Group Value Formulary - 4th Quarter 2020
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Group Value Formulary
4th Quarter 2020Page |2
Table of Contents
What is my prescription drug coverage? ...................................................................... 3
What is the Group Value Formulary?........................................................................... 3
How was the formulary created and how are new medications reviewed? .................. 3
Does the formulary ever change? ................................................................................ 3
How am I notified of changes to the formulary? .......................................................... 4
What are brand-name and generic drugs? ................................................................... 4
What is generic substitution? ...................................................................................... 4
What are specialty drugs? ........................................................................................... 4
What are pharmaceutical management procedures?................................................... 5
Are there any restrictions on my coverage? ................................................................. 5
How do I request an exception to the Group Value formulary? .................................... 5
What drugs are not covered by my prescription drug benefit? ..................................... 5
How much medication does my copayment cover and does my plan cover
maintenance medications? .........................................................................................6
How can I save money on prescriptions? ..................................................................... 6
Contraceptive Coverage .............................................................................................. 6
Preventive Care Medications & Medications Covered Under Health Care Reform ........ 7
Smoking Cessation Medication Coverage .................................................................... 7
Diabetic Supplies ........................................................................................................ 7
Oral Oncology Program ............................................................................................... 7
Revised 12/30/2019Page |3
What is my prescription drug coverage?
As part of your FirstCare Health Plans coverage, you may have a prescription drug
benefit. This document will help you understand your prescription drug benefit and the
Group Value formulary.
Not every prescription drug benefit is the same. The best way to determine your
prescription drug coverage is to review your Plan Benefit Documents or call the FirstCare
Customer Service department.
What is the Group Value Formulary?
A formulary is a list of covered drugs selected by FirstCare in consultation with a team of
health care providers. The list represents the prescription drugs believed to be a
necessary part of a quality treatment program. FirstCare will generally cover the drugs
listed on the formulary provided the drug is medically necessary and plan rules
followed. The list, updated regularly, contains both brand-name and generic
medications.
The Group Value formulary is a tiered formulary, meaning there are different
copayments for different levels of drugs. The formulary includes preferred drugs
covered under your prescription benefit. Drugs not listed on the formulary are not
covered. Non-formulary drugs require prior authorization or may be subject to clinical
edits. Formularies continually change to reflect the most recent advances in drug
therapy; therefore, this list is not inclusive and does not guarantee coverage.
How was the formulary created and how are new medications reviewed?
The FirstCare Pharmacy and Therapeutics (P&T) Committee meets regularly to review
new drugs approved by the FDA and new information regarding drugs that are already
on the formulary. The Committee, primarily made up of physicians, pharmacists, and
nurses, review information and scientific evidence concerning safety, effectiveness, and
current use in therapy.
Does the formulary ever change?
Since the P&T Committee meets regularly to review new information, the formulary
may change. Below are some possible reasons the formulary could change:
• Generic forms of the brand drug become available. The brand-name medication
may no longer be covered when a generic is available. The generic medication
may be covered at the lower copayment.
• New drugs may be added by the P&T Committee or the FDA may withdraw a
drug from the market.
Revised 12/30/2019Page |4
• If a drug becomes available without a prescription (becomes over-the-counter),
then the drug may be removed from the formulary. Often, drugs available over-
the-counter are not covered under the prescription benefit.
How am I notified of changes to the formulary?
The Group Value formulary, updated quarterly, can be found on our website at
firstcare.com. To view changes to the formulary, refer to the monthly Formulary
Changes document posted on the website. If you have any questions or wish to obtain a
printed copy of the formularies or pharmaceutical management procedures, please
contact FirstCare Customer Service at 800-884-4901.
What are brand-name and generic drugs?
FirstCare covers both brand-name and generic drugs. Medication that has a trade name
and is protected by a patent (can be produced and sold only by the company holding the
patent) is considered a brand name drug. A generic drug is a medication approved by
the FDA and created to be the same as the brand-name drug in dosage form, safety,
strength, route of administration, quality, and performance characteristics. Generally,
generic drugs cost less than brand-name drugs but the quality and effectiveness are the
same. Generic drugs may differ from the brand-name drug in color, shape, flavor, or
inactive ingredients. Some brand-name drugs have a generic equivalent and others do
not. If a generic form of a brand-name drug becomes available, the brand-name
medication may no longer be covered by your prescription benefit and the generic
medication may be covered at a lower copayment.
What is generic substitution?
Generic substitution occurs when a pharmacist dispenses an FDA approved generic drug
in place of a brand-name drug. Generic substitution will automatically occur at
pharmacies in the FirstCare network. Prescribers may choose to use a brand-name
product and not allow generic substitution. Per state law, the prescriber must
handwrite the statement “brand necessary” or "brand medically necessary” on the
prescription. This does not guarantee coverage. The brand-name product may not be a
covered drug on the formulary, and thus not covered by your prescription benefit.
What are specialty drugs?
Specialty drugs are those drugs used to treat complex or chronic conditions and which
usually require close monitoring, such as multiple sclerosis, hepatitis, rheumatoid
arthritis, and cancer. Specialty drugs may be self-administered in the home by injection
(under the skin or into a muscle), by inhalation, by mouth, or on the skin. These drugs
may also require special handling, special manufacturing processes, and may have
limited prescribing or limited pharmacy availability.
Revised 12/30/2019Page |5 What are pharmaceutical management procedures? Pharmaceutical management procedures are processes that help ensure safe and appropriate use of drugs and ensure access to cost-effective therapy options. As part of such processes, restrictions (described in the following section) may be applied to certain drugs on the formulary. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include safety edits, quantity limits, prior authorization, step therapy, and others. Please refer to the legend for a complete listing of requirements. All restrictions are effective as of the beginning of the plan year unless noted otherwise on the Formulary Changes document. How do I request an exception to the Group Value formulary? You, a representative, or a prescriber can submit a request to FirstCare to make an exception to the formulary. For example, if there are clinically significant reasons why you cannot take a drug in accordance with the coverage requirements (e.g. step therapy, quantity limits, etc.), an exception request can be submitted for review. Additionally, if you 1) have tried the formulary alternatives, or there are clinically significant reasons why the alternatives would not be appropriate for your specific condition, and 2) the requested drug is medically necessary, and 3) the drug is not excluded from coverage, an exception request to cover a drug not listed on formulary can be submitted for review. To request an exception, you, a representative, or a prescriber can submit a coverage exception request to FirstCare via firstcare.com, fax, mail, or phone. You and your prescriber will be notified of the determination in writing. If approved, the drug will be covered at the applicable copayment. If the request is denied, you may still purchase the medication at full cost. For questions regarding this process, contact FirstCare customer service at 1-800-884-4901. What drugs are not covered by my prescription drug benefit? Please refer to your Plan Benefit Documents for complete plan coverage, limitations, and exclusions specific to your prescription drug benefit. Often, over-the-counter medications and herbal products are not covered under FirstCare benefit plans. Revised 12/30/2019
Page |6
How much medication does my copayment cover and does my plan cover
maintenance medications?
You can get up to a 30-day supply of medication for a single copayment. Note that
medications with a quantity limit, restrict the amount of drug you can get per
prescription or per copayment. For example, categories that include drugs used for a
short amount of time, such as antibiotics, antivirals, and most topical medications are
available in 30-day supplies.
Maintenance drugs are medications prescribed for chronic, long-term conditions and
are taken on a regular, recurring basis. To obtain this benefit, the prescriber must write
the prescription for 3-months and the medication must be a covered maintenance drug.
Your prescription benefit plan may not allow certain products or categories such as
opioids, testosterone, sleep agents, benzodiazepines, specialty drugs, and drugs with
quantity limits to be filled as maintenance.
How can I save money on prescriptions?
Review your Plan Benefit Documents for prescription copays and deductible
information. Generic medications will usually be the lowest copayment option; ask your
provider or pharmacist whether your prescription can be filled with a generic
medication.
Take this formulary with you when you visit your provider to confirm medications are
covered by your prescription plan benefit. Your provider will be able to review drug
categories for possible lower copay options when prescribing medications.
