Your 2018 Prescription Drug List - myUHC.com
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Your 2018 Prescription Drug List Louisiana Advantage Three-Tier This Prescription Drug List (PDL) is accurate as of July 2018 and is subject to change after this date. The next anticipated update will be January 2019. This PDL applies to members of our UnitedHealthcare medical plans with a pharmacy benefit subject to the Advantage Three-Tier PDL. Your estimated coverage and copayment/ coinsurance may vary based on the benefit plan you choose and the effective date of the plan. Effective July 1, 2018
Table of Contents
Drug tiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Gastrointestinal
Restrictions on which medications Acid Suppression. . . . . . . . . . . . . . . . . . . . . . . . 15
are covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Nausea/Vomiting. . . . . . . . . . . . . . . . . . . . . . . . 15
Drugs by category . . . . . . . . . . . . . . . . . . . . . . . 8 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Anti-Infectives Gout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Hepatitis C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Antifungals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 HIV/AIDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Infertility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Inflammatory Conditions: Rheumatoid
Cardiovascular/Heart Disease Arthritis, Crohn’s Disease, Psoriasis,
Coagulation Therapy . . . . . . . . . . . . . . . . . . . . . . 9 Ulcerative Colitis. . . . . . . . . . . . . . . . . . . . . . . . 16
High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . 9
Medications for Sexual Dysfuntion . . . . . . . 17
High Cholesterol. . . . . . . . . . . . . . . . . . . . . . . . . 10
Men’s Health
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Central Nervous System
Testosterone Therapy. . . . . . . . . . . . . . . . . . . . . 17
Attention Deficit Disorder. . . . . . . . . . . . . . . . . . 10
Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . 17
Migraine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Musculoskeletal
Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . 11 Muscle Spasms. . . . . . . . . . . . . . . . . . . . . . . . . . 18
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . . 11 Pain Relief. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Seizure Disorders. . . . . . . . . . . . . . . . . . . . . . . . 12 Overactive Bladder. . . . . . . . . . . . . . . . . . . . . . 18
Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Respiratory
Diabetes Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Blood Glucose Monitoring. . . . . . . . . . . . . . . . . 13 Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Insulin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Pulmonary Arterial Hypertension. . . . . . . . . . . 19
Non-Insulin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Smoking Cessation. . . . . . . . . . . . . . . . . . . . . 19
Endocrine
Transplant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Growth Hormone. . . . . . . . . . . . . . . . . . . . . . . . 14
Vitamins/Electrolytes. . . . . . . . . . . . . . . . . . . 20
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Thyroid Hormone Replacement. . . . . . . . . . . . 14 Women’s Health
Eye Conditions Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Hormone Replacement. . . . . . . . . . . . . . . . . . . 22
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Dry Eye Disease. . . . . . . . . . . . . . . . . . . . . . . . . 15 Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . 22
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23We want to help you better understand your medication options.
Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get
the most out of your pharmacy benefit, we’ve included some of the most commonly asked questions about the
Prescription Drug List (PDL).
What is a PDL?
This document is a list of the most commonly prescribed medications. It includes both brand-name and generic
prescription medications approved by the Food and Drug Administration (FDA). Medications are listed by
common categories or classes and placed in tiers that represent the cost you pay out-of-pocket. They are then
listed in alphabetical order. Bring this list with you when you see your doctor. It makes it easier for you and your
doctor to make informed decisions about your medications and may help you save money.
Please note: Where differences are noted between this PDL and your benefit plan documents, the benefit
plan documents will rule. This PDL is not a complete list of medications, and not all medications listed may be
covered under your plan. Please look at your benefit plan documents provided by your employer or health plan
to see which medications are covered under your plan.
What is a tier?
Tiers indicate the amount you pay for your prescription, which is determined by your employer or benefit plan.
Tier 1 medications provide the highest overall value with the lowest out-of-pocket costs. Choosing medications
in lower tiers may save you money. Ask your doctor if a Tier 1 or Tier 2 option could work for you.
Your Cost Drug Tier1 What’s Covered Helpful Hints
Medications that provide the highest overall
$ Use Tier 1 drugs for the lowest
1 value. Mostly generic drugs. Some brand-name
Lowest out-of-pocket costs.
drugs may also be included.
$$ Medications that provide good overall value. Use Tier 2 drugs, instead of Tier 3, to
2
Mid-range A mix of brand-name and generic drugs. help reduce your out-of-pocket costs.
Medications that provide the lowest overall
$$$ Ask your doctor if a Tier 1 or Tier 2
3 value. Mostly brand-name drugs, as well as
Higher option could work for you.
some generics.
1
Some plans may have different tiers. If you have a high deductible plan, the tier cost levels may apply once you hit your
deductible.
Who decides which medications are covered?
Thousands of medications are already available and more come to the market regularly. Often, several
medications are available to treat the same condition.
The UnitedHealthcare® Pharmacy and Therapeutics Committee, which includes both internal and external
physicians and pharmacists, meets regularly to provide clinical reviews of all medications. Using this
information, the PDL Management Committee, which includes senior UnitedHealth Group® physicians and
business leaders, meets to evaluate overall health care value. They also determine coverage and tier status for
all medications.
4How is the overall value of a medication determined?
Many sources and factors are considered, including:
• Clinical Value: How safe and effective a medication is compared to other medications used to treat the same
or similar medical conditions.
• Cost: How much a medication costs compared to other medications used to treat similar medical conditions.
• Outcomes Data: Studies that show how a medication may affect total health care costs.
Why are certain medications excluded?
We review medications based on their total value, including effectiveness and safety, how much they cost, and
the availability of alternative medications to treat the same or similar medical conditions. Certain medications
may be excluded from coverage or subject to prior authorization (sometimes referred to as precertification) if
similar alternatives are available at a lower cost.
Examples include medications that work the same way, but one is much more expensive than the other, or
options that are available without a prescription (also referred to as over-the-counter medications). There are
also some instances where the same product can be made by two or more manufacturers, but greatly vary
in cost. In these instances, only the lower-cost product may be covered. You should review your benefit plan
documents to confirm if any medications are excluded from your plan. You can log in to the member website
listed on your health plan ID card at any time to check your medication coverage. Talk to your doctor to see if
there are lower-cost options or over-the-counter medications available.
What is the difference between brand-name and generic
medications?
Generic medications contain the same active ingredients (what makes the medication work) as brand-name
medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can
approve a generic version with the same active ingredients. These types of medications are known as generic
medications. Sometimes, the same company that makes a brand-name medication also makes the generic
version.
What if my doctor writes a brand-name prescription?
The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or
lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost
option, but not always. For some benefit plans, if a brand-name drug is prescribed and a generic equivalent is
available, your cost-share may be the copayment PLUS the cost difference between the brand-name drug and
the generic equivalent.
5How often are PDLs updated?
• Medications may move to a lower tier at any time.
• Medications may move to a higher tier when a generic becomes available.
• Medications may move to a higher tier or be excluded from coverage most often upon your group’s renewal.
When a medication changes tiers, you may have to pay a different amount for that medication. You can log in
to the member website listed on your health plan ID card at any time to check your medication coverage and
lower-cost options.
Are there other restrictions on which medications are covered?
Yes. Some medications may have additional requirements or limits depending on your benefit plan. You should
review your benefit plan documents to confirm if any of these programs apply to your plan. The medications that
have programs that apply are noted with letters next to them. Examples include:
May be excluded from coverage or subject to prior authorization and/or trial/failure of another
medication(s). Referred to as First Start in New Jersey. (E)
Lower-cost options are available and covered.
