprofen tablet 1 z Qvar 2
z Vicodin/ES 3 flurbiprofen 1 clonazepam 1
z Aerobid/M 3 divalproex sodium/ER 1
Xartemis XR 3 ibuprofen 1 Pz Alvesco 3 felbamate 1
z Xtampza ER 3 indomethacin 1 Pz ArmonAir 3 gabapentin 1
Zohydro ER 3 ketoprofen 1 Pz Arnuity Ellipta 3 lamotrigine/ODT 1
Analgesics, Salicylates ketorolac inj. 1 Pz Flovent HFA/Diskus 3 levetiracetam 1
choline mag. trisalicylate 1 z ketorolac tab 1 Leukotrienes oxcarbazepine 1
diflunisal 1 meclofenamate 1 montelukast 1 primidone 1
salsalate 1 meloxicam 1 zafirlukast 1 topiramate 1
z Yosprala 3 nabumetone 1 z zileuton ER 3 topiramate ER 1
Anti-Rheumatic z Zyflo 3 valproic acid 1
naproxen/EC 1 zonisamide 1
hydroxychloroquine 1 oxaprozin 1 Other Agents
cromolyn inh. soln. 1 Tegretol 2
leflunomide 1 piroxicam 1 Vimpat 2
methotrexate 1 sulindac 1 z fluticasone-salmeterol (Prasco) 1
Aptiom 3
z penicillamine 1 tolmetin 1
ipratropium inh. soln. 1
Banzel 3
+Pz Actemra 2 Pz
ipratropium/albuterol 1
Briviact 3
+Pz Cimzia
Diclofenac Epolamine patch 3 z
z
wixela inhub 1
Pz diclofenac sodium 3% gel
2 z
3 Diacomit 3
+z Enbrel 2 Anoro Ellipta 2
+ Epidiolex 3
+z
diclofenac sodium/misoprostol 3 Atrovent HFA 2
z
Pz
Humira 2 Fintepla 3
+z diclofenac sodium topical solution 3 z Bevespi 2
Pz
Otezla 2 z Fycompa 3
Duexis 3 z Combivent Respimat 2
Pz
Ridaura 2 lamotrigine ER 3
Pz Lyrica CR
Dulera 2
+z Flector 3 z
Rinvoq 2
Pz +z Esbriet 2 3
+z Xeljanz 2 indomethacin 20mg 3 z Nuedexta 3
+z Xeljanz XR 2 Pz Licart 3 z Fluticasone-Salmeterol (Teva) 2
Oxtellar XR 3
Incruse Ellipta 2
z
z
+z
Cuprimine 3 mefenamic acid 3 Potiga 3
Kalydeco 2
z Depen 3 naproxen CR 375mg tablet 3 +z Ofev 2 pregabalin 3
+z Kevzara 3 Pz Pennsaid 3 +z Orkambi 2 Qudexy XR 3
Pz Kineret 3 Pz Qmiiz ODT 3 + Sabril 3
Pz
+ Pulmozyme 2
+Pz Olumiant 3 z Sprix 3 z Spiriva 2 Sympazan 3
+Pz Orencia SC 3 Tivorbex 3 z Spiriva Respimat 2 Tegretol XR 100mg 3
Otrexup 3 Pz Vimovo 3 z Stiolto Respimat 2 tiagabine 3
Pz
Rasuvo 3 z Symbicort 2 Trokendi XR 3
Vivlodex 3
+Pz Simponi Pz +z Symdeko 2 + vigabatrin oral powder 3
z
3 Zipsor 3 Xcopri 3
Cox-2s Pz Zorvolex 3 z Trelegy Ellipta 2
celecoxib 3 +z Trikafta 2 Succinimides
Pz
z
Parkinson’s Disease Advair diskus 3 ethosuximide 1
P
Migraine (Miscellaneous) Celontin 3
z benztropine 1 Advair HFA 3
Aimovig 2 Pz AirDuo 3 Skin
z Ajovy 2 bromocriptine 1
P Breo Ellipta 3
z Emgality 2 carbidopa/levodopa 1
+ Bronchitol 3 Acne/Rosacea
z Nurtec ODT 3 carbidopa/levodopa SA 1 P Budesonide-Formoterol 3 adapalene/benzoyl peroxide 1
z Ubrelvy 3 entacapone 1 Daliresp 3 adapalene cream/gel 1
Migraine (Analgesics, Non-opioid) pramipexole 1 Pz Duaklir Pressair 3 amnesteem 1
butalbital/APAP 50mg-325mg 1 ropinirole 1 Fasenra pen 3 avita cream 1
+
butalbital/APAP/caffeine 1 selegiline 1 benzoyl peroxide 1
z Glassia 3 claravis 1
butalbital/aspirin/caffeine 1 trihexyphenidyl 1 z Lonhala Magnair 3
Pz dihydroergotamine mesylate
clindamycin/benzoyl peroxide
1 +z Apokyn 3 +z Nucala syringe/auto-inject 3 1.2%-2.5% gel 1
z eletriptan 1 carbidopa 3 Orkambi granules 3 clindamycin/benzoyl peroxide 1-5% gel 1
ergotamine/caffeine 1 +z Duopa 3 z Seebri 3 clindamycin phospate 1