Contraceptive Coverage
As specified by health care reform, women must have access to a full range of FDA-
approved contraceptive methods and plans must cover without cost sharing at least one
form of contraception in each of the FDA identified methods. However, plans can use
reasonable medical management within each category to determine what birth control
products are available at $0 cost-share.
• Please refer to the preventive drug notation (PV) on the formulary to determine
which contraceptives are available at a $0 cost-share.
• Certain over-the-counter (OTC) contraceptives for women may also be covered
at a $0 cost-share. These must be filled at a network pharmacy with a
prescription prescribed by a health care professional.
Coverage may vary according to your plan. Please refer to applicable plan benefit
documents.
Revised 12/30/2019Page |7 Preventive Care Medications & Medications Covered Under Health Care Reform Preventive care medications as well as other medications covered under Health Care Reform are covered according to your plan benefits. These medications are noted as preventive drugs (PV). Please note this list is subject to change. To obtain this benefit, you must fill at a network pharmacy with a prescription prescribed by a health care professional (includes prescription and over-the-counter medications). Smoking Cessation Medication Coverage All FDA approved tobacco cessation medications, including prescription and over-the- counter medications, are allowed at $0 cost-share per the Patient Protection and Affordable Care Act (PPACA). You are limited to 2 smoking cessation attempts per year, up to 180 days total. Please refer to the preventive drug notation (PV) on the formulary to determine which contraceptives are available at a $0 cost-share. Please note some drugs may be subject to step therapy or prior authorization. To obtain this benefit, you must fill at a network pharmacy with a prescription prescribed by a health care professional (includes prescription and over-the-counter medications). Diabetic Supplies The preferred diabetic testing supplies include all Accu-Chek® (Roche Diagnostics) Products and OneTouch® (LifeScan) products. Oral Oncology Program Prescriptions for drugs included in the oral oncology program will be restricted to a 2- week supply for the first 2 months of therapy. Revised 12/30/2019
Reading your formulary
The formulary gives you choices so you and your doctor can determine your best course of
treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example,
TOPAMAX) and generic medications in lowercase (for example, topiramate).
Tier information
Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your
plan may have multiple or no tiers. Please note: If you have a high deductible plan, the tier cost
levels will apply once you meet your deductible.
Drug Tier Includes Helpful Tips
Tier 0 drugs may be available at a $0 cost share based
Tier 0 Preventive on Health Care Reform regulations. Please refer to the
Notes column in this drug list for more information.
Use Tier 1 drugs instead of brand-name drugs, to help
Tier 1 Preferred Generics
reduce your out-of-pocket costs.
Tier 2 drugs will generally have lower co-payments than
Tier 2 Preferred Brand
non-preferred brand-name drugs.
Non-preferred Brands Many Tier 3 drugs have lower-cost options in Tier 1 or 2.
Tier 3
and Generics Ask your doctor if they could work for you.
Tier SP1 Specialty Preferred Generics
Specialty drugs are sometimes used to treat complex
Tier SP2 Specialty Preferred Brands and chronic conditions and may require special
monitoring and handling. Use preferred options in SP1
Tier SP3 Specialty Non-preferred
and SP2 when available.
Brands
Drug list information
In this drug list, some medications are noted with letters next to them to help you see which ones
may have coverage requirements or limits. Your benefit plan determines how these medications
may be covered for you.
AL Age limits – Medications may only be covered if you meet the minimum or maximum
age limit.
PA Prior Authorization – Your doctor is required to provide additional information to
determine coverage.
PV Preventive drugs – Zero cost share preventive medications covered under Health
Care Reform according to your plan benefits. Please note: this list is subject to change.
SF Split Fill – Oral Oncology medications restricted to a two week supply for the first two
months of therapy.
QL Quantity Limit – Medication may be limited to a certain quantity.
ST Step Therapy – Trial of lower-cost medication(s) is required before a higher-cost
medication can be covered.
8Table of Contents
Analgesics - Drugs for Pain............................ 10 Genitourinary Agents - Drugs for Bladder,
Analgesics - Drugs for Pain and Inflammation11 Genital and Kidney Conditions..................... 39
Anesthetics..................................................... 12 Genitourinary Agents - Drugs for Prostate
Anti-Addiction / Substance Abuse Treatment Conditions.................................................... 40
Agents.......................................................... 12 Hormonal Agents - Adrenal............................ 40
Antibacterials.................................................. 12 Hormonal Agents - Men's Health....................40
Anticoagulants................................................ 14 Hormonal Agents - Osteoporosis................... 40
Anticonvulsants - Drugs for Seizures............. 14 Hormonal Agents - Pituitary............................40
Antidementia Agents - Drugs for Alzheimer's Hormonal Agents - Sex Hormones and Birth
Disease and Dementia................................. 15 Control..........................................................41
Antidepressants..............................................15 Hormonal Agents - Thyroid.............................44
Antiemetics - Drugs for Nausea and Vomiting 16 Immunological Agents - Drugs for Immune
Antifungals......................................................16 System Stimulation or Suppression............. 44
Antigout Agents.............................................. 17 Immunological Agents - Drugs for