Health Care Reform Preventive (H)
This medication is part of a health care reform preventive benefit and may be available at no additional cost
to you.
Health Care Reform Preventive with prior authorization (H-PA)
May be part of health care reform preventive and available at no additional cost to you if prior authorization
criteria is met.
Prior Authorization (sometimes referred to as precertification) (PA)
Requires your doctor to provide information about why you are taking a medication to determine how it may
be covered by your plan.
Refill and Save Program (RS)
Save money on your copayment when you refill your prescription on time as prescribed. Program eligibility
may vary.
Specialty Medication (SP)
Specialty medications treat complex or rare conditions and may require special storage and handling. You may
be required to obtain these medications from a specialty pharmacy.
Step Therapy (referred to as First Start in New Jersey) (ST)
Requires you to try one or more other medications before the medication you are requesting may be covered.
Supply Limits (SL)
Specifies the largest quantity of medication covered per copayment or in a defined period of time.
6I’m taking a specialty medication. Who can I contact for
more information?
Specialty medications are high-cost and are used to treat rare or complex conditions that require
additional care and support. For most plans, these medications are managed through the specialty
pharmacy program. Take advantage of personalized support designed to help you get the most out
of your treatment plan. Visit the member website listed on your health plan ID card or call the toll-free
phone number on your ID card to learn more.
Please note, not all specialty medications are listed here. If you’re taking a specialty medication that is
on a higher tier, call the toll-free phone number on your health plan ID card to talk with a pharmacist
about finding lower-cost options or a financial assistance program.
Who can I contact if I have questions about my PDL?
Online
Log in to the member website listed on your health plan ID card. Once online, you’ll have access to the
following information and tools:
• Pharmacy benefit and coverage information
• Possible lower-cost medication options
• Medication interactions and side effects
• Participating retail pharmacies by ZIP code
• Your prescription history
And, if home delivery services are included in your pharmacy benefit, you can also:
• Refill prescriptions
• Check the status of your order
• Set up reminders for refills
• Manage your account
Check your PDL often for updates.
By phone
Call the toll-free phone number on your health plan ID card to speak with a customer service
representative. We can answer any questions you have about your pharmacy benefit plan, including
lower-cost options.
7Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Anti-Infectives: Antibiotics Anti-Infectives: Antifungals
Amoxicillin Capsule, Chewable Cresemba 3 SL
1
Tablet
Econazole Cream 3 SL
Amoxicillin/Potassium Clavulanate
1
Chewable Tablet, Tablet Fluconazole Tablet 1
Azithromycin Tablet 1 Itraconazole Capsule 1 SL
Cefadroxil Capsule, Tablet 1 Ketoconazole Cream 1 SL
Cefdinir Capsule 1 Noxafil Tablet, Suspension 2
Cefixime Suspension 3 Nystatin Cream, Ointment 1
Cefprozil Tablet 1 Terbinafine Tablet 1 SL
Cefuroxime Tablet 1 Anti-Infectives: Antivirals
Cephalexin Capsule 1 Acyclovir Ointment 3 PA, SL, ST
Ciprodex 3 Acyclovir Tablet 1
Ciprofloxacin Tablet 1 Famciclovir Tablet 2
Clarithromycin Tablet 1 Oseltamivir Capsule, Suspension 2 SL
Clindamycin Capsule 1 Valacyclovir Tablet 1 SL
Dificid 3 SL Valganciclovir 1 SL
Doxycycline Hyclate 50, 100 mg Zovirax Cream 3 E, SL
2
Capsule, Tablet
Doxycycline Monohydrate Cancer
1
50, 100 mg Capsule Alunbrig 2 PA, SL, SP
Levofloxacin Tablet 1 Bexarotene Capsule 3 E, PA, SL, SP
Metronidazole Tablet 1 Bicalutamide 1
Minocycline Capsule 1 Bosulif 2 PA, SL, SP, ST
Minocycline Tablet 3 E Cyclophosphamide Capsule 2
Moxifloxacin Tablet 3 Hydroxyurea Capsule 1
Nitrofurantoin Capsule 1 Idhifa 2 PA, SL, SP
Nitrofurantoin Macrocrystal Capsule 1 Imatinib Tablet 1 PA, SL, SP
Ofloxacin Otic Solution 2 Imbruvica 2 PA, SL, SP
Ofloxacin Tablet 1 Leucovorin Calcium Tablet 1
Penicillin V Potassium Tablet 1 Mercaptopurine Tablet 1
Sulfamethoxazole-Trimethoprim
1 Revlimid 2 PA, SL, SP
Tablet
Suprax Capsule, Chewable Tablet, Rydapt 2 PA, SL, SP
3
Tablet Sutent 2 PA, SL, SP
Bold type = Brand-name drug PA = Prior authorization required
[Plain type = Generic drug] RS = May be eligible for the refill and save program
E = May be excluded from coverage SL = Supply limit
H = May be part of health care reform preventive SP = Specialty medication
H-PA = May be part of health care reform preventive with prior authorization ST = Step therapy
8Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Targretin Capsule 2 SP Diltiazem Sustained-Release Tablet 2
Targretin Gel 3 SL Doxazosin 1
Tasigna 2 PA, SL, SP, ST Edarbi 3 SL
Xeloda 1 SL, SP Edarbyclor 3 SL
Zykadia 2 PA, SL, SP Enalapril 1
Zytiga 2 PA, SL, SP Furosemide 1
Cardiovascular/Heart Disease: Coagulation Therapy Guanfacine 1
Bevyxxa 3 SL Hydralazine 1
Brilinta 3 SL Hydrochlorothiazide 1
Clopidogrel 1 Irbesartan 1
Eliquis 3 SL Labetalol 1
Enoxaparin Sodium 2 SL Lisinopril 1
Pradaxa 2 SL Lisinopril-Hydrochlorothiazide 1
Prasugrel 3 SL Losartan 1
Savaysa 3 SL Losartan-Hydrochlorothiazide 1
Warfarin Sodium 1 Metoprolol Succinate Extended-
2
Release 50, 100, 200 mg
Xarelto 2 SL
Metoprolol Tartrate 25, 50, 100 mg 1
Cardiovascular/Heart Disease: High Blood Pressure
Nadolol 1
Amlodipine 1
Nifedipine Extended-Release 1
Amlodipine-Benazepril 1
Olmesartan 2 SL
Amlodipine-Valsartan 2
Olmesartan-Hydrochlorothiazide 2 SL
Atenolol 1
Propranolol Extended-Release
2
Atenolol-Chlorthalidone 1 Capsule
Benazepril 1 Propranolol Tablet 1
Benazepril-Hydrochlorothiazide 1 Quinapril 1
Bidil 2 Ramipril 1
Bisoprolol 1 Spironolactone 1