z
isometh/dichloralphen/APAP 1 Gocovri 3 Tudorza 3 erythromycin/benz peroxide 1
Utibron 3
z
naratriptan 1 z minocycline 1
Pz
z Inbrija 3 Yupelri 3
z rizatriptan 1 z Kynmobi 3 Sympathomimetics
prascion RA 1
+z
z sumatriptan 1 sodium sulfacetamide 1
Nourianz 3 albuterol sulfate ER 1 sod. sulfacetamide/sulfur emulsion cleanser 1
z
tramadol/ER tablet 1 Ongentys 3 z albuterol sulfate HFA sod. sulfacetamide/sulfur lot 1
Pz
tramadol/acetaminopen 1
Osmolex ER 3 (generic ProAir HFA, Proventil HFA) 1 sotret 1
z zolmitriptan 1
Pz Amerge 3 pergolide 3 albuterol tab, syr 1 tretinoin cr/gel 1
Pz pramipexole ER 3 metaproterenol syr 1 Absorica 3
P
Axert 3
z rasagiline 3 terbutaline tab 1 Acanya 3
butalbital/APAP 50mg-300mg 3
ropinirole ER 3 z Foradil 2 P Aczone 3
Cafergot 3 P
Pz Cambia Rytary 3 z Maxair Autohaler 2 Adapalene lotion 3
3 z Serevent Diskus 2 adapalene solution 3
P P
z Ergomar 3 tolcapone 3
Albuterol Sulfate HFA 3 adapalene swab 3
Pz Frova 3 z Xadago 3 Arcapta 3 P Aklief 3
z frovatriptan 3 Potassium P Levalbuterol Tartrate HFA 3 P Altreno 3
Pz Imitrex 3 z ProAir HFA/RespiClick 3 P Amzeeq 3
Pz Maxalt 3 Potassium agents Pz Proventil HFA 3 P Avar 3
Pz Maxalt MLT 3 potassium bicarb/potassium chloride 1 z Striverdi Respimat 3 P Avita gel 3
Pz Onzetra 3 potassium bicarbonate 1 Pz Ventolin HFA 3 azelaic acid gel 3
Pz Relpax 3 potassium citrate ER 1 P Xopenex HFA 3 P Azelex 3
z Reyvow 3 potassium chloride 1 Xanthine Derivatives P Benzaclin 3
z Sumavel 3 Potassium Removing agent aminophylline 1 P Benzamycin 3
Pz Tosymra 3 sod. polystyrene sulfonate 1 theochron 1 P Cleocin T 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. = ACA Preventive Drug
5Section I — Therapeutic drug categories (cont’d)
TIER TIER TIER TIER
clindamycin/benzoyl peroxide Picato 2 methylprednisolone 4mg, 8mg, 16mg, 32mg 1 mesalamine enema 1
1.2%-2.5% pump 3 Regranex 2 z prednisolone oral 1 + sapropterin 1
clindamycin/benzoyl peroxide 1-5% pump 3 Carac 3 prednisone oral 1 sulfasalazine 1
dapsone 5% 3 +z Dupixent 3 Medrol 2mg 2 sulfasalazine EC 1
P Differin 3 Eucrisa 3 +z Emflaza 3 Cholbam 2
P Doryx 3 Fluoroplex 3 P Hemady 3 z Amitiza 3
P doxycycline hyclate DR 3 Fluorouracil 0.5% cr 3 Rayos 3 Apriso 3
P Doxycycline IR-DR 3 z Azulfidine 3
P
Klisyri 3 Stomach/Ulcer
Duac 3 Pz Qbrexza budesonide ER tablet 3
P
3
Duac CS 3 Anorectal z Dipentum 3
P
Regenecare 3
Epiduo 3 z hydrocortisone rectal cr. & supp. 1 + Gattex 3
P
Zonalon 3
Evoclin 3 hydrocortisone rectal enema 1 Giazo 3
P Fabior 3 Psoralens
pramoxine/HC acetate 2.5% 1 + Kuvan 3
P Finacea 3 methoxsalen capsule 1
Analpram-HC 1-1% 3 Linzess 3
P Metrogel topical 1% 3 8-MOP 2
Analpram-HC 2.5% cr/lot 3 mesalamine DR capsule 400mg 3
P minocycline HCl ER 3 Scabicides & Pediculicides mesalamine DR tablet 1.2g 3
Pz
Cortifoam 3
Minolira ER 3 acticin 1 mesalamine DR tablet 800mg 3
P
Proctofoam-HC 3
Mirvaso 3 permethrin 1 mesalamine suppository 3
P Noritate 3 spinosad 1 Anticholinergics/Antispasmodic/GI Motility
Motegrity 3
P belladonna/phenobarbital 1 z
Onexton 3 Lindane 2 z Movantik 3