Antimigraine Agents....................................... 17 Vaccination...................................................46
Antimyasthenic Agents................................... 17 Inflammatory Bowel Disease Agents..............47
Antimycobacterials......................................... 18 Metabolic Bone Disease Agents - Drugs for
Antineoplastics - Drugs for Cancer.................18 Osteoporosis................................................ 47
Antiparasitics.................................................. 20 Metabolic Bone Disease Agents - Other........ 47
Antiparkinson Agents......................................21 Miscellaneous Therapeutic Agents.................47
Antiplatelets.................................................... 21 Ophthalmic Agents - Drugs for Eye Allergy,
Antipsychotics - Drugs for Mood Disorders.... 21 Infection and Inflammation........................... 49
Antivirals......................................................... 21 Ophthalmic Agents - Drugs for Glaucoma......50
Anxiolytics - Drugs for Anxiety........................23 Ophthalmic Agents - Drugs for Miscellaneous
Bipolar Agents - Drugs for Mood Disorders....23 Eye Conditions............................................. 51
Blood Products / Modifiers / Volume Otic Agents - Drugs for Ear Conditions.......... 51
Expanders - Drugs for Bleeding Disorders...23 Respiratory Tract / Pulmonary Agents -
Cardiovascular Agents - Drugs for Heart and Drugs for Allergies, Cough, Cold..................52
Circulation Conditions.................................. 23 Respiratory Tract / Pulmonary Agents -
Central Nervous System Agents - Drugs for Drugs for Asthma and Other Lung
Attention Deficit Disorder..............................27 Conditions 52
Central Nervous System Agents - Drugs for Respiratory Tract / Pulmonary Agents -
Multiple Sclerosis......................................... 27 Drugs for Cystic Fibrosis.............................. 53
Central Nervous System Agents - Respiratory Tract / Pulmonary Agents -
Miscellaneous...............................................27 Drugs for Pulmonary Hypertension.............. 54
Dental and Oral Agents - Drugs for Mouth Skeletal Muscle Relaxants - Drugs for
and Throat Conditions.................................. 27 Muscle Pain and Spasm...............................54
Dermatological Agents - Drugs for Skin Sleep Disorder Agents....................................54
Conditions.................................................... 28 Index of Drugs................................................ 55
Diabetes - Antidiabetic Agents....................... 31
Diabetes - Glucose Monitoring....................... 32
Diabetes - Glycemic Agents........................... 35
Diabetes - Insulins.......................................... 35
Electrolytes / Minerals / Metals / Vitamins...... 36
Gastrointestinal Agents - Drugs for Acid
Reflux and Ulcer...........................................38
Gastrointestinal Agents - Drugs for Bowel,
Intestine and Stomach Conditions................38
Genetic or Enzyme Disorder - Drugs for
Replacement, Modification, Treatment.........39
9Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Analgesics - Drugs for lorcet 1 QL
Pain 1 QL
lorcet hd
acetaminophen-codeine 1 QL 2 QL
LORTAB
acetaminophen-codeine 1 QL methadone hcl intensol 1
#2
methadone hcl oral 1
acetaminophen-codeine 1 QL concentrate
#3
methadone hcl oral 1
acetaminophen-codeine 1 QL solution
#4
methadone hcl oral tablet 1 PA
ascomp-codeine 1
methadone hcl oral tablet 1
buprenorphine soluble
3 PA; QL
transdermal
methadose oral
butalbital-acetaminophen 1
1 concentrate 10 mg/ml
oral tablet 50-325 mg
methadose oral tablet
butalbital-apap-caff-cod 1 1
soluble
butalbital-apap-caffeine 1 1
methadose sugar-free
butalbital-asa-caff- morphine sulfate
1
codeine (concentrate) oral 1 QL
butalbital-aspirin-caffeine 1 solution 100 mg/5ml, 20
butorphanol tartrate mg/ml
1 QL
nasal morphine sulfate er oral 1 PA; QL
carisoprodol-aspirin- tablet extended release
1
codeine morphine sulfate oral 1 QL
codeine sulfate 1 QL morphine sulfate rectal 1 QL
endocet 1 QL NUCYNTA 3 QL
fentanyl transdermal NUCYNTA ER 3 PA; QL
patch 72 hour 100 OXYCODONE HCL ER 1 PA; QL
mcg/hr, 12 mcg/hr, 25 1 PA; QL
mcg/hr, 50 mcg/hr, 75 oxycodone hcl oral
1 QL
mcg/hr capsule
hydrocodone- oxycodone hcl oral
1 QL
acetaminophen oral concentrate 100 mg/5ml
solution 2.5-108 mg/5ml, 1 QL oxycodone hcl oral
1 QL
5-217 mg/10ml, 7.5-325 solution
mg/15ml oxycodone hcl oral tablet 1 QL
hydrocodone- oxycodone-
acetaminophen oral 1 QL
acetaminophen oral
tablet tablet 10-325 mg, 2.5- 1 QL
hydrocodone-ibuprofen 1 QL 325 mg, 5-325 mg, 7.5-
hydromorphone hcl oral 1 QL 325 mg
hydromorphone hcl rectal 1 QL oxycodone-aspirin 1 QL
OXYCONTIN 2 PA; QL
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
10Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
pentazocine-naloxone hcl 1 QL fenoprofen calcium oral
1
tencon 1 capsule 400 mg
tramadol hcl er (biphasic) 1 QL fenoprofen calcium oral 1
tablet
tramadol hcl er oral tablet 1 QL
extended release 24 hour flurbiprofen oral 1
tramadol hcl ir 1 QL gnp aspirin low dose 0 PV
tramadol-acetaminophen 1 QL goodsense aspirin low 0 PV
dose
Analgesics - Drugs for
Pain and Inflammation ibu 1
adult aspirin regimen 0 PV ibuprofen oral tablet 400 1
mg, 600 mg, 800 mg
aspirin adult 0 PV
INDOCIN 2
aspirin adult low strength
oral tablet delayed 0 PV indomethacin er 1
release indomethacin oral
1
aspirin childrens 0 PV capsule 25 mg, 50 mg
aspirin ec low dose 0 PV ketoprofen er 1
aspirin ec low strength 0 PV ketoprofen oral 1
aspirin ec oral tablet ketorolac tromethamine
0 PV 1 QL
delayed release 325 mg oral
aspirin low dose 0 PV meclofenamate sodium 1
oral
aspirin oral tablet 0 PV
mefenamic acid oral 3
aspirin oral tablet 0 PV
delayed release meloxicam oral 1
BAYER ASPIRIN 0 PV nabumetone oral 1
BAYER ASPIRIN EC naproxen dr 1
0 PV
LOW DOSE naproxen oral 1
celecoxib oral 1 QL naproxen sodium oral 1
diclofenac potassium 1 tablet 275 mg, 550 mg
diclofenac sodium er 1 oxaprozin 1
diclofenac sodium oral 1 piroxicam oral 1
diclofenac sodium qc aspirin low dose oral
1 QL 0 PV
transdermal gel 1 % tablet delayed release
diclofenac sodium salsalate oral 1
1 PA
transdermal solution ST JOSEPH LOW DOSE