Bisoprolol-Hydrochlorothiazide 1 Telmisartan 2
Bystolic 2 Telmisartan-Hydrochlorothiazide 2
Byvalson 2 SL Terazosin 1
Cartia XT 2 Triamterene-Hydrochlorothiazide 1
Carvedilol Immediate-Release Tablet 1 Valsartan 2
Chlorthalidone 1 Valsartan-Hydrochlorothiazide 1
Clonidine Tablet 1 Verapamil 1
Diltiazem 24 Hour CD 2 Verapamil Sustained-Release 3
Diltiazem Sustained-Release
2
Capsule
9Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Cardiovascular/Heart Disease: High Cholesterol Central Nervous System: Attention Deficit Disorder
Atorvastatin 1 H-PA, SL Adderall XR 2 PA, SL
Choline Fenofibrate 3 E Amphetamine Salt Combo 1 PA
Ezetimibe Tablet 3 SL Atomoxetine 3 SL
Ezetimibe/Simvastatin 3 SL Concerta 2 PA, SL
Fenofibrate 54, 160 mg Tablet 2 Dexmethylphenidate Immediate-
1 PA
Release Tablet
Fluvastatin Extended-Release Tablet 3 SL, ST
Dextroamphetamine-Amphetamine
1 PA
Gemfibrozil 1 Immediate-Release Tablet
Livalo 3 E, SL, ST Dextroamphetamine Sulfate
3 PA
Immediate-Release Tablet
Lovastatin 1 H
Guanfacine Extended-Release 2 SL
Niacin Extended-Release Tablet 3 Methylphenidate Chewable Tablet 3 PA
Niaspan 2 Methylphenidate Extended-Release
Omega-3-Acid Ethyl Esters Capsule 3 PA Capsule (generic Metadate CD, 2 PA, SL
Ritalin LA)
Praluent 2 PA, SL, SP, ST Methylphenidate Extended-Release
3 E, PA, SL
Pravastatin 1 Tablet (generic Concerta)
Methylphenidate Extended-Release
Repatha 3 PA, SL, SP, ST Tablet (Metadate ER, generic 3 PA, SL
Rosuvastatin 2 SL Ritalin SR)
Methylphenidate Immediate-Release
Simvastatin 1 H-PA 1 PA
Tablet
Vascepa 3 PA Vyvanse 2 PA, SL
Welchol 2 Central Nervous System: Depression
Cardiovascular/Heart Disease: Other Amitriptyline Tablet 1
Amiodarone 1 Bupropion Extended-Release Tablet 1
Corlanor 3 PA, SL Bupropion Sustained-Release Tablet 1
Digoxin 1 Bupropion Tablet 1
Entresto 3 PA, SL Citalopram Tablet 1
Flecainide 1 Desvenlafaxine Extended-Release
2 SL
Isosorbide Mononitrate ER 1 Tablet (generic Pristiq)
Doxepin 1
Multaq 3 PA
Duloxetine Capsule 3 SL
Nitroglycerin Sublingual Tablet 1
Escitalopram Tablet 1
Ranexa 2
Fetzima 3 SL, ST
Sotalol 1
Fluoxetine Capsule (generic Prozac) 1
Bold type = Brand-name drug PA = Prior authorization required
[Plain type = Generic drug] RS = May be eligible for the refill and save program
E = May be excluded from coverage SL = Supply limit
H = May be part of health care reform preventive SP = Specialty medication
H-PA = May be part of health care reform preventive with prior authorization ST = Step therapy
10Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Fluvoxamine Tablet 1 Aripiprazole Tablet 2 SL
Mirtazapine Tablet 1 Armodafinil 3 PA, SL
Nortriptyline Capsule 1 Austedo 2 PA, SL, SP
Paroxetine Tablet 1 Buspirone Tablet 1
Sertraline Tablet 1 Carbidopa-Levodopa 1
Trazodone Tablet 1 Diazepam Tablet 1
Trintellix 3 SL, ST Donepezil 5, 10 mg ODT, Tablet 1
Venlafaxine Extended-Release Ingrezza 3 PA, SL, SP
1
Capsule
Latuda 3 SL
Venlafaxine Tablet 1
Lithium Capsule 1
Viibryd 3 SL
Lorazepam Tablet 1
Central Nervous System: Migraine
Memantine Immediate-Release Tablet 2
Acetaminophen/Butalbital/Caffeine
1 SL
325 mg/50 mg/40 mg Modafinil Tablet 3 PA, SL
Eletriptan 2 SL Naloxone Vials 1
Frovatriptan 3 SL Narcan Nasal Spray 2 SL
Naratriptan 1 SL Olanzapine Tablet 1 SL
Rizatriptan ODT, Tablet 1 SL Pramipexole Tablet 1
Sumatriptan Nasal Spray 2 SL Quetiapine Extended-Release Tablet 3 SL
Sumatriptan Succinate Tablet, Quetiapine Immediate-Release
1 SL 1
Injection Tablet
Central Nervous System: Multiple Sclerosis Risperidone Tablet 1
Ampyra 2 PA, SL, SP Ropinirole Tablet 1
Aubagio 3 PA, SL, SP Suboxone Film 3 E, PA, SL
Avonex 2 PA, SL, SP Tolcapone 2
Betaseron 2 PA, SL, SP Xyrem 3 PA, SL
Copaxone 2 PA, SL, SP Zelapar 3
Gilenya 3 PA, SL, SP Ziprasidone Capsule 2 SL
E, PA, SL, Zubsolv 2 SL
Glatiramer (generic Copaxone) 3
SP, ST
Central Nervous System: Sedatives/Hypnotics
Plegridy 3 PA, SL, SP
Eszopiclone Tablet 2 SL
Rebif 3 PA, SL, SP, ST
Temazepam Capsule 1
Tecfidera 2 PA, SL, SP
Triazolam Tablet 1
Zinbryta 3 PA, SL, SP
Zaleplon Capsule 1 SL
Central Nervous System: Other
Alprazolam Extended-Release Zolpidem Extended-Release Tablet 3 E, SL
1
Tablet Zolpidem Immediate-Release Tablet 1 SL
Alprazolam Tablet 1
11Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Central Nervous System: Seizure Disorders Clindamycin 1.2%/Benzoyl Peroxide
3 SL
5% Gel
Carbamazepine Extended-Release
2 Clindamycin Gel 3 SL
Capsule
Carbamazepine Extended-Release Clindamycin Lotion 3
3
Tablet
Clindamycin Solution, Swabs 1
Carbamazepine Immediate-Release
1 Clobetasol Propionate Cream,
Tablet 2 SL
Ointment
Clonazepam Tablet 1
Clobetasol Propionate Solution 1 SL
Diazepam Tablet 1
Clotrimazole-Betamethasone Cream 1 SL
Divalproex Delayed-Release Tablet 1
Clotrimazole-Betamethasone Lotion 1
Divalproex Extended-Release Tablet 2
Dapsone 5% Gel 3 E, SL
Gabapentin Capsule, Tablet 1
Desonide 0.05% Cream, Lotion,
Lamotrigine Immediate-Release 3 SL
1 Ointment
Tablet
Desoximetasone Gel, Ointment 3 SL
Levetiracetam Extended-Release
2
Tablet Diflorasone Diacetate 0.05% Cream 3 SL
Levetiracetam Immediate-Release Diflorasone Diacetate 0.05%
1 3
Tablet Ointment
Lyrica 3 SL, ST Dupixent 3 PA, SL, SP, ST
Oxcarbazepine Tablet 1 Elidel 3 SL, ST
Phenytoin Capsule, Suspension 1 Enstilar Foam 3 SL
Topiramate Immediate-Release Eucrisa 3 SL, ST
1
Tablet
Finacea 3
Zonisamide Capsule 1
Fluocinolone Cream, Oil, Solution 3 SL
Dermatology
Fluocinolone Ointment 2 SL
Aczone 3 SL
Adapalene 0.1%/Benzoyl Peroxide Fluocinonide 0.05% Cream 1
3 E, SL
2.5% Gel Fluorouracil 0.5% Cream 3 SL
Adapalene Cream, Gel, Lotion 3 E, PA, SL
Halobetasol Ointment 2 SL
Betamethasone Dipropionate 0.05%
3 Hydrocortisone 2.5% Cream,
Augmented Lotion, Ointment 1
Ointment
Betamethasone Dipropionate 0.05%
2 Imiquimod 5% Cream 1 SL
Cream, Ointment
Calcipotriene/Betamethasone Metronidazole 0.75% Topical Gel 1
3 SL
Ointment
Minocycline Extended-Release 3 E, PA