P Oracea 3 Ulesfia 2 chlordiazepoxide/clindinium 1
+z Palynziq 3
P Retin-A/Micro 3 Eurax 3 dicyclomine 1
Pentasa 3
P Rhofade 3 Sklice 3 glycopyrrolate 1 Relistor 3
P Rosula 3 Topical Anti-Inflammatory Agents
hyoscyamine/CR 1 z Symproic 3
Pz Seysara 3 alclometasone 1
metoclopramide 1 Trulance 3
P
z
Solodyn 3 Donnatal tablet 2 Uceris 3
amcinonide 1
Soolantra 3 Antidiarrheal z Xermelo 3
P
aug. betamethasone diprop 1
tazarotene cream 3 diphenoxylate/atropine 1 Zelnorm 3
P
betamethasone dipropionate 1 z
Tazorac 3 z nitazoxanide 1
P
betamethasone valerate 1 Proton Pump Inhibitors
tretinoin microsphere gel 3 paregoric 1
P clobetasol emol/emuls 1 z esomeprazole magnesium 1
Veltin gel 3 Alinia suspension 2
P clobetasol proprionate z z lansoprazole 1
Winlevi 3 Fulyzaq 2 Pz
P foam/gel/oint/cr/sol 1 lansoprazole DR ODT 1
Ximino 3 Alinia tablet 3
P desonide 1 z z Nexium 24HR 1
Ziana gel 3 Antiemetic/Antivertigo z omeprazole 1
desoximetasone 1
Antibiotics (Topical)
diflorasone 1 z aprepitant 1 z pantoprazole 1
clindamycin sol/swabs/gel/lotion 1
fluocinolone acetonide 1 z granisetron 1 z Prevacid 24HR 1
erythromycin sol/swabs/gel 1 meclizine 1 z Prilosec-OTC 1
fluocinonide 1
gentamicin cr/oint 1
fluticasone propionate 1 z ondansetron 1 z rabeprazole 1
metronidazole cream/lotion/ 0.75% gel 1 prochlorperazine 1 z Zegerid OTC 1
mupirocin 1 halobetasol 1
promethazine 1 z Nexium DR 2.5mg, 5mg packet 2
Pz
Bactroban cream 3 halobetasol propionate 1 scopolamine patch 1
z
Aciphex 3
Pz
Centany 3 halobetasol propionate foam 1 trimethobenzamide 1
P
Dexilant 3
Xepi 3 hydrocortisone 2.5% 1 Antivert 50mg 2 Pz Nexium 3
Antipsoriatics hydrocortisone valerate 1 z Anzemet 2 z Nexium DR 10mg, 20mg, 40mg packet 3
acitretin 1 hydrocortisone/iodoquinol 1 z Emend 2 Pz omeprazole/sodium bicarbonate 3
calcipotriene 1 mometasone cr/oint 1 Pz Akynzeo 3 Pz Prevacid 3
tacrolimus 1 prednicarbate 1 z Bonjesta 3 Pz Prilosec 3
+z Cosentyx 2 triamcinolone acetonide 1 z doxylamine-pyridoxine 3 Pz Protonix 3
Dritho-Scalp 2 Cordran tape 2 z Granisol 3 Pz Zegerid 3
Elidel 2 betamethasone valerate foam 3 z Sancuso 3
+z Skyrizi 2 Capex Shampoo 3 z Syndros 3 Thyroid
Soriatane CK 2 clobetasol propionate lotion/shampoo/spray 3 z Varubi 3 Antithyroid
+z Stelara 2 Cordran ointment 3 z Zuplenz 3 methimazole 1
+z Tremfya 2 Pz Duobrii 3 Bowel Evacuants propylthiouracil 1
P calcipotriene-betamethasone ointment 3 fluocinonide cream (generic Vanos) 3 peg 3350/electrolyte 1 Thyroid
calcitriol ointment 3 flurandrenolide cream 3 Trilyte 1 levothroid 1
P Enstilar 3 halcinonide cream 3 Nulytely 3 levothyroxine 1
+Pz Siliq 3 hydrocortisone butyrate/emoll cream 3 Prepopik 3 levoxyl 1
P Taclonex 3 P Impoyz 3 Suprep 3 liothyronine 1
+Pz Taltz 3 Kenalog/aerosol 3 Digestants thyroid 1
P Wynzora 3 z Lexette 3 Zenpep 2 unithroid 1
Burn preparation z triamcinolone spray 3 P Creon 3 Synthroid 2
silver sulfadiazine 1 Topical Antipruritics/Anesthetics P Pancreaze 3 Thyroid (Armour) 2
Fungicides lidocaine 1 P Pertzye 3 Thyrolar 2
betamethasone/clotrimazole 1 z lidocaine patch 1 Sucraid 3 Tirosint 3