diclofenac-misoprostol 3 ORAL TABLET 0 PV
DELAYED RELEASE
diflunisal oral 1
sulindac oral 1
ec-naproxen 1
tolmetin sodium 1
etodolac 1
etodolac er 1
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
11Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Anesthetics NALOXONE HCL
glydo 1 INJECTION SOLUTION 2
AUTO-INJECTOR
lidocaine external 1
ointment naloxone hcl injection 1
solution cartridge
lidocaine external patch 5 1
% naloxone hcl injection 1
solution prefilled syringe
lidocaine hcl external 1
solution naltrexone hcl oral 1
lidocaine hcl NARCAN 2
1
urethral/mucosal NICORETTE PV; QL; AL
lidocaine-prilocaine MOUTH/THROAT GUM 0 (Min 18
1 2 MG Years)
external cream
Anti-Addiction / PV; QL; AL
Substance Abuse nicotine polacrilex 0 (Min 18
Treatment Agents mouth/throat Years)
acamprosate calcium 1 PV; QL; AL
0 (Min 18
buprenorphine hcl 1 QL nicotine step 1 Years)
sublingual
PV; QL; AL
buprenorphine hcl- 0 (Min 18
naloxone hcl sublingual 3 QL Years)
nicotine step 2
film
PV; QL; AL
buprenorphine hcl- 0 (Min 18
naloxone hcl sublingual 1 QL Years)
nicotine step 3
tablet sublingual
ST; PV;
PV; QL; AL QL; AL
bupropion hcl er 3 (Min 18 3
(Min 18
(smoking det) Years) Years)
NICOTROL
ST; PV; ST; PV;
QL; AL QL; AL
3 3
(Min 18 (Min 18
CHANTIX Years) Years)
NICOTROL NS
ST; PV; 3 QL
SUBOXONE
QL; AL
3 Antibacterials
CHANTIX CONTINUING (Min 18
MONTH PAK Years) amoxicillin 1
ST; PV; amoxicillin-potassium
1
QL; AL clavulanate er
3
CHANTIX STARTING (Min 18
amoxicillin-potassium 1
MONTH PAK Years)
clavulanate oral
disulfiram oral 1 1
ampicillin
naloxone hcl injection 1
solution
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
12Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
AUGMENTIN ORAL ERY-TAB 2
SUSPENSION 2 erythromycin base 1
RECONSTITUTED 125-
31.25 MG/5ML erythromycin 1
ethylsuccinate oral
avidoxy 1
erythromycin oral 1
azithromycin oral 1
FIRVANQ 3
cefaclor 1
gentamicin sulfate 1
cefaclor er 1 external
cefadroxil 1 levofloxacin oral 1
cefdinir 1 linezolid oral suspension 3 QL
cefixime 1 reconstituted
cefpodoxime proxetil 1 linezolid oral tablet 1 QL
cefprozil 1 methenamine hippurate 1
cefuroxime axetil 1 methenamine mandelate
1
cephalexin 1 oral
ciprofloxacin hcl oral 1 metronidazole oral 1
clarithromycin er 1 metronidazole vaginal 1
clarithromycin oral 1 minocycline hcl oral 1
CLEOCIN VAGINAL mondoxyne nl oral
2 1
SUPPOSITORY capsule 100 mg
clindamycin hcl oral 1 MONUROL 2
clindamycin palmitate hcl 1 morgidox oral 1
clindamycin phosphate moxifloxacin hcl oral 1
1
vaginal mupirocin calcium 3
CLINDESSE 3 mupirocin external 1
demeclocycline hcl 3 neomycin sulfate oral 1
dicloxacillin sodium 1 nitrofurantoin 1
DIFICID 3 nitrofurantoin 1
doxycycline hyclate oral macrocrystal oral
1
capsule nitrofurantoin
doxycycline hyclate oral monohydrate 1
1 macrocrystals
tablet 100 mg, 20 mg
doxycycline monohydrate paromomycin sulfate oral 3
oral capsule 100 mg, 50 1 penicillin v potassium 1
mg silver sulfadiazine
1
doxycycline monohydrate external
oral tablet 100 mg, 50 1 ssd 1
mg, 75 mg
sulfadiazine oral 3
ERYPED 400 2
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
13Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
sulfamethoxazole- Anticonvulsants -
1
trimethoprim oral Drugs for Seizures
sulfatrim pediatric 1 APTIOM 3
SUPRAX ORAL BANZEL SP2 PA
SUSPENSION 2 carbamazepine er 1
RECONSTITUTED 500
carbamazepine oral 1
MG/5ML
CARBATROL 2
SUPRAX ORAL TABLET
2
CHEWABLE CELONTIN 2
tetracycline hcl oral 1 clobazam oral 3 PA
tinidazole oral 1 suspension
1 clobazam oral tablet 1 PA
trimethoprim oral
DEPAKOTE 2
vancomycin hcl
intravenous solution DEPAKOTE ER 2
3
reconstituted 1 gm, 500 DEPAKOTE SPRINKLES 2
mg, 750 mg
DIASTAT ACUDIAL 2 QL
vancomycin hcl oral 3
DIASTAT PEDIATRIC 2 QL
vandazole 1
diazepam rectal 1 QL
VIBRAMYCIN ORAL 2 DILANTIN 2
SYRUP
3 PA DILANTIN INFATABS 2
XIFAXAN
Anticoagulants divalproex sodium er 1
ARIXTRA SP3 QL divalproex sodium oral 1
ELIQUIS 2 QL EPIDIOLEX SP2 PA
ELIQUIS DVT/PE epitol 1
2 QL
STARTER PACK ethosuximide oral 1
enoxaparin sodium felbamate 1
1 QL
subcutaneous FELBATOL 2
fondaparinux sodium SP1 QL 3
FYCOMPA
FRAGMIN SP3 QL 1
gabapentin oral
heparin sodium (porcine) 1 2
GABITRIL
heparin sodium (porcine) KEPPRA ORAL 2
1
pf
KEPPRA XR 2
jantoven 1
LAMICTAL 2
LOVENOX SP3 QL
SUBCUTANEOUS LAMICTAL STARTER 2
warfarin sodium oral 1 lamotrigine er 3
XARELTO 2 QL lamotrigine oral kit 3
XARELTO STARTER lamotrigine oral tablet 1
2 QL
PACK
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
14Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
lamotrigine oral tablet valproic acid oral 1
1
chewable vigabatrin SP1 PA
lamotrigine oral tablet 3 vigadrone SP1 PA
dispersible
VIMPAT ORAL 3
lamotrigine starter kit- 1
blue ZARONTIN 2
lamotrigine starter kit- ZONEGRAN 3
1
green zonisamide oral 1
lamotrigine starter kit- Antidementia Agents -
1
orange Drugs for Alzheimer's
1 Disease and Dementia
levetiracetam er
1 donepezil hcl 1
levetiracetam oral
MYSOLINE 2 galantamine 1
hydrobromide er
NEURONTIN 2
galantamine
oxcarbazepine 1 1
hydrobromide oral tablet
OXTELLAR XR 3 memantine hcl er 1 QL
phenobarbital oral 1 memantine hcl oral 1
PHENYTEK 2 NAMENDA XR
2 QL
phenytoin infatabs 1 TITRATION PACK
phenytoin oral 1 rivastigmine 1
phenytoin sodium rivastigmine tartrate 1
1
extended Antidepressants
primidone oral 1 amitriptyline hcl oral 1
roweepra 1 amoxapine 1
roweepra xr 1 bupropion hcl er (sr) 1 QL
SABRIL SP3 PA bupropion hcl er (xl) oral
subvenite 1 tablet extended release 1 QL
subvenite starter kit-blue 1 24 hour 150 mg, 300 mg
bupropion hcl oral 1
subvenite starter kit- 1
green chlordiazepoxide- 1
subvenite starter kit- amitriptyline
1
orange citalopram hydrobromide 1
TEGRETOL 2 clomipramine hcl oral 1
TEGRETOL-XR 2 desipramine hcl oral 1
tiagabine hcl 1 desvenlafaxine succinate
1 QL
TOPAMAX 2 er
2 doxepin hcl oral capsule 1
TOPAMAX SPRINKLE
topiramate oral 1 doxepin hcl oral
1
concentrate
TRILEPTAL 2
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
15Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
duloxetine hcl oral Antiemetics - Drugs for
capsule delayed release Nausea and Vomiting
1 QL
particles 20 mg, 30 mg, aprepitant 3 QL
60 mg
BONJESTA 3 PA; QL
escitalopram oxalate 1
compro 1
FETZIMA 3 QL