Carac 2
Mirvaso 3 SL
Ciclopirox Cream, Gel, Lotion,
1 Mometasone Furoate Cream, Lotion,
Solution 1
Ointment
Claravis 2 PA
Mupirocin Ointment 1 SL
Bold type = Brand-name drug PA = Prior authorization required
[Plain type = Generic drug] RS = May be eligible for the refill and save program
E = May be excluded from coverage SL = Supply limit
H = May be part of health care reform preventive SP = Specialty medication
H-PA = May be part of health care reform preventive with prior authorization ST = Step therapy
12Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Oracea 3 Diabetes: Insulin
Oxsoralen-Ultra 2 Afrezza 3 E, PA, SL
Picato 3 SL Basaglar 1 SL
Regranex 2 PA, SL Humalog KwikPens (all formulations) 2 SL
Rhofade 3 PA, SL Humalog Vials (all formulations) 1 SL
Solodyn 3 E, PA Humulin KwikPens (all formulations) 2 SL
Taclonex Suspension 3 SL Humulin Vials (all formulations) 1 SL
Tacrolimus Ointment 2 SL, ST Lantus Solostar 3 E, SL
Tazarotene 0.1% Cream (generic Lantus Vials 3 E, SL
3 E, PA, SL
Tazorac)
Levemir FlexTouch 2 SL
Tazorac 3 PA, SL
Levemir Vials 2 SL
Tretinoin Cream 3 PA, SL
Novolin Vials (all formulations) 3 SL, ST
Tretinoin Gel 3 E, PA, SL
Novolog FlexPen (all formulations) 3 SL, ST
Tretinoin Microspheres 3 E, PA, SL
Novolog Vials (all formulations) 3 SL, ST
Triamcinolone Acetonide Cream,
1
Lotion, Ointment Toujeo SoloStar 3 E, SL
Vectical 3 SL Tresiba FlexTouch 3 E, SL
Diabetes: Blood Glucose Monitoring Diabetes: Non-Insulin
Accu-Chek Test Strips 3 E, SL Adlyxin 3 SL
Contour Next 2 Bydureon 2 SL
Contour Next EZ 2 Byetta 2 SL
Contour Next One 2 Farxiga 3 SL, ST
Contour Next Test Strips 2 SL Glimepiride 1
Contour Test Strips 3 E, SL Glipizide 1
FreeStyle Test Strips 3 E, SL Glipizide Extended-Release 1
OneTouch Test Strips 1 SL Glyburide 1
OneTouch Ultra Meter 1 Glyxambi 3 E, SL, ST
OneTouch Ultra Mini 1 Invokamet 2 SL
OneTouch Ultra Test Strips 1 SL Invokamet XR 2 SL
OneTouch Verio 1 Invokana 2 SL, ST
OneTouch Verio Flex 1 Janumet 3 SL, ST
OneTouch Verio IQ 1 Januvia 3 SL, ST
OneTouch Verio Sync 1 Jardiance 2 SL, ST
OneTouch Verio Test Strips 1 SL
13Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Jentadueto 2 SL Methylprednisolone Tablet 1
Jentadueto XR 2 SL Prenisolone Oral Solution 1
Kazano 2 SL Prednisone Tablet 1
Kombiglyze XR 2 SL Endocrine: Thyroid Hormone Replacement
Metformin 1 Armour Thyroid 3
Metformin Extended-Release Tablet Levothyroxine Sodium Tablet 1
1
(generic Glucophage XR)
Liothyronine Sodium Tablet 2
Nesina 2 SL
Methimazole Tablet 1
Onglyza 2 SL
NP Thyroid Tablet 1
Oseni 2 SL
Synthroid 2
Pioglitazone 1 SL
Eye Conditions: Allergies
Soliqua 2 PA, SL
Azelastine 0.05% Ophthalmic
Synjardy 2 SL 1
Solution
Synjardy XR 2 SL Lastacaft 3 SL
Tradjenta 2 SL Olopatadine 0.1% Ophthalmic
3 SL
Solution
Trulicity 3 SL
Eye Conditions: Antibiotics
Victoza 2-Pak 2 SL
Erythromycin 0.5% Ophthalmic
1
Victoza 3-Pak 3 SL Ointment
Xigduo XR 3 E, SL, ST Gentamicin Ophthalmic Ointment,
1
Solution
Xultophy 3 E, SL
Moxeza 3
Endocrine: Growth Hormone 2
Moxifloxacin Ophthalmic Solution 3
Nutropin, Nutropin AQ 2 PA, SL, SP
Ofloxacin 0.3% Ophthalmic Solution 1
2
Coverage is determined by the consumer’s prescription
Tobramycin/Dexamethasone 0.3%-
drug benefit plan. Please consult plan documents regarding 2
0.1% Ophthalmic Suspension
benefit coverage and cost-share.
Tobramycin Ophthalmic Solution 1
Endocrine: Other
Calcitriol Capsule 1
Desmopressin Tablet 1
Dexamethasone Tablet 1
Bold type = Brand-name drug PA = Prior authorization required
[Plain type = Generic drug] RS = May be eligible for the refill and save program
E = May be excluded from coverage SL = Supply limit
H = May be part of health care reform preventive SP = Specialty medication
H-PA = May be part of health care reform preventive with prior authorization ST = Step therapy
14Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Eye Conditions: Dry Eye Disease Gastrointestinal: Other
Restasis Single Use Vials 3 PA, SL Amitiza 3 PA, SL, ST
Xiidra 3 PA, SL Apriso 2
Eye Conditions: Glaucoma Canasa 2
Alphagan P 0.1% 2 SL Cortifoam 2
Azopt 2 SL Creon 2
Combigan 2 SL Diphenoxylate-Atropine Tablet 1
Latanoprost 0.005% Ophthalmic Golytely 2
1
Solution
Hyoscyamine Tablet 1
Lumigan 2 SL
Lialda 2
Timolol 0.25%, 0.5% Ophthalmic
1
Solution (generic Timoptic) Linzess 2 PA, SL
Travatan Z 2 SL Mesalmine Delayed-Release Tablet
3 E
(generic Lialda)
Gastrointestinal: Acid Suppression
Metoclopramide Tablet 1
Dexilant 3 SL
Movantik 2 PA, SL
Omeclamox-Pak 3 SL
Moviprep 3
Omeprazole Capsule 1
Polyethylene Glycol 3350 2
Pantoprazole Tablet 1
Prepopik 3
Pylera 3 SL
Sulfasalazine Tablet 1
Ranitadine Syrup 1
Suprep 3
Rabeprazole Tablet 3 SL
Uceris Foam 2
Sucralfate Tablet 1
Uceris Tablet 3
Gastrointestinal: Nausea/Vomiting
Viberzi 3 PA, SL
Akynzeo 3 SL
Zenpep 2
Aprepitant Capsule 2 SL
Gout
Emend Suspension 2 SL
Allopurinol Tablet 1
Ondansetron 1
Mitigare 2
Ondansetron ODT 1
Uloric 3 SL, ST
Scopolamine Transdermal Patch 3
Zurampic 3 PA, SL
Varubi 2 SL
15Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Hepatitis C Norvir 2 SP
Daklinza 3 PA, SL, SP, ST Odefsey 3 SP
Epclusa 2 PA, SL, SP Prezcobix 2 SP
Harvoni 2 PA, SL, SP Prezista 2 SP
Mavyret 2 PA, SL, SP Selzentry 2 PA, SP
Ribavirin Tablet 1 SP Stribild 3 SP, ST
Sovaldi 3 PA, SL, SP, ST Tenofovir Tablet 2 SP
Technivie 3 PA, SL, SP, ST Tivicay 3 SP
Viekira Pak 3 PA, SL, SP, ST Triumeq 2 SP
Viekira XR 3 PA, SL, SP, ST Truvada 3 SP
Vosevi 2 PA, SL, SP Tybost 2 SP
Zepatier 3 PA, SL, SP, ST Vitekta 2 SP
HIV/AIDS Infertility 2
Abacavir-Lamivudine 2 SP Cetrotide 2 SP
Atazanavir Capsule 2 SP Clomiphene 1 SP
Atripla 2 SP Crinone 3 PA, ST
Complera 3 SP Endometrin 2 PA
Descovy 3 SP Gonal-F 2 SP
Efavirenz 2 SP Gonal-F RFF 2 SP
Epzicom 3 E, SP Ovidrel 3 SP
Evotaz 2 SP
2
Coverage is determined by the consumer’s prescription
drug benefit plan. Please consult plan documents regarding
Genvoya 3 SP, ST benefit coverage and cost-share.