ciclopirox cream 1 selenium sulf 2.5% suspension 1 P Ultresa 3 Vaccines
ciclopirox soln 1 Rectiv 3 Viokace 3 Adacel 2
econazole 1 Topical Antivirals Gallstone Solubilizing Agents Bexsero 2
ketoconazole 1 acyclovir cream 1 ursodiol 1 Boostrix 2
nystatin 1 acyclovir ointment 1 +z Ocaliva 3 Daptacel 2
nystatin/triamcinolone 1 Denavir 3 H2 Antagonists Diphtheria-Tetanus Toxoids-Ped 2
nystop 1
Smoking Cessation cimetidine 1 Infanrix 2
Exelderm 2
famotidine 1 Influenza 2
z Jublia 3 bupropion 1 Menactra 2
z Kerydin 3 Nicorelief gum 1 nizatidine 1
Menhibrix 2
naftifine 3 Nicorelief lozenge 1 ranitidine (all) 1
Menomune-A-C-Y-W-135 2
Miscellaneous Nicotine Gum 1 Other Antiulcer
Menveo A-C-Y-W-135-Dip 2
aluminum chloride 20% 1 Nicotine lozenges 1 misoprostol 1
Pneumovax 23 2
z doxepin cream 1 Nicotine patches various 1 propantheline bromide 1
Prevnar 13 2
fluorouracil 5% cr/sol 1 Chantix 2 sucralfate 1
Shingrix 2
fluorouracil 2% sol 1 Commit 2 Helidac 3
Tenivac 2
imiquimod 5% cream 1 Nicotrol Inhaler 2 lansoprazole/amox/clarith 3 Tetanus Diphtheria Toxoids 2
ivermectin 1 Nicotrol NS 2 Other GI Products Trumenba 2
podofilox 1 Zyban 3 alosetron 1 Zostavax 2
z prudoxin 1 balsalazide 1
sodium chloride irrigating soln 1 Steroids budesonide EC 1 Vitamins
+z Benlysta SC 2 cortisone acetate 1 cromolyn sodium 1 calcitriol 1
Panretin 2 dexamethasone oral 1 enulose 1 calcitriol inj 1
Phisohex 2 hydrocortisone oral 1 lactulose 1 calcium acetate 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. = ACA Preventive Drug
6Section I — Therapeutic drug categories (cont’d)
TIER TIER TIER TIER
cholecalciferol 1 Chorionic gonadotropin 3 dasetta 1 norlyda 1
cyanocobalamin inj. 1 Ganirelix 3 daysee 1 norlyroc 1
ergocalciferol capsule 1 P Gonal F 3 deblitane 1 nortrel 1
etidronate 1 Menopur 3 delyla 1 ocella 1
fluoride drops OTC 1 Pregnyl 3 desogestrel-ethinyl estradiol 1 ogestrel 1
fluoride tablets OTC 1 Hormones desogestr-eth estrad eth estra 1 opcicon one-step 1
folic acid Rx 1mg tab 1 dotti 1 drospirenone-ethinyl estradiol 1 option 2 1
folic acid tablets OTC 1 z estradiol/noreth ac 1 econtra ez 1 orsythia 1
leucovorin 1 z estradiol oral 1 econtra one-step 1 philith 1
levocarnitine 1 z estradiol patches 1 elinest 1 pimtrea 1
multivitamin + fluoride (Rx-only) 1 z estropipate 1 emoquette 1 pirmella 1
+ nitisinone 1 z estrogen/methyltesterone 1 enpresse 1 portia 1
Pediatric sodium fluoride chewable tab & z jinteli 1 enskyce 1 previfem 1
drops 1 medroxyprogesterone 1 errin 1 quasense 1
potassium aminobenzoate 1 norethindrone 1 estarylla 1 react 1
pre-natal vitamins (Rx-only) 1 Combipatch 2 ethynodiol-ethinyl estradiol 1 reclipsen 1
z
sevelamer 1 Premphase 2 fallback solo 1 setlakin 1
vit A,D,C + fluoride (Rx-only) 1 Prempro 2 falmina 1 sharobel 1
vit A,D,C + fluoride and iron (Rx-only) 1 Alora 3 femynor 1 simliya 1
z
Galzin 2 Cenestin 3 gianvi 1 simpesse 1
Mephyton 2 Climara Pro 3 gildagia 1 sprintec 1
z
Nascobal 2 Crinone 3 gildess 1 sronyx 1
phytonadione 2 Duavee 3 gildess 24 fe 1 syeda 1
Prenate Elite 2 Enjuvia 3 gildess fe 1 tarina 24 Fe 1
Renagel 2 Estraderm 3 hailey 24 Fe 1 tarina fe 1