doxylamine-pyridoxine 3 PA; QL
FETZIMA TITRATION 3 QL
dronabinol 3 PA; QL
fluoxetine hcl (pmdd) 1
EMEND ORAL
fluoxetine hcl oral 1 SUSPENSION 3 QL
capsule RECONSTITUTED
fluoxetine hcl oral granisetron hcl oral 3 QL
1 QL
capsule delayed release
metoclopramide hcl oral
fluoxetine hcl oral 1
1 solution
solution
metoclopramide hcl oral
fluoxetine hcl oral tablet 1 1
tablet
fluvoxamine maleate 1 ondansetron hcl injection 1
fluvoxamine maleate er 3 QL ondansetron hcl oral
1 QL
imipramine hcl oral 1 solution
imipramine pamoate 3 ondansetron hcl oral 1 QL
maprotiline hcl 1 tablet 24 mg
mirtazapine oral 1 ondansetron hcl oral 1
tablet 4 mg, 8 mg
nefazodone hcl 1
ondansetron odt 1
nortriptyline hcl oral 1
perphenazine oral 1
paroxetine hcl 1
prochlorperazine 1
paroxetine hcl er 1
prochlorperazine 1
PAXIL ORAL 2 edisylate injection
SUSPENSION
prochlorperazine maleate
phenelzine sulfate oral 1 1
oral
protriptyline hcl 1 scopolamine 1
sertraline hcl oral 1 trimethobenzamide hcl
1
tranylcypromine sulfate 1 oral
trazodone hcl oral 1 Antifungals
trimipramine maleate oral 1 bio-statin oral powder 1
TRINTELLIX 3 ST; QL ciclodan 1
venlafaxine hcl 1 ciclopirox 1
venlafaxine hcl er 1 ciclopirox olamine 1
VIIBRYD 3 QL external
clotrimazole mouth/throat 1
VIIBRYD STARTER
3 QL
PACK
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
16Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
clotrimazole- voriconazole oral 3
1
betamethasone Antigout Agents
CRESEMBA ORAL SP3 allopurinol oral 1
dermazene 1 COLCHICINE ORAL 1
econazole nitrate CAPSULE
1
external colchicine oral tablet 1
EXELDERM 2 colchicine-probenecid 1
fluconazole oral 1 febuxostat 3
griseofulvin microsize 1 probenecid 1
oral
Antimigraine Agents
griseofulvin 1 AIMOVIG 2 PA; QL
ultramicrosize
almotriptan malate 3 QL
hydrocortisone-
1
iodoquinol dihydroergotamine 1
itraconazole oral 1 PA mesylate injection
ketoconazole external dihydroergotamine
1 1 QL
cream mesylate nasal
eletriptan hydrobromide 1 QL
ketoconazole external 1
shampoo EMGALITY 2 PA; QL
ketoconazole oral 1 EMGALITY (300 MG
2 PA; QL
naftifine hcl 1 DOSE)
ergotamine-caffeine 1
NAFTIN EXTERNAL 2
GEL 2 % frovatriptan succinate 3 QL
NOXAFIL ORAL MIGERGOT 3
2
SUSPENSION naratriptan hcl 1 QL
nyamyc 1 rizatriptan benzoate 1 QL
nystatin external 1 sumatriptan nasal 1 QL
nystatin mouth/throat 1 sumatriptan succinate 1 QL
nystatin oral 1 oral
nystatin-triamcinolone 1 sumatriptan succinate 1 QL
nystop 1 refill
oxiconazole nitrate 1 sumatriptan succinate 1 QL
subcutaneous solution
OXISTAT EXTERNAL
2 sumatriptan succinate
LOTION
subcutaneous solution 1 QL
posaconazole 1 auto-injector
SULCONAZOLE zolmitriptan oral 1 QL
2
NITRATE
Antimyasthenic Agents
terbinafine hcl oral 1 QL
pyridostigmine bromide
terconazole 1 1
er
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
17Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
pyridostigmine bromide COMETRIQ (60 MG
1 SP2 PA
oral solution DAILY DOSE)
pyridostigmine bromide COPIKTRA SP2 PA; SF
1
oral tablet 60 mg COTELLIC SP2 PA
Antimycobacterials 1
cyclophosphamide oral
dapsone oral 1 SP2 PA; SF
DAURISMO
ethambutol hcl oral 1 3
DROXIA
isoniazid oral 1 SP2 PA; SF
ERIVEDGE
pyrazinamide oral 1 SP2 PA
ERLEADA
rifabutin 3
erlotinib hcl oral tablet SP1 PA; SF
rifampin oral 1 100 mg, 150 mg
SIRTURO SP3 erlotinib hcl oral tablet 25 SP1 PA; SF; QL
Antineoplastics - Drugs mg
for Cancer etoposide oral SP1
abiraterone acetate SP1 PA; SF everolimus oral tablet 2.5
SP1 PA; QL
AFINITOR SP2 PA; QL mg, 5 mg, 7.5 mg
AFINITOR DISPERZ SP2 PA exemestane 1 PV
ALECENSA SP2 PA FARESTON SP2
ALUNBRIG SP2 PA; QL FARYDAK SP2 PA
anastrozole oral 1 PV flutamide 1
AYVAKIT SP2 PA; SF; QL GILOTRIF SP2 PA; QL
BALVERSA SP2 PA; SF GLEEVEC SP2 PA
bexarotene SP1 PA; SF GLEOSTINE SP2
bicalutamide 1 HYCAMTIN ORAL SP2
BOSULIF SP2 PA; SF hydroxyurea oral 1
BRAFTOVI SP2 PA IBRANCE SP2 PA
BRUKINSA SP2 PA; SF ICLUSIG ORAL TABLET SP2 PA; QL
15 MG
CABOMETYX SP2 PA; SF
ICLUSIG ORAL TABLET SP2 PA
CALQUENCE SP2 PA; SF
45 MG
capecitabine SP1 PA SP2 PA; QL
IDHIFA
CAPRELSA ORAL SP2 PA; QL imatinib mesylate SP1 PA
TABLET 100 MG
IMBRUVICA SP2 PA
CAPRELSA ORAL SP2 PA
TABLET 300 MG INLYTA SP2 PA; SF
COMETRIQ (100 MG INREBIC SP2 PA; SF
SP2 PA
DAILY DOSE) IRESSA SP2 PA
COMETRIQ (140 MG JAKAFI ORAL TABLET
SP2 PA SP2 PA; SF; QL
DAILY DOSE) 10 MG
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
18Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
JAKAFI ORAL TABLET NEXAVAR SP2 PA; SF
15 MG, 20 MG, 25 MG, 5 SP2 PA; SF NILANDRON SP2
MG
nilutamide SP1
KISQALI (200 MG SP2 PA
DOSE) NINLARO SP2 PA
KISQALI (400 MG NUBEQA SP2 PA; SF
SP2 PA
DOSE) ODOMZO SP2 PA
KISQALI (600 MG PEMAZYRE SP2 PA; SF; QL
SP2 PA
DOSE) PIQRAY (200 MG DAILY SP2 PA
KOSELUGO SP2 PA DOSE)
LENVIMA (10 MG DAILY PIQRAY (250 MG DAILY
SP2 PA SP2 PA
DOSE) DOSE)
LENVIMA (12 MG DAILY PIQRAY (300 MG DAILY
SP2 PA SP2 PA
DOSE) DOSE)
LENVIMA (14 MG DAILY POMALYST SP2 PA
SP2 PA
DOSE) PURIXAN SP2
LENVIMA (18 MG DAILY SP2 PA QINLOCK SP2 PA
DOSE)
RETEVMO SP2 PA; SF
LENVIMA (20 MG DAILY SP2 PA
DOSE) REVLIMID SP2 PA
LENVIMA (24 MG DAILY ROZLYTREK SP2 PA; SF
SP2 PA
DOSE) RUBRACA SP2 PA; SF
LENVIMA (4 MG DAILY RYDAPT SP2 PA
SP2 PA
DOSE) SPRYCEL SP2 PA; SF
LENVIMA (8 MG DAILY STIVARGA SP2 PA
SP2 PA
DOSE)
SUTENT SP2 PA
letrozole oral 1
SYNRIBO SP2 PA
leucovorin calcium oral 1
TABRECTA SP2 PA
LEUKERAN 2
TAFINLAR SP2 PA; SF
LONSURF SP2 PA
TAGRISSO ORAL SP2 PA; QL
LORBRENA SP2 PA; SF
TABLET 40 MG
LYNPARZA SP2 PA
TAGRISSO ORAL SP2 PA
LYSODREN SP2 TABLET 80 MG
MATULANE SP2 TALZENNA SP2 PA; SF
MEKINIST SP2 PA tamoxifen citrate oral 1
MEKTOVI SP2 PA tablet 10 mg
melphalan 1 tamoxifen citrate oral
1 PV
tablet 20 mg
mercaptopurine oral 1
TARCEVA ORAL
MYLERAN 2 SP2 PA; SF
TABLET 100 MG, 150
NERLYNX SP2 PA; SF; QL MG
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
19Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
TARCEVA ORAL XPOVIO (80 MG ONCE
SP2 PA; SF; QL SP2 PA
TABLET 25 MG WEEKLY)
TARGRETIN EXTERNAL SP2 PA XPOVIO (80 MG TWICE SP2 PA
TARGRETIN ORAL SP2 PA; SF WEEKLY)
TASIGNA SP2 PA XTANDI SP2 PA; SF
TAZVERIK SP2 PA; SF YONSA SP2 PA; SF
TEMODAR ORAL SP2 PA ZEJULA SP2 PA; SF
temozolomide SP1 PA ZELBORAF SP2 PA
THALOMID SP2 PA ZOLINZA SP2 PA; SF
TIBSOVO SP2 PA; SF ZYDELIG SP2 PA