Intelence 2 SP Inflammatory Conditions: Rheumatoid Arthritis, Crohn’s
Disease, Psoriasis, Ulcerative Colitis
Isentress 2 SP
Actemra 3 PA, SL, SP, ST
Kaletra Tablet 2 SP
Cimzia 2 PA, SL, SP
Lamivudine-Zidovudine 1 SP
Cosentyx 3 PA, SL, SP, ST
Lopinavir-Ritonavir Oral Solution 2 SP
Enbrel 3 PA, SL, SP, ST
Nevirapine 1 SP
Humira 2 PA, SP, SL
Nevirapine Extended-Release 3 E, SP
Hydroxychloroquine Sulfate 1
Bold type = Brand-name drug PA = Prior authorization required
[Plain type = Generic drug] RS = May be eligible for the refill and save program
E = May be excluded from coverage SL = Supply limit
H = May be part of health care reform preventive SP = Specialty medication
H-PA = May be part of health care reform preventive with prior authorization ST = Step therapy
16Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Kevzara 3 PA, SL, SP, ST Men’s Health: Testosterone Therapy
Leflunomide 1 Androderm 2 PA, SL
Methotrexate Tablet 1 Androgel 3 E, PA, SL
Orencia 3 PA, SL, SP, ST Methyltestosterone Capsule 2
Otezla 2 PA, SL, SP Testim 2 PA, SL
Otrexup 3 E, SL, ST Testosterone 1% Topical Gel 3 E, PA, SL
Rasuvo 3 SL, ST Testosterone Cypionate Injection 1
Siliq 3 PA, SL, SP, ST Miscellaneous
Simponi 2 PA, SL, SP Anastrozole Tablet 1
Stelara 2 PA, SL, SP Aranesp 2 SL, SP
Taltz 3 PA, SL, SP, ST Auryxia 3
Tremfya 2 PA, SL, SP Bethkis 2 PA, SL, SP
Xeljanz 3 PA, SL, SP, ST Cayston 2 PA, SL
Xeljanz XR 3 PA, SL, SP, ST Cerdelga 2 PA, SP
Medications for Sexual Dysfunction 2
Chlorhexidine Gluconate 1
Addyi 3 PA, SL Chlorpheniramine/Hydrocodone/
2 PA, SL
Pseudoephedrine Solution
Cialis 3 SL
Epinephrine (generic EpiPen/
2 SL
Intrarosa 3 SL EpiPen-Jr.)
Levitra 3 SL EpiPen/EpiPen-Jr. 3 E, SL
Osphena 3 SL Hydrocodone/Chlorpheniramine
3 PA, SL
Suspension
Sildenafil Tablet (generic Viagra) 3 SL
Lanthanum Chewable Tablet 3
Stendra 3 PA, SL
Letrozole Tablet 1
2
Coverage is determined by the consumer’s prescription
Lidocaine Transdermal Patch
drug benefit plan. Please consult plan documents regarding 3 PA, SL
benefit coverage and cost-share. (generic Lidoderm)
Men’s Health: Prostate Nityr 2 PA, SP
Alfuzosin Tablet 1 Nuedexta 2 PA
Doxazosin Tablet 1 Obredon 3 PA, SL, ST
Dutasteride Capsule 3 Pegasys 2 PA, SP, SL
Finasteride Tablet 1 Phenazopyridine 1
Rapaflo 3 Procrit 2 SL, SP
Tamsulosin Capsule 1 Promethazine/Codeine 1 PA
Terazosin Capsule, Tablet 1 Promethazine/Dextromethorphan 1
Pulmozyme 2 PA, SL, SP
Rectiv 3 SL
Rezira 3
17Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Sevelamer 2 Ibuprofen Tablet 1
Syprine 3 PA, SP Indomethacin Capsule 1
Tobi Podhaler 3 PA, SL, SP Ketorolac Tablet 1
Velphoro 2 Lazanda 3 PA, SL
Veltassa 3 PA, SL Meloxicam Tablet 1
Zarxio 2 SP Methadone Tablet, Oral Solution,
1 PA, SL
Concentrate Solution
Musculoskeletal: Muscle Spasms
Morphine Sulfate Extended-Release
1 PA, SL
Baclofen Tablet 1 Tablet
Carisoprodol 350 mg Tablet 1 Morphine Sulfate Oral Solution 1
Cyclobenzaprine 1 Nabumetone Tablet 1
Metaxalone Tablet 3 Naproxen Tablet 1
Methocarbamol Tablet 1 Nucynta 3 SL
Tizanidine Tablet 1 Nucynta ER 3 PA, SL
Musculoskeletal: Osteoporosis Oxycodone Tablet 1
Alendronate Sodium Tablet 1 Oxycodone/Acetaminophen 5/325,
1 SL
7.5/325, 10/325 mg Tablet
Forteo 3 PA, SP
Oxycontin 3 E, PA, SL, ST
Ibandronate Tablet 2 SL
Sprix 3
Raloxifene Tablet 2
Tramadol-Acetaminophen 1
Risedronate Sodium Tablet 3 SL
Tramadol Immediate-Release Tablet 1
Tymlos 3 PA, SP
Tramadol Sustained-Release Tablet 2 SL
Musculoskeletal: Pain Relief
Trezix 3 SL
Acetaminophen/Codeine Tablet 1 SL Vicodin 5/300, 7.5/300, 10/300 mg
3 E, SL
Belbuca 3 PA, SL Tablet
Celecoxib 2 SL Voltaren Gel 2
Diclofenac Tablet 1 Xtampza ER 2 PA, SL
Etodolac Capsule 1 Zohydro ER 3 PA, SL, ST
Fentanyl 12, 25, 50, 75, 100 mcg Overactive Bladder
2 PA, SL
Patch Dicyclomine Tablet 1
Fentanyl Citrate Lozenge 2 PA, SL Oxybutynin Extended-Release
2
Hydrocodone/Acetaminophen Tablet
1 SL
5/325, 7.5/325, 10/325 mg Tablet Oxybutynin Tablet 1
Hydrocodone/Ibuprofen Tablet 1
Toviaz 3
Hydromorphone Immediate-Release
1
Tablet
Bold type = Brand-name drug PA = Prior authorization required
[Plain type = Generic drug] RS = May be eligible for the refill and save program
E = May be excluded from coverage SL = Supply limit
H = May be part of health care reform preventive SP = Specialty medication
H-PA = May be part of health care reform preventive with prior authorization ST = Step therapy
18Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Respiratory: Allergies Striverdi Respimat 2 SL
Azelastine 0.1% Nasal Spray 3 Symbicort 3 RS, SL
Cyproheptadine Tablet 1 Tudorza 2 SL
Fluticasone Nasal Spray 2 SL Ventolin HFA 2 SL
Hydroxyzine Capsule, Tablet 1 Xopenex HFA 3 SL
Levocetirizine Tablet 1 Respiratory: Pulmonary Arterial Hypertension
Promethazine Tablet 1 Adcirca 3 PA, SL, SP
Zetonna 3 SL Adempas 2 PA, SL, SP
Respiratory: Asthma/COPD Letairis 2 PA, SL, SP
Advair Diskus/HFA 3 RS, SL Opsumit 2 PA, SL, SP
Albuterol Nebs 1 Orenitram 3 PA, SL, SP
Alvesco 1 SL Sildenafil Tablet (generic Revatio) 1 SL, SP
Anoro Ellipta 3 SL Tracleer 2 PA, SL, SP
Arnuity Ellipta 3 SL Tyvaso 2 PA, SP
Asmanex TwistHaler, HFA 1 SL Uptravi 3 PA, SL, SP
Bevespi Aerosphere 2 SL Smoking Cessation
Breo Ellipta 3 RS, SL Bupropion Sustained-Release Tablet 1 H-PA
Budesonide Nebs 2 SL Chantix Tablet 3 H-PA
Combivent Respimat 3 SL Nicoderm CQ 3 H-PA
Dulera 3 E, SL, ST Nicorette Gum 3 H-PA
Flovent Diskus/HFA 3 SL Nicorette Lozenge 2 H-PA
Fluticasone/Salmeterol RespiClick Nicorette Mini-Lozenge 2 H-PA
2 SL
(generic AirDuo RespiClick)
Nicotine Gum 1 H-PA
Incruse Ellipta 2 SL
Nicotine Lozenge 1 H-PA
Ipratropium-Albuterol Nebs 2
Nicotine Patch 1 H-PA
Ipratropium Nebs 1
Nicotrol Inhaler 3 H-PA
Levalbuterol Nebs 3 E, SL
Nicotrol Nasal Spray 3 H-PA
Montelukast Chewable Tablet, Tablet 1
Thrive Gum 1 H-PA
Montelukast Granules 2
Transplant
Perforomist 3 SL
Azathioprine Tablet 1
ProAir HFA/RespiClick 3 SL
Cyclosporine Modified Capsule 1 SP
Proventil HFA 3 SL
Mycophenolate Capsule,
Pulmicort Flexhaler 3 SL, ST 1 SP
Suspension
QVAR Redihaler 1 SL Mycophenolic Acid Tablet 2 SP
Serevent Diskus 3 SL Sirolimus Tablet 1 SP
Spiriva Handihaler/Respimat 3 SL Tacrolimus Capsule 1 SP
19Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Vitamins/Electrolytes Elinest 1 H
Fluoride 1 Ella 1 H, SL
Folic Acid 1 Emoquette 1 H
Klor-Con M10 1 Enpresse 1 H
Klor-Con M20 1 Enskyce 1 H
Potassium Chloride 1 Errin 1 H
Potassium Citrate 1 Estarylla 1 H
Women’s Health: Contraceptives Fallback 1 H
Aftera 1 H Falmina 1 H
Altavera 1 H Fayosim 3 E
Alyacen 7/7/7, 1/35 1 H Gildess 2
Apri 1 H Gildess Fe 1 H
Aranelle 1 H Heather 1 H
Aubra 1 H Introvale 2 H
Aviane 1 H Jencycla 1 H
Azurette 2 Jolessa 2 H
Blisovi Fe 1 H Jolivette 1 H
Camila 1 H Juleber 1 H
Caziant 1 H Junel 2
Cesia 1 H Junel Fe 1 H
Chateal 1 H Kurvelo 1 H
Cryselle 1 H Kelnor 1/35 1 H
Cyclafem 7/7/7, 1/35 1 H Larin Fe 1 H
Cyred 1 H Larissia 1 H
Dasetta 7/7/7, 1/35 1 H Leena 1 H
Deblitane 1 H Lessina 1 H
Delyla 1 H Levonest 1 H
Desogestrel-Ethinyl Estradiol Levonorgestrel 1.5 mg 1 H
1 H
(generic Ortho-Cept)
Levonorgestrel-Ethinyl Estradiol
Drospirenone-Ethinyl Estradiol- (generic Alesse, Nordette, 1 H
3 E
Levomefolate Calcium Triphasil)
Econtra EZ 1 H
Bold type = Brand-name drug PA = Prior authorization required
[Plain type = Generic drug] RS = May be eligible for the refill and save program
E = May be excluded from coverage SL = Supply limit
H = May be part of health care reform preventive SP = Specialty medication