z
Auryxia 3 estradiol 0.01% cream 3 heather 1 tarina Fe 1-20 eq 1
lanthanum carbonate tablet 3 Estrasorb packet 3 incassia 1 tilia fe 1
z
paricalcitol 3 Estring 3 introvale 1 tri femynor 1
z
Poly-Vi-Flor + Iron 3 Estrogel 3 isibloom 1 tri-estarylla 1
z
z Rayaldee 3 Evamist 3 jasmiel 1 tri-legest fe 1
Tri-Vi-Flor 3 Femring 3 jencycla 1 tri-linyah 1
z
Velphoro 3 Imvexxy 3 jolessa 1 tri-lo-marzia 1
z
Intrarosa 3 jolivette 1 tri-lo-mili 1
Weight Loss
z
Menest 3 juleber 1 tri-mili 1
benzphetamine 1 z junel 1 trinessa 1
Menostar 3
diethylpropion 1 z junel fe 1 trinessa lo 1
Oriahnn 3
phendimetrazine 1 z kaitlib fe 1 tri-previfem 1
Orilissa 3
phentermine 1 kalliga 1 tri-sprintec 1
Ortho-Est 3
Belviq 3 kariva 1 trivora 1
Osphena 3
z Belviq XR 3 z kelnor 1-35 1 tri-vylibra 1
Prefest 3
z Contrave 3 kelnor 1-50 1 tri-vylibra lo 1
Premarin 3
z Imcivree 3 kimidess 1 tulana 1
Premarin vag cream 3
z Lomaira 3 kurvelo 1 velivet 1
progesterone, micronized 3
z Qsymia 3 larin 1 vestura 1
yuvafem 3
z Saxenda 3 larin fe 1 vienva 1
Suprenza ODT 3 Miscellaneous larissia 1 viorele 1
paroxetine 7.5mg 1
Xenical 3
z layolis fe 1 vyfemla 1
Addyi 3
Women’s Health z leena 1 vylibra 1
Vyleesi 3
lessina 1 wera 1
Please refer to your plan documents to confirm your Oral Contraceptives
cost share for contraceptives. Cost share may vary
levonest 1 wymzya fe 1
afirmelle 1
levonorgestrel 1 zarah 1
by plan. altavera 1
levonorgestrel-eth estradiol 1 zenchent 1
Contraceptives - Other alyacen 1
1
levonorg-eth estrad eth estrad 1 zenchent fe 1
eluryng vaginal ring amethia 1
etonogestrel/ethinyl estradiol vaginal ring 1
levora 1 zeosa 1
amethia lo 1
lillow 1 zovia 1
xulane 1 amethyst 1
lomedia 24 fe 1 zumandimine 1
Mirena 2 apri 1
3
loryna 1 Lo Loestrin Fe 2
Caya Contoured Diaphragm aranelle 1
3
low-ogestrel 1 Natazia 2
Conceptrol ashlyna 1
3
lo-zumandimine 1 Balcoltra 3
Depo-SubQ Provera aubra 1
lutera 1 drospirenone-eth estra-levomef 3
aubra eq 1
FC2 Female Condom 3 lyza 1 Ella 3
aurovela 1
3
Femcap 3 marlissa 1 fayosim 3
aurovela 24 Fe 1
3
gynol II melodetta 24 fe 1 norgestimate-ethinyl estradiol 3
aviane 1
3
Kyleena mibelas 24 fe 1 rajani 3
ayuna 1
+ Liletta microgestin 1 rivelsa 3
azurette 1
+ Nexplanon 3 microgestin fe 1 Slynd 3
balziva 1
3
NuvaRing 3 mili 1 Taytulla 3
bekyree 1
3
Paragard mono-linyah 1 tri-lo-estarylla 3
blisovi 24 fe 1
3
Skyla mononessa 1 tri-lo-sprintec 3
blisovi fe 1
3
Today Contraceptive Sponge my choice 1 tydemy 3
briellyn 1
VCF my way 1 Oxytocic Agents
camila 1
Fertility Induction Agents myzilra 1 methylergonovine maleate 1
camrese 1
clomiphene 1 necon 1 Methergine 3
camrese lo 1
progesterone in oil 1 new day 1 Vaginal Preparations
caziant 1
serophene 1 next choice one dose 1 miconazole vag supp 1
chateal 1
Bravelle 2 nikki 1 nystatin vag tab 1
chateal eq 1
Cetrotide 2 nora-be 1 terconazole 1
cryselle 1
Follistim AQ 2 norethindrone acetate 1 vandazole vag 1
cyclafem 1
Novarel 2 norethindrone-ethin estradiol 1 Cleocin Vag/Ovules 3
cyred 1
Ovidrel 2 norethin-eth estra ferrous fum 1 Clindesse 3
Repronex 2