toremifene citrate SP1 ZYKADIA SP2 PA; SF
tretinoin oral SP1 ZYTIGA SP2 PA; SF
SP2 PA Antiparasitics
TUKYSA
SP2 PA albendazole oral 1 PA
TURALIO
SP2 PA atovaquone oral 3
TYKERB
SP3 PA atovaquone-proguanil hcl 1
VALCHLOR
VENCLEXTA SP2 PA chloroquine phosphate
1 QL
oral
VENCLEXTA STARTING
SP2 PA COARTEM 2
PACK
SP2 PA; SF crotan 1
VERZENIO
DARAPRIM 2 PA
VITRAKVI ORAL
SP2 PA; SF
CAPSULE hydroxychloroquine
1
VITRAKVI ORAL sulfate tablet 200 mg oral
SP2 PA
SOLUTION hydroxychloroquine 1 QL
VIZIMPRO SP2 PA; SF sulfate tablet 200 mg oral
SP2 PA; SF IMPAVIDO SP3
VOTRIENT
SP2 PA; SF ivermectin oral 1
XALKORI
SP2 PA lindane 1
XELODA
SP2 PA malathion 3
XOSPATA
mefloquine hcl 1
XPOVIO (100 MG ONCE SP2 PA
WEEKLY) NEBUPENT 2
XPOVIO (40 MG ONCE pentamidine isethionate 1
SP2 PA
WEEKLY) inhalation
XPOVIO (40 MG TWICE permethrin external 1
SP2 PA
WEEKLY) praziquantel oral 3
XPOVIO (60 MG ONCE primaquine phosphate 1
SP2 PA
WEEKLY)
pyrimethamine oral SP1 PA
XPOVIO (60 MG TWICE
SP2 PA quinine sulfate oral 1 PA
WEEKLY)
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
20Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
spinosad 3 aripiprazole oral tablet
3 QL
Antiparkinson Agents dispersible 15 mg
amantadine hcl oral 1 chlorpromazine hcl oral 1
APOKYN SP3 PA; QL clozapine oral tablet 1 QL
benztropine mesylate clozapine oral tablet 3 QL
1 dispersible
oral
bromocriptine mesylate FANAPT 3 QL
1
oral FANAPT TITRATION 3 QL
carbidopa oral 3 PACK
carbidopa-levodopa er 1 fluphenazine hcl oral 1
carbidopa-levodopa oral haloperidol lactate oral 1
1
tablet haloperidol oral 1
carbidopa-levodopa oral LATUDA 3 QL
3
tablet dispersible loxapine succinate 1
carbidopa-levodopa- olanzapine oral 1 QL
3
entacapone
paliperidone er 3 QL
entacapone 3
pimozide 1
pramipexole
1 quetiapine fumarate 1 QL
dihydrochloride
rasagiline mesylate oral 3 quetiapine fumarate er 1 QL
ropinirole hcl 1 risperidone 1 QL
ropinirole hcl er 3 SAPHRIS 3 QL
selegiline hcl oral 1 thioridazine hcl oral 1
tolcapone 3 thiothixene 1
trihexyphenidyl hcl 1 trifluoperazine hcl 1
Antiplatelets VRAYLAR 3 QL
aspirin-dipyridamole er 1 ziprasidone hcl 1 QL
BRILINTA 2 Antivirals
cilostazol 1 abacavir sulfate SP1
clopidogrel bisulfate oral 1 abacavir sulfate- SP1
lamivudine
dipyridamole oral 1
abacavir-lamivudine- SP1
prasugrel hcl 1
zidovudine
Antipsychotics - Drugs 1
acyclovir external
for Mood Disorders
acyclovir oral 1
aripiprazole oral solution 1 QL
adefovir dipivoxil SP1
aripiprazole oral tablet 1 QL
APTIVUS SP2
aripiprazole oral tablet
1 QL atazanavir sulfate SP1
dispersible 10 mg
ATRIPLA SP2
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
21Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
BARACLUDE ORAL KALETRA SP2
SP2 QL
SOLUTION lamivudine oral solution SP1
BARACLUDE ORAL SP3 QL lamivudine oral tablet
TABLET 1
100 mg
BIKTARVY SP2 lamivudine oral tablet SP1
CIMDUO SP2 150 mg, 300 mg
COMBIVIR SP3 lamivudine-zidovudine SP1
COMPLERA SP2 LEXIVA SP2
CRIXIVAN SP2 lopinavir-ritonavir SP1
DELSTRIGO SP2 MAVYRET SP2 PA; QL
DESCOVY SP2 PA; PV nevirapine SP1
didanosine SP1 nevirapine er SP1
DOVATO SP2 NORVIR SP2
EDURANT SP2 ODEFSEY SP2
efavirenz SP1 oseltamivir phosphate
1 QL
efavirenz-lamivudine- oral
SP1
tenofovir PEGASYS SP2 PA
emtricitabine SP1 PEGASYS PROCLICK SP2 PA
EMTRIVA SP2 PEGINTRON SP2 PA
entecavir SP1 QL PIFELTRO SP2
EPCLUSA SP2 PA; QL PREZCOBIX SP2
EPIVIR SP3 PREZISTA SP2
EPIVIR HBV ORAL RETROVIR ORAL SP3
2
SOLUTION REYATAZ SP2
EPZICOM SP3 ribavirin oral SP1
EVOTAZ SP2 rimantadine hcl 1
famciclovir oral 1 ritonavir 1
fosamprenavir calcium SP1 SELZENTRY SP2 PA
FUZEON SP2 stavudine SP1
GENVOYA SP2 STRIBILD SP2
HARVONI SP2 PA; QL SUSTIVA SP3
HEPSERA SP3 SYMFI SP2
INTELENCE SP2 SYMFI LO SP2
INTRON A SP3 PA SYMTUZA SP2
INVIRASE SP2 TEMIXYS SP2
ISENTRESS SP2 tenofovir disoproxil SP1 PV
ISENTRESS HD SP2 fumarate
JULUCA SP2 TIVICAY SP2
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
22Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
TIVICAY PD SP2 lorazepam oral
1 QL
TRIUMEQ SP2 concentrate 2 mg/ml
TRIZIVIR SP3 lorazepam oral tablet 1 QL
TRUVADA SP2 PV oxazepam 1 QL
TYBOST SP2 triazolam 1 QL
1 QL Bipolar Agents - Drugs
valacyclovir hcl oral
for Mood Disorders
valganciclovir hcl SP1
lithium 1
VEMLIDY SP2
lithium carbonate er 1
VIRACEPT SP2
lithium carbonate oral 1
VIRAMUNE SP3
Blood Products /
VIRAMUNE XR SP3 Modifiers / Volume
VIREAD SP2 Expanders - Drugs for
Bleeding Disorders
XOFLUZA (40 MG 3 QL
DOSE) anagrelide hcl 1
XOFLUZA (80 MG ARANESP (ALBUMIN
3 QL
DOSE) FREE) INJECTION SP2 PA
ZIAGEN ORAL SOLUTION PREFILLED
SP2 SYRINGE
SOLUTION
SP3 NEULASTA SP3 PA
ZIAGEN ORAL TABLET
SP1 NEULASTA ONPRO SP3 PA
zidovudine
Anxiolytics - Drugs for NEUPOGEN INJECTION
Anxiety SOLUTION PREFILLED SP3 PA
SYRINGE
alprazolam er 1 QL
PROMACTA SP3 PA
alprazolam oral tablet 1 QL
tranexamic acid oral 1
alprazolam xr 1 QL
Cardiovascular Agents
buspirone hcl oral 1 - Drugs for Heart and
chlordiazepoxide hcl 1 QL Circulation Conditions
clonazepam oral 1 QL acebutolol hcl oral 1
clorazepate dipotassium 1 QL ALDACTAZIDE ORAL 2
diazepam intensol 1 TABLET 50-50 MG
1 aliskiren fumarate 3
diazepam oral
1 QL amiloride hcl oral 1
estazolam
hydroxyzine hcl oral 1 amiloride- 1
hydrochlorothiazide
hydroxyzine pamoate 1 amiodarone hcl oral 1
oral
2 QL amlodipine besylate oral 1
KLONOPIN
lorazepam intensol 1 QL amlodipine besylate- 1
benazepril hcl
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
23Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
amlodipine besylate- clonidine hcl oral 1
1
valsartan colesevelam hcl 3
amlodipine-atorvastatin 3 COLESTID FLAVORED 2
amlodipine-olmesartan 1 ORAL PACKET
amlodipine-valsartan- 1 COLESTID ORAL 2
hctz PACKET
atenolol oral 1 colestipol hcl 1
atenolol-chlorthalidone 1 CORLANOR 3 PA; QL
PV; AL digitek 1
(Min 40 digox 1
1 Years and
atorvastatin calcium oral Max 75 digoxin oral 1
tablet 10 mg, 20 mg Years) DILATRATE-SR 2
atorvastatin calcium oral diltiazem hcl er beads 1
1
tablet 40 mg, 80 mg diltiazem hcl er coated 1
benazepril hcl oral 1 beads
benazepril- 1 diltiazem hcl er oral
hydrochlorothiazide capsule extended 1
betaxolol hcl oral 1 release 12 hour
bisoprolol fumarate 1 diltiazem hcl oral 1
bisoprolol- dilt-xr 1
1
hydrochlorothiazide disopyramide phosphate 1