H-PA = May be part of health care reform preventive with prior authorization ST = Step therapy
20Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Levonorgestrel-Ethinyl Estradiol Portia 1 H
2 H
(generic Seasonale)
Previfem 1 H
Levora-28 1 H
Quasense 2 H
Lo Loestrin Fe 3
Rajani 3 E
Loryna 3
React 1 H
Low-Ogestrel 1 H
Reclipsen 1 H
Lutera 1 H
Rivelsa 3 E
Lyza 1 H
Setlakin 2 H
Marlissa 1 H
Sharobel 1 H
Medroxyprogesterone Acetate 1 H
Solia 1 H
Mibelas 24 Fe Chewable Tablet 3 E
Sprintec 1 H
Microgestin 2
Sronyx 1 H
Microgestin Fe 1 H
Take Action 1 H
Mono-Linyah 1 H
Tarina Fe 1 H
MonoNessa 1 H
Tri-Estarylla 1 H
My Way 1 H
Tri-Linyah 1 H
Myzilra 1 H
Tri-Lo-Estarylla 2
Natazia 2
Tri-Lo-Marzia 2
Necon 7/7/7, 0.5/35, 1/35, 1/50,
1 H
10/11 Tri-Lo-Sprintec 2
Next Choice 1 H Tri-Previfem 1 H
Nora BE 1 H Tri-Sprintec 1 H
Norethindrone 0.35 mg 1 H Trinessa 1 H
Norethindrone-Ethinyl Estradiol- Trinessa Lo 2
1 H
Ferrous Fumarate
Norgestimate-Ethinyl Estradiol Trivora-28 1 H
(generic Ortho-Cyclen, Ortho 1 H Velivet 1 H
Tri-Cyclen)
Vestura 3
Norgestimate-Ethinyl Estradiol Lo
2
(generic Ortho Tri-Cyclen Lo) Vienva 1 H
Norlyroc 1 H Viorele 2
Nortrel 7/7/7, 0.5/35, 1/35 1 H Wera 1 H
Nuvaring 2 H Xulane 3 H
Opcicon 1 H Yasmin 28 2
Orsythia 1 H Yaz 2
Pirmella 7/7/7, 1/35 1 H Zovia 1/35E, 1/50E 1 H
Plan B One Step 1 H
21Drug Requirements Drug Requirements
Drug Name Drug Name
Tier & Limits Tier & Limits
Women’s Health: Hormone Replacement Women’s Health: Miscellaneous
Climara Pro 3 SL Raloxifene 2 H-PA
Divigel 3 Tamoxifen 1 H-PA
Duavee 3 SL Women’s Health: Prenatal Vitamins
Estrace Cream 3 Brand Prenatal Vitamins 3
Estradiol Cream (generic Estrace) 3 E
Estradiol/Norethindrone Acetate
2
Tablet
Estradiol Tablet 1
Estradiol Twice-Weekly Transdermal
3 E, SL
Patch (generic Vivelle-Dot)
Estradiol Weekly Transdermal Patch
1 SL
(generic Climara)
Estring 2 SL
Estrogen/Methyltestosterone Tablet 1
Evamist 2
Medroxyprogesterone 1
Minivelle 3 SL
Premarin 3
Premphase 3
Prempro 3
Progesterone Micronized Capsule 2
Vivelle-Dot 2 SL
Yuvafem 2
Bold type = Brand-name drug PA = Prior authorization required
[Plain type = Generic drug] RS = May be eligible for the refill and save program
E = May be excluded from coverage SL = Supply limit
H = May be part of health care reform preventive SP = Specialty medication
H-PA = May be part of health care reform preventive with prior authorization ST = Step therapy
22Index
A Anastrozole Tablet................................... 17 Bexarotene Capsule................................. 8
Abacavir-Lamivudine.............................. 16 Androderm................................................ 17 Bicalutamide............................................... 8
Accu-Chek Test Strips............................ 13 Androgel.................................................... 17 Bidil............................................................... 9
Acetaminophen/Butalbital/Caffeine Anoro Ellipta.............................................. 19 Bisoprolol..................................................... 9
325 mg/50 mg/40 mg....................... 11 Aprepitant Capsule................................. 15 Bisoprolol-Hydrochlorothiazide............. 9
Acetaminophen/Codeine Tablet......... 18 Apri..............................................................20 Blisovi Fe....................................................20
Actemra...................................................... 16 Apriso......................................................... 15 Bosulif........................................................... 8
Acyclovir Ointment.................................... 8 Aranelle......................................................20 Brand Prenatal Vitamins........................22
Acyclovir Tablet.......................................... 8 Aranesp...................................................... 17 Breo Ellipta................................................ 19
Aczone....................................................... 12 Aripiprazole Tablet.................................. 11 Brilinta.......................................................... 9
Adapalene 0.1%/Benzoyl Peroxide Armodafinil................................................ 11 Budesonide Nebs.................................... 19
2.5% Gel................................................ 12 Armour Thyroid........................................ 14 Bupropion Extended-Release
Adapalene Cream, Gel, Lotion............. 12 Arnuity Ellipta............................................ 19 Tablet...................................................... 10
Adcirca....................................................... 19 Asmanex TwistHaler, HFA..................... 19 Bupropion Sustained-Release
Adderall XR............................................... 10 Atazanavir Capsule................................. 16 Tablet............................................... 10, 19
Addyi........................................................... 17 Atenolol........................................................ 9 Bupropion Tablet..................................... 10
Adempas................................................... 19 Atenolol-Chlorthalidone........................... 9 Buspirone Tablet...................................... 11
Adlyxin........................................................ 13 Atomoxetine.............................................. 10 Bydureon................................................... 13
Advair Diskus/HFA.................................. 19 Atorvastatin............................................... 10 Byetta......................................................... 13
Afrezza....................................................... 13 Atripla......................................................... 16 Bystolic......................................................... 9
Aftera..........................................................20 Aubagio...................................................... 11 Byvalson...................................................... 9
AirDuo RespiClick................................... 19 Aubra..........................................................20
C
Akynzeo..................................................... 15 Auryxia....................................................... 17
Austedo...................................................... 11 Calcipotriene/Betamethasone
Albuterol Nebs......................................... 19
Aviane.........................................................20 Ointment................................................ 12
Alendronate Sodium Tablet.................. 18
Avonex........................................................ 11 Calcitriol Capsule.................................... 14
Alesse.........................................................20
Azathioprine Tablet................................. 19 Camila........................................................20
Alfuzosin Tablet........................................ 17
Azelastine 0.05% Ophthalmic Canasa....................................................... 15
Allopurinol Tablet..................................... 15
Solution.................................................. 14 Carac.......................................................... 12
Alphagan P 0.1%...................................... 15
Azelastine 0.1% Nasal Spray................. 19 Carbamazepine Extended-Release
Alprazolam Extended-Release
Azithromycin Tablet.................................. 8 Capsule.................................................. 12