cyred eq 1 norgestrel-ethiny estra 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. = ACA Preventive Drug
7Section II — Index
DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE
A amitriptyline 4 B butalbital/APAP/caffeine 5 Ciloxan 2 Cystagon 4
abacavir-lamivudine 3 amitriptyline/ chlordiazepoxide 4 bacitracin ophth 2 butalbital/APAP/codeine 4 Cimduo 3 Cystaran 2
abacavir/lamivudine/zidovudine 3 amitriptyline/perphenazine 4 bacitracin/polymyxin 2 butalbital/aspirin/caffeine 5 cimetidine 6
butalbital/aspirin/codeine 4 Cimzia 5
D
Abilify 4 amlodipine 2 baclofen 4
amlodipine/atorvastatin 2 butorphanol NS 4 cinacalcet 4 dalfampridine ER 4
Abilify Mycite 4 Bactroban cream 6 Daliresp 5
abiraterone acetate 1 amlodipine/benazepril 2 Bafiertam 4 Butrans 4 Cinryze 3
amlodipine/valsartan 2 Bydureon 1 Cipro HC 2 danazol 4
Absorica 5 Balcoltra 7 dantrolene sodium 4
Abstral 4 amlodipine/valsartan/HCTZ 3 balsalazide 6 Byetta 1 ciprofloxacin 3
Bystolic 2 ciprofloxacin/dexamethasone 2 dapsone 5% 6
acamprosate calcium tablet EC 4 amnesteem 5 Balversa 1
Byvalson 3 ciprofloxacin ophth 2 dapsone tablets 3
Acanya 5 amoxapine 4 balziva 7
ciprofloxacin otic 2 Daptacel 6
acarbose 1 amoxicillin 3 Banzel 5 C
citalopram 4 dasetta 7
Accu-Chek 2 amoxicillin-clavulanate ER 3 Baqsimi 2 Cablivi 1 claravis 5 Daurismo 1
acebutolol 2 ampicillin 3 Baraclude solution 3 Cabometyx 1 daysee 7
acetaminophen w/codeine 4 Amturnide 3 Basaglar 1 Clarinex-D 1
Cafergot 5 Clarispray 1 Dayvigo 4
acetazolamide 3 Amzeeq 5 Baxdela 3 calcipotriene 6 DDAVP nasal spray 4
acetazolamide ER 3 anagrelide 1 Beconase AQ 1 clarithromycin susp 3
calcipotriene-betamethasone clarithromycin tabs 3 DDAVP sol, tab 4
acetic acid HC otic 2 Analpram-HC 1-1% 6 bekyree 7 ointment 6 deblitane 7
acetic acid otic 2 Analpram-HC 2.5% cr/lot 6 Belbuca 4 clemastine 1
calcitonin-salmon 4 deferasirox 1
acetic acid/aluminum acetate 2 anastrozole 1 belladonna & opium supp 4 Cleocin 3
calcitriol 6 deferiprone 1
acetylcysteine inh soln. 1 Androderm patch 3 belladonna/phenobarbital 6 Cleocin T 5
calcitriol inj 6 delyla 7
Aciphex 6 Android 3 Belsomra 4 Cleocin Vag/Ovules 7
calcitriol ointment 6t Demerol 4
acitretin 6 Anoro Ellipta 5 Belviq 7 Climara Pro 7
calcium acetate 6 Denavir 6
Actemra 5 Antara 2 Belviq XR 7 clindamycin 3
Calquence 1 Depen 5
acticin 6 benazepril 2 clindamycin/benzoyl peroxide
Antivert 50mg 6 Cambia 5 Depo-SubQ Provera 6
Actimmune 1 benazepril/HCTZ 2 1.2%-2.5% gel 5
Anzemet 6 camila 7 Descovy 3
Actiq 4 Benicar 2 clindamycin/benzoyl peroxide
Apidra 1 Campral dosepack 4 1.2%-2.5% pump 6 desipramine 4
Actonel 4 Apokyn 5 Benicar HCT 3 camrese 7 desloratadine 1
Acular PF 2 Benlysta SC 6 clindamycin/benzoyl peroxide
aprepitant 6 camrese lo 7 1-5% gel 5 desmopressin solution 4
acyclovir cream 6 apri 7 Benzaclin 5 candesartan 2 desmopressin tabs 4
clindamycin/benzoyl peroxide
acyclovir ointment 6 Apriso 6 Benzamycin 5 candesartan/HCTZ 2 desogestr-eth estrad eth estra 7
1-5% pump 6
acyclovir oral 3 Aptensio XR 4 benzonatate 1 capecitabine 1 desogestrel-ethinyl estradiol 7
clindamycin phospate 5
Aczone 5 Aptiom 5 benzoyl peroxide 5 Capex Shampoo 6 desonide 6