bumetanide oral 1 DIURIL 2
BYSTOLIC 3 dofetilide 3
candesartan cilexetil 1 doxazosin mesylate oral 1
candesartan cilexetil-hctz 1 enalapril maleate oral 1
captopril oral 1 enalapril- 1
captopril- hydrochlorothiazide
1
hydrochlorothiazide ENTRESTO 3 QL
CARDIZEM LA ORAL EPANED 3
TABLET EXTENDED eplerenone 1
3
RELEASE 24 HOUR 120
MG ezetimibe 1
CAROSPIR 3 ezetimibe-simvastatin 1
cartia xt 1 felodipine er 1
carvedilol 1 fenofibrate micronized 1
chlorthalidone 1 fenofibrate oral capsule 1
cholestyramine light 1 fenofibrate oral tablet 145
mg, 160 mg, 48 mg, 54 1
cholestyramine oral 1
mg
clonidine 1 1
fenofibric acid
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
24Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
FIBRICOR 1 PV; AL
flecainide acetate 1 (Min 40
1 Years and
PV; AL Max 75
(Min 40 lovastatin Years)
1 Years and
Max 75 matzim la 1
fluvastatin sodium Years) methyldopa 1
PV; AL methyldopa-
1
(Min 40 hydrochlorothiazide
1 Years and metolazone 1
Max 75
fluvastatin sodium er Years) metoprolol succinate er 1
fosinopril sodium 1 metoprolol tartrate oral 1
fosinopril sodium-hctz 1 metoprolol-
1
hydrochlorothiazide
furosemide oral 1
mexiletine hcl oral 1
gemfibrozil oral 1
midodrine hcl 1
guanfacine hcl 1
minitran 1
hydralazine hcl oral 1
minoxidil oral 1
hydrochlorothiazide oral 1
moexipril hcl 1
indapamide 1
MULTAQ 2
irbesartan 1
nadolol oral 1
irbesartan- 1
hydrochlorothiazide niacin er 1
(antihyperlipidemic)
ISORDIL TITRADOSE 2
ORAL TABLET 40 MG nifedipine er 1
isosorbide dinitrate 1 nifedipine er osmotic 1
release
isosorbide mononitrate 1
nifedipine oral 1
isosorbide mononitrate er 1
nimodipine oral 3
isradipine 1
NITRO-BID 2
JUXTAPID SP3 PA; QL
NITRO-DUR
labetalol hcl oral 1 TRANSDERMAL PATCH
2
LANOXIN ORAL 24 HOUR 0.3 MG/HR,
TABLET 125 MCG, 250 2 0.8 MG/HR
MCG nitroglycerin sublingual 1
lisinopril oral 1 nitroglycerin transdermal 1
lisinopril- 1 nitroglycerin translingual 1
hydrochlorothiazide
nitro-time 1
losartan potassium oral 1
NORPACE CR 2
losartan potassium-hctz 1
NORTHERA SP3 PA
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
25Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
NYMALIZE SP3 REPATHA SURECLICK SP3 PA; QL
olmesartan medoxomil PV; AL
1
oral (Min 40
olmesartan medoxomil- 1 Years and
1 rosuvastatin calcium oral Max 75
hctz
tablet 10 mg, 5 mg Years)
olmesartan-amlodipine- 1
hctz rosuvastatin calcium oral 1
tablet 20 mg, 40 mg
omega-3-acid ethyl 1
esters PV; AL
(Min 40
pacerone oral tablet 200 1 Years and
1
mg Max 75
pentoxifylline er 1 simvastatin oral Years)
perindopril erbumine 1 sorine 1
phenoxybenzamine hcl sotalol hcl (af) 1
1
oral sotalol hcl oral 1
pindolol 1 spironolactone oral 1
PRALUENT SP3 PA; QL spironolactone-hctz 1
PV; AL taztia xt 1
(Min 40
1 Years and TEKTURNA HCT 3
Max 75 telmisartan 1
pravastatin sodium Years) telmisartan-hctz 1
prazosin hcl oral 1 tiadylt er 1
prevalite 1 1
timolol maleate oral
propafenone hcl 1 torsemide 1
propafenone hcl er 3 trandolapril 1
propranolol hcl er 1 trandolapril-verapamil hcl
3
propranolol hcl oral 1 er
propranolol-hctz 1 triamterene-hctz 1
QBRELIS 3 valsartan 1
quinapril hcl 1 valsartan-
1
quinapril- hydrochlorothiazide
1
hydrochlorothiazide VASCEPA 3
quinidine gluconate er 1 VECAMYL 3
quinidine sulfate 1 verapamil hcl er 1
ramipril 1 verapamil hcl oral 1
ranolazine er 1
REPATHA SP3 PA; QL
REPATHA SP3 PA; QL
PUSHTRONEX SYSTEM
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
26Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Central Nervous Central Nervous
System Agents - Drugs System Agents - Drugs
for Attention Deficit for Multiple Sclerosis
Disorder AMPYRA SP3 PA; QL
amphetamine sulfate 3 QL AUBAGIO SP3 PA; QL
amphetamine- 1 QL AVONEX PEN SP2 PA; QL
dextroamphetamine
AVONEX PREFILLED SP2 PA; QL
amphetamine-
1 QL COPAXONE SP2 PA; QL
dextroamphetamine er
atomoxetine hcl 1 QL dalfampridine er SP1 PA; QL
clonidine hcl er 1 dimethyl fumarate oral SP1 PA; QL
DAYTRANA 2 QL EXTAVIA SP2 PA; QL
dexmethylphenidate hcl 1 QL GILENYA SP2 PA; QL
dexmethylphenidate hcl glatiramer acetate SP1 PA; QL
3 QL
er glatopa SP1 PA; QL
dextroamphetamine PLEGRIDY SP2 PA; QL
1 QL
sulfate er PLEGRIDY STARTER
SP2 PA; QL
dextroamphetamine 1 QL PACK
sulfate oral tablet TECFIDERA SP2 PA; QL
guanfacine hcl er 1 Central Nervous
metadate er 1 QL System Agents -
3 QL Miscellaneous
methamphetamine hcl
caffeine citrate oral 3
methylphenidate hcl er 1 QL
(cd) pregabalin oral 1 QL
methylphenidate hcl er riluzole 3 PA
1 QL
(la) SAVELLA 3 QL
methylphenidate hcl er SAVELLA TITRATION
oral tablet extended 3 QL
PACK
release 10 mg, 18 mg, 20 1 QL
tetrabenazine SP1 PA
mg, 27 mg, 36 mg, 54
mg Dental and Oral Agents
- Drugs for Mouth and
methylphenidate hcl er
1 QL Throat Conditions
oral tablet extended
release 24 hour cavarest 1
methylphenidate hcl oral 1 QL cevimeline hcl 3
QUILLICHEW ER 3 QL chlorhexidine gluconate
1
QUILLIVANT XR 3 QL mouth/throat
2 QL clinpro 5000 1
VYVANSE
denta 5000 plus 1
dentagel 1
fluoridex 1
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
27Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
fluoridex enhanced adapalene external gel
1 1
whitening 0.3 %
fluoridex sensitivity relief 1 ala-cort external cream 1
lidocaine viscous hcl 1 2.5 %
neutral sodium fluoride alclometasone 1
mouth/throat solution 0.2 1 dipropionate
% amcinonide external 3
oralone 1 cream
paroex 1 amcinonide external
3
lotion
periogard 1
amnesteem 1 PA
pilocarpine hcl oral 1
avar cleanser 1
PREVIDENT 5000
2 AL (Max 40
BOOSTER PLUS 1
avita Years)
PREVIDENT 5000 DRY
2 azelaic acid external 3
MOUTH
PREVIDENT 5000 AZELEX 2
2
ENAMEL PROTECT benzoyl peroxide-
1
PREVIDENT 5000 erythromycin
2
ORTHO DEFENSE beser external lotion 3
PREVIDENT 5000 PLUS 2 betamethasone 1
PREVIDENT 5000 dipropionate aug
2
SENSITIVE betamethasone 1
PREVIDENT DENTAL 2 dipropionate external
prevident mouth/throat 1 betamethasone valerate 1
external
sf 1
calcipotriene external
sf 5000 plus 1 3
cream
sodium fluoride 5000 1 calcipotriene external
plus 3
ointment
sodium fluoride 5000 calcipotriene external
1 3
ppm solution
sodium fluoride 5000 calcipotriene-betameth
1 3 QL
sensitive diprop
sodium fluoride dental 1 calcitriol external 3
triamcinolone acetonide CAPEX 2
1
mouth/throat
claravis 1 PA