Tablet...................................................... 11
Azopt.......................................................... 15 Carbamazepine Extended-Release
Alprazolam Tablet.................................... 11
Azurette......................................................20 Tablet...................................................... 12
Altavera......................................................20
Carbamazepine Immediate-Release
Alunbrig........................................................ 8 B Tablet...................................................... 12
Alvesco....................................................... 19
Baclofen Tablet........................................ 18 Carbidopa-Levodopa............................. 11
Alyacen 7/7/7, 1/35.................................20
Basaglar..................................................... 13 Carisoprodol 350 mg Tablet................. 18
Amiodarone.............................................. 10
Belbuca...................................................... 18 Cartia XT...................................................... 9
Amitiza........................................................ 15
Benazepril................................................... 9 Carvedilol Immediate-Release Tablet... 9
Amitriptyline Tablet.................................. 10
Benazepril-Hydrochlorothiazide............ 9 Cayston...................................................... 17
Amlodipine.................................................. 9
Betamethasone Dipropionate 0.05% Caziant.......................................................20
Amlodipine-Benazepril............................. 9
Augmented Lotion, Ointment........... 12 Cefadroxil Capsule, Tablet...................... 8
Amlodipine-Valsartan............................... 9
Betamethasone Dipropionate 0.05% Cefdinir Capsule........................................ 8
Amoxicillin Capsule, Chewable
Cream, Ointment................................. 12 Cefixime Suspension................................ 8
Tablet........................................................ 8
Betaseron.................................................. 11 Cefprozil Tablet.......................................... 8
Amoxicillin/Potassium Clavulanate
Bethkis....................................................... 17 Cefuroxime Tablet..................................... 8
Chewable Tablet, Tablet...................... 8
Bevespi Aerosphere............................... 19 Celecoxib................................................... 18
Amphetamine Salt Combo................... 10
Bevyxxa....................................................... 9 Cephalexin Capsule.................................. 8
Ampyra....................................................... 11
23Cerdelga.................................................... 17 Cosentyx.................................................... 16 Divalproex Extended-Release
Cesia...........................................................20 Creon.......................................................... 15 Tablet...................................................... 12
Cetrotide.................................................... 16 Cresemba.................................................... 8 Divigel.........................................................22
Chantix Tablet........................................... 19 Crinone....................................................... 16 Donepezil 5, 10 mg ODT, Tablet.......... 11
Chateal.......................................................20 Cryselle......................................................20 Doxazosin..............................................9, 17
Chlorhexidine Gluconate....................... 17 Cyclafem 7/7/7, 1/35..............................20 Doxazosin Tablet..................................... 17
Chlorpheniramine/Hydrocodone/ Cyclobenzaprine...................................... 18 Doxepin...................................................... 10
Pseudoephedrine Solution............... 17 Cyclophosphamide Capsule.................. 8 Doxycycline Hyclate 50, 100 mg
Chlorthalidone............................................ 9 Cyclosporine Modified Capsule.......... 19 Capsule, Tablet...................................... 8
Choline Fenofibrate................................. 10 Cyproheptadine Tablet........................... 19 Doxycycline Monohydrate 50, 100 mg
Cialis........................................................... 17 Cyred..........................................................20 Capsule.................................................... 8
Ciclopirox Cream, Gel, Lotion, Drospirenone-Ethinyl Estradiol-
D
Solution.................................................. 12 Levomefolate Calcium........................20
Cimzia......................................................... 16 Daklinza..................................................... 16 Duavee.......................................................22
Ciprodex...................................................... 8 Dapsone 5% Gel...................................... 12 Dulera......................................................... 19
Ciprofloxacin Tablet.................................. 8 Dasetta 7/7/7, 1/35.................................20 Duloxetine Capsule................................. 10
Citalopram Tablet.................................... 10 Deblitane....................................................20 Dupixent..................................................... 12
Claravis....................................................... 12 Delyla..........................................................20 Dutasteride Capsule............................... 17
Clarithromycin Tablet................................ 8 Descovy..................................................... 16
Desmopressin Tablet.............................. 14 E
Climara.......................................................22
Climara Pro...............................................22 Desogestrel-Ethinyl Estradiol................20 Econazole Cream...................................... 8
Clindamycin 1.2%/Benzoyl Peroxide Desonide 0.05% Cream, Lotion, Econtra EZ................................................20
5% Gel.................................................... 12 Ointment................................................ 12 Edarbi........................................................... 9
Clindamycin Capsule................................ 8 Desoximetasone Gel, Ointment........... 12 Edarbyclor................................................... 9
Clindamycin Gel....................................... 12 Desvenlafaxine Extended-Release Efavirenz..................................................... 16
Clindamycin Lotion................................. 12 Tablet...................................................... 10 Eletriptan.................................................... 11
Clindamycin Solution, Swabs............... 12 Dexamethasone Tablet.......................... 14 Elidel........................................................... 12
Clobetasol Propionate Cream, Dexilant...................................................... 15 Elinest.........................................................20
Ointment................................................ 12 Dexmethylphenidate Eliquis........................................................... 9
Clobetasol Propionate Solution........... 12 Immediate-Release Tablet................. 10 Ella...............................................................20
Clomiphene............................................... 16 Dextroamphetamine Sulfate Emend Suspension................................. 15
Clonazepam Tablet................................. 12 Immediate-Release Tablet................. 10 Emoquette.................................................20
Clonidine Tablet......................................... 9 Dextroamphetamine-Amphetamine Enalapril....................................................... 9
Clopidogrel.................................................. 9 Immediate-Release Tablet................. 10 Enbrel......................................................... 16
Clotrimazole-Betamethasone Diazepam Tablet................................11, 12 Endometrin................................................ 16
Cream..................................................... 12 Diclofenac Tablet..................................... 18 Enoxaparin Sodium................................... 9
Clotrimazole-Betamethasone Dicyclomine Tablet.................................. 18 Enpresse....................................................20
Lotion...................................................... 12 Dificid............................................................ 8 Enskyce.....................................................20
Combigan.................................................. 15 Diflorasone Diacetate 0.05% Enstilar Foam............................................ 12
Combivent Respimat.............................. 19 Cream..................................................... 12 Entresto...................................................... 10
Complera................................................... 16 Diflorasone Diacetate 0.05% Epclusa...................................................... 16
Concerta.................................................... 10 Ointment................................................ 12 Epinephrine............................................... 17
Contour Next............................................ 13 Digoxin....................................................... 10 EpiPen/EpiPen-Jr.................................... 17
Contour Next EZ...................................... 13 Diltiazem 24 Hour CD............................... 9 Epzicom..................................................... 16
Contour Next One................................... 13 Diltiazem Sustained-Release Errin.............................................................20
Contour Next Test Strips....................... 13 Capsule.................................................... 9 Erythromycin 0.5% Ophthalmic
Contour Test Strips................................. 13 Diltiazem Sustained-Release Tablet..... 9 Ointment................................................ 14
Copaxone.................................................. 11 Diphenoxylate-Atropine Tablet............. 15 Escitalopram Tablet................................ 10
Corlanor..................................................... 10 Divalproex Delayed-Release Tablet.... 12 Estarylla......................................................20
Cortifoam................................................... 15 Estrace.......................................................22
24Estrace Cream..........................................22 Frovatriptan............................................... 11 I
Estradiol Cream.......................................22 Furosemide................................................. 9 Ibandronate Tablet.................................. 18
Estradiol Tablet.........................................22 Ibuprofen Tablet....................................... 18
G
Estradiol Twice-Weekly Transdermal Idhifa............................................................. 8
Patch.......................................................22 Gabapentin Capsule, Tablet................. 12
Imatinib Tablet............................................ 8
Estradiol Weekly Transdermal Gemfibrozil................................................ 10
Imbruvica..................................................... 8
Patch.......................................................22 Gentamicin Ophthalmic Ointment,
Imiquimod 5% Cream............................. 12
Estradiol/Norethindrone Acetate Solution.................................................. 14
Incruse Ellipta........................................... 19
Tablet......................................................22 Genvoya..................................................... 16
Indomethacin Capsule........................... 18
Estring........................................................22 Gildess.......................................................20
Ingrezza...................................................... 11
Estrogen/Methyltestosterone Gildess Fe..................................................20
Intelence.................................................... 16
Tablet......................................................22 Gilenya........................................................ 11
Intrarosa..................................................... 17
Eszopiclone Tablet.................................. 11 Glatiramer.................................................. 11
Introvale......................................................20
Etodolac Capsule.................................... 18 Glimepiride................................................ 13
Invokamet.................................................. 13
Eucrisa........................................................ 12 Glipizide..................................................... 13
Invokamet XR........................................... 13
Evamist.......................................................22 Glipizide Extended-Release................. 13
Invokana..................................................... 13
Evotaz......................................................... 16 Glucophage XR........................................ 14
Ipratropium Nebs..................................... 19
Ezetimibe Tablet...................................... 10 Glyburide................................................... 13
Ipratropium-Albuterol Nebs.................. 19
Ezetimibe/Simvastatin............................ 10 Glyxambi.................................................... 13
Irbesartan.................................................... 9
Golytely...................................................... 15
F Isentress..................................................... 16
Gonal-F....................................................... 16
Isosorbide Mononitrate ER................... 10
Fallback......................................................20 Gonal-F RFF.............................................. 16
Itraconazole Capsule................................ 8
Falmina.......................................................20 Guanfacine............................................9, 10
Famciclovir Tablet...................................... 8 Guanfacine Extended-Release............ 10 J
Farxiga........................................................ 13 Janumet..................................................... 13
H
Fayosim......................................................20 Januvia....................................................... 13
Fenofibrate 