clindamycin sol/swabs/gel/lotion 6
Adacel 6 Aptivus 3 benzphetamine 7 Caplyta 4 desoximetasone 6
Clindesse 7
adapalene/benzoyl peroxide 5 benztropine 5 Caprelsa 1 Desvenlafaxine ER 4
aranelle 7 clobazam 5
adapalene cream/gel 5 Bepreve 2 captopril 2 Desvenlafaxine fumarate ER 4
Aranesp 1 clobetasol emol/emuls 6
Adapalene lotion 5 Berinert 3 captopril/HCTZ 2 desvenlafaxine succinate ER 4
Arcalyst 1 clobetasol propionate lotion/sham-
adapalene solution 5 Besivance 2 Carac 6 Detrol 1
Arcapta 5 poo/spray 6
adapalene swab 5 betamethasone dipropionate 6 Carbaglu 4 Detrol LA 1
aripiprazole 4 clobetasol proprionate foam/gel/oint/
Addyi 7 betamethasone valerate 6 carbamazepine 5 cr/sol 6 dexameth/neomycin/poly B 2
armodafinil 4
Adempas 3 betamethasone valerate foam 6 carbamazepine XR clomiphene 7 dexamethasone oral 6
Adhansia XR 4 ArmonAir 5
betamethasone/clotrimazole 6 200mg, 400mg 5 clomipramine 4 dexchlorpheniramine 1
Adlyxin 1 Arnuity Ellipta 5 Betaseron 4 carbidopa 5 clonazepam 5 Dexilant 6
Admelog 1 Ascensia Breeze 2 betaxolol 2 carbidopa/levodopa 5 clonidine, oral, patch 2 dexmethylphenidate 4
Adrenaclick 5 ashlyna 7 betaxolol HCl 2 carbidopa/levodopa SA 5 clopidogrel 1 dexmethylphenidate XR 4
Advair diskus 5 Asmanex 5 Bethkis 3 carbinoxamine 1 clorazepate 4 dextroamphetamine tabs 4
Advair HFA 5 aspirin 325mg OTC 1 Betoptic-S 2 Cardec/DM 1 clotrimazole lozenge 3 Diacomit 5
Advicor 2 aspirin 81mg OTC 1 Bevespi 5 Cardura XL 2 clozapine 4 diazepam 4
Adzenys 4 aspirin-dipyridamole 1 Bevyxxa 1 carisoprodol 4 Coartem 3 diclofenac 2
Aerobid/M 5 Astagraf XL 3 bexarotene 1 carisoprodol/ASA 4 codeine sulfate 4 Diclofenac Epolamine patch 5
Afinitor 1 Atacand 2 Bexsero 6 Carospir 3 colchicine/probenecid 2 diclofenac potassium 5
afirmelle 7 Atacand HCT 3 Biaxin XL 3 carteolol 2 colchicine (generic Colcrys) 2 diclofenac sodium 5
Afrezza 2 atazanavir 3 bicalutamide 1 cartia XT 2 colesevelam 2 diclofenac sodium 3% gel 5
Aimovig 5 Atelvia 4 Biktarvy 3 carvedilol 2 Colestid 2 diclofenac sodium gel 1% 5
AirDuo 5 atenolol 2 bimatoprost 0.03% 2 carvedilol ER 2 colestipol 2 diclofenac sodium
Ajovy 5 atenolol/chlorthalidone 2 Binosto 4 Caverject 3 Combipatch 7 topical solution 5
Aklief 5 Ativan 4 bisoprolol 2 Caya Contoured Diaphragm 7 Combivent Respimat 5 diclofenac sodium/misoprostol 5
Akynzeo 6 atomoxetine 4 bisoprolol/HCTZ 2 Cayston 3 Cometriq 1 dicloxacillin 3
albuterol sulfate ER 5 atorvastatin calcium 2 blisovi 24 fe 7 caziant 7 Commit 6 dicyclomine 6
Albuterol Sulfate HFA 5 atovaquone 3 blisovi fe 7 CeeNu 1 Complera 3 didanosine 3
albuterol sulfate HFA atovaquone/proguanil HCl 3 Boniva 4 cefaclor 3 Conceptrol 7 diethylpropion 7
(generic ProAir HFA, Proventil HFA) 5 Atripla 3 Bonjesta 6 cefadroxil 3 Conjupri 2 Differin 6
albuterol tab, syr 5 atropine sulfate ophth 2 Boostrix 6 cefdinir 3 Consensi 3 Dificid 3
alclometasone 6 Atrovent HFA 5 bosentan 3 cefixime 3 Contour 2 diflorasone 6
Alecensa 1 Atrovent Nasal Spray 1 Bosulif 1 cefpodoxime 3 Contrave 7 diflunisal 5
alendronate 4 Aubagio 4 Braftovi 1 cefprozil 3 Copaxone 4 digoxin 2