Dermatological Agents
- Drugs for Skin clindacin etz external 1
Conditions swab
acitretin 3 clindacin-p 1
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
28Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
clindamycin phos- desoximetasone external
1
benzoyl perox external 1 gel
gel 1-5 %, 1.2-5 % desoximetasone external 3
clindamycin phosphate 1 liquid
external gel desoximetasone external 1
clindamycin phosphate 1 ointment 0.25 %
external lotion diclofenac sodium 1 QL
clindamycin phosphate transdermal gel 3 %
1
external solution diflorasone diacetate
3
clindamycin phosphate external cream
1
external swab diflorasone diacetate
1
clobetasol prop emollient external ointment
1
base DRYSOL 2
clobetasol propionate e 1 DUPIXENT SP2 PA; QL
clobetasol propionate 3 ELIDEL 2 ST
emulsion
EPIFOAM 2
clobetasol propionate 1
external cream ery 1
clobetasol propionate erythromycin external 1
3
external foam EUCRISA 2 ST
clobetasol propionate 1 FINACEA EXTERNAL 3 ST
external gel FOAM
clobetasol propionate fluocinolone acetonide
1 1
external liquid body
clobetasol propionate fluocinolone acetonide
1 1
external lotion external
clobetasol propionate fluocinolone acetonide
1 1
external ointment scalp
clobetasol propionate 3 fluocinonide emulsified
1
external shampoo base
clobetasol propionate fluocinonide external 1
1
external solution FLUOROPLEX 2
clodan external shampoo 3
fluorouracil external
1
CONDYLOX 2 cream 5 %
desonide external cream 1 fluorouracil external 1
desonide external lotion 1 solution
desonide external fluticasone propionate 1
1 external cream
ointment
desoximetasone external fluticasone propionate 3
1 external lotion
cream 0.25 %
fluticasone propionate 1
external ointment
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
29Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
gordons urea 1 prednicarbate 1
halobetasol propionate REGRANEX 2 PA
1
external cream rosadan external cream 1
halobetasol propionate 1 rosadan external gel 1
external ointment
SANTYL 2
hydrocortisone ace-
pramoxine external 1 selenium sulfide external 1
cream 2.5-1 % lotion
hydrocortisone butyrate selenium sulfide external 1
1 shampoo 2.25 %
external cream
hydrocortisone butyrate sodium sulfacetamide 1
1 wash liquid 10 % external
external ointment
hydrocortisone butyrate SODIUM
1 SULFACETAMIDE
external solution 2
WASH LIQUID 10 %
hydrocortisone external 1 EXTERNAL
cream 2.5 %
sss 10-5 external foam 1
hydrocortisone external 1
lotion 2.5 % sulfacetamide sodium 1
(acne)
hydrocortisone external 1
ointment 2.5 % sulfacetamide sodium 1
external liquid
hydrocortisone valerate 1
sulfacetamide sodium- 1
imiquimod external 1 sulfur external emulsion
isotretinoin oral 1 PA sulfacetamide sodium-
methoxsalen rapid 3 sulfur external liquid 9-4 1
metronidazole external 1 %, 9-4.5 %
mometasone furoate sulfacetamide sodium-
1 sulfur external lotion 10-5 1
external
%
myorisan 1 PA
sulfacetamide sodium-
neuac external gel 1 sulfur external 1
PICATO 3 ST suspension 10-5 %
pimecrolimus 1 sulfacetamide-sulfur in 3
podocon 1 urea
podofilox external 1 TACLONEX EXTERNAL 3 QL
SUSPENSION
PRAMOSONE
EXTERNAL CREAM 1-1 2 tacrolimus external
1
% ointment
AL (Max 40
PRAMOSONE 2 1
tazarotene external Years)
EXTERNAL LOTION
TAZORAC EXTERNAL AL (Max 40
PRAMOSONE 2 2
CREAM 0.05 % Years)
EXTERNAL OINTMENT
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
30Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
TAZORAC EXTERNAL AL (Max 40 glipizide-metformin hcl 1
2
GEL Years) glyburide micronized 1
TEXACORT 2 glyburide oral 1
tovet external foam 3 glyburide-metformin 1
AL (Max 40 INVOKAMET 2
1
tretinoin external cream Years)
INVOKANA 2
tretinoin external gel 0.01 AL (Max 40
1 JANUMET 2
%, 0.025 % Years)
tretinoin external gel 0.05 AL (Max 40 JANUMET XR 2
3
% Years) JANUVIA 2
AL (Max 40 JARDIANCE 2
1
tretinoin microsphere Years) 2
JENTADUETO
tretinoin microsphere AL (Max 40 2
1 JENTADUETO XR
pump Years)
metformin hcl er 1
triamcinolone acetonide
3 metformin hcl oral tablet 1
external aerosol solution
triamcinolone acetonide miglitol 3
1
external cream nateglinide 1
triamcinolone acetonide OZEMPIC 2 QL
1
external lotion pioglitazone hcl 1
triamcinolone acetonide pioglitazone hcl-
external ointment 0.025 1 3
glimepiride
%, 0.1 %, 0.5 %
pioglitazone hcl-
triderm 1 1
metformin hcl
urea external cream 40 repaglinide 1
1
%
RYBELSUS 3 QL
uremez-40 1
SYMLINPEN 120 3 PA
zenatane 1 PA
SYMLINPEN 60 3 PA
Diabetes - Antidiabetic
Agents SYNJARDY 2
acarbose oral 1 tolbutamide 1
BYDUREON 3 QL TRADJENTA 2
BYDUREON BCISE TRULICITY
3 QL SUBCUTANEOUS
AUTOINJECTOR
SOLUTION PEN- 2 QL
BYETTA 10 MCG PEN 3 QL
INJECTOR 0.75
BYETTA 5 MCG PEN 3 QL MG/0.5ML, 1.5
glimepiride 1 MG/0.5ML
glipizide er 1 VICTOZA 2 QL
glipizide ir 1
glipizide xl 1
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
31Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Diabetes - Glucose AGAMATRIX CONTROL
2
Monitoring LEVEL 4
ACCU-CHEK AVIVA 1 AGAMATRIX PRESTO 2 QL
DEVICE TEST
ACCU-CHEK AVIVA ASSURE PLATINUM 2 QL
CONNECT KIT 1
AUTOLET LANCING 2
W/DEVICE DEVICE
ACCU-CHEK AVIVA BAYER CONTOUR LINK
1 2
PLUS KIT W/DEVICE 2.4 KIT W/DEVICE
ACCU-CHEK AVIVA BIOTEL CARE BLOOD
1 QL 2
PLUS TEST STRIPS GLUCOSE SYST
ACCU-CHEK COMPACT BLOOD GLUCOSE
1 2 QL
PLUS CARE KIT TEST
ACCU-CHEK COMPACT 1 CARETOUCH
PLUS CONTROL CONTROL SOL LEVEL 2
ACCU-CHEK COMPACT 1 QL 2
PLUS TEST STRIPS CARETOUCH 2
ACCU-CHEK FASTCLIX 1 LANCING/EJECTOR
LANCET KIT CARETOUCH TEST 2 QL
ACCU-CHEK GUIDE KIT 1 CEQUR SIMPLICITY 2U 2
W/DEVICE
CEQUR SIMPLICITY 2
ACCU-CHEK GUIDE INSERTER
1
CONTROL
CEQUR SIMPLICITY 2
ACCU-CHEK GUIDE STARTER
1 QL
TEST STRIPS
CHEMSTRIP UGK 1
ACCU-CHEK GUIDE KIT
1 CONTOUR CONTROL 2
W/DEVICE
ACCU-CHEK CONTOUR NEXT
2
MULTICLIX LANCET 1 CONTROL
DEVICE KIT CONTOUR NEXT LINK 2
ACCU-CHEK NANO CONTOUR NEXT
2
SMARTVIEW KIT 1 MONITOR
W/DEVICE CONTOUR NEXT TEST 2 QL
ACCU-CHEK CONTOUR TEST 2 QL
1
SMARTVIEW CONTROL
DIATHRIVE BLOOD 2
ACCU-CHEK GLUCOSE METER
SMARTVIEW TEST 1 QL
STRIPS DIATHRIVE BLOOD 2 QL
GLUCOSE TEST
ACCU-CHEK SOFTCLIX 1
LANCET DEVICE KIT DIATHRIVE GLUCOSE 2
CONTROL SOLN
AGAMATRIX CONTROL 2
LEVEL 2 DIATHRIVE GLUCOSE
2 QL
TEST
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
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