alfuzosin 4 aubra 7 Bravelle 7 Ceftin 3 Copiktra 1 dihydroergotamine mesylate 5
Alinia tablet 6 Breo Ellipta 5 cefuroxime 3 Cordran ointment 6 Dilantin 5
aubra eq 7
Alinia suspension 6 briellyn 7 celecoxib 5 Cordran tape 6 Dilatrate SR 3
aug. betamethasone diprop 6
aliskiren 2 Brilinta 1 Celexa 4 Corlanor 3 diltia XT 2
aurovela 7 Cortifoam 6
Alkeran 1 aurovela 24 Fe 7 brimonidine 2 Cellcept 3 diltiazem 2
allopurinol 2 brinzolamide 2 Celontin 5 cortisone acetate 6
Auryxia 7 diltiazem CD/SR/ER/XR 2
Alomide 2 Cenestin 7 Cosentyx 6
Austedo 3 Briviact 5 dimethyl fumarate 4
Alora 7 Centany 6 Cotellic 1
Auvi-Q 5 Brukinsa 1 Diovan 2
alosetron 6 Cotempla XR 4
Avalide 3 bromfenac 2 cephalexin 3 Diovan HCT 3
Alphagan P 0.1% 2 Coumadin 1
Avandamet 1 bromocriptine 5 Cequa 2 Dipentum 6
alprazolam/ER 4 Cozaar 2
Avandaryl 1 brompheniramine/phenylephrine 1 Cerdelga 4 diphenhydramine 1
Creon 6
Alprolix 1 brompheniramine/ cetirizine 1 diphenoxylate/atropine 6
Avandia 1 Cresemba 3
altavera 7 pseudoephedrine 1 Cetrotide 7 Diphtheria-Tetanus Toxoids-Ped 6
Avapro 2 Crestor 2
Altoprev 2 Bronchitol 5 Chantix 6 dipyridamole 1
Avar 5 Crinone 7
Altreno 5 budesonide EC 6 chateal 7 disopyramide 2
aviane 7 Crixivan 3
aluminum chloride 20% 6 budesonide ER tablet 6 chateal eq 7 disulfiram 4
avita cream 5 cromolyn inh. soln. 5
Alunbrig 1 Budesonide-Formoterol 5 chloral hydrate 4 cromolyn ophth 2 Ditropan XL 1
Alvesco 5 Avita gel 5
budesonide inh. (0.25mg/2ml, chlordiazepoxide 4 cromolyn sodium 6 divalproex sodium/ER 5
alyacen 7 Avonex 4 0.5mg/2ml) 5 chlordiazepoxide/clindinium 6 cryselle 7 dofetilide 2
alyq 3 Axert 5 budesonide nasal spray 1 chloroquine phosphate 3 Cuprimine 4 Dojolvi 4
amantadine 3 Axiron 3 bumetanide 3 chlorothiazide 3 Cutaquig 4 Domeboro 2
Ambien 4 ayuna 7 Bunavail 4 chlorpromazine 4 donepezil 1
Ayvakit 1 Cuvitru 4
Ambien CR 4 buprenorphine 4 chlorpropamide 1 cyanocobalamin inj. 7 Donnatal tablet 6
ambrisentan 3 Azasite 2 Buprenorphine 7.5mg TD patch 4 chlorthalidone 3 Doptelet 1
cyclafem 7
amcinonide 6 azathioprine 3 buprenorphine TD patch (generic) 4 chlorzoxazone 4 Doryx 6
cyclobenzaprine 4
Amerge 5 azelaic acid gel 5 buprenorphine-naloxone 4 Cholbam 6 cyclobenzaprine 7.5mg 4 dorzolamide 2% eye drops 2
amethia 7 azelastine nasal spray 1 buprenorphine/naloxone film 4 cholecalciferol 7 cyclobenzaprine ER 4 dorzolamide/timolol eye drops 2
amethia lo 7 azelastine ophth 2 bupropion 4 cholestyramine 2 cyclophosphamide 1 dotti 7
amethyst 7 Azelex 5 bupropion 6 choline mag. trisalicylate 5 cyclosporine 3 doxazosin 2
amiloride 3 azithromycin suspension 3 bupropion 12HR 4 Chorionic gonadotropin 7 cyproheptadine 1 doxepin 4
amiloride/HCTZ 3 azithromycin tablets 3 bupropion 24HR 4 Cialis 3 cyred 7 doxepin cream 6
aminophylline 5 Azopt 2 buspirone 4 ciclopirox cream 6 cyred eq 7 doxycycline 3
amiodarone 2 Azulfidine 6 butalbital/APAP 50mg-300mg 5 ciclopirox soln 6 Cystadane 4 doxycycline hyclate 50mg, 75mg,
Amitiza 6 azurette 7 butalbital/APAP 50mg-325mg 5 cilostazol 1 Cystadrops 2 150mg tab 3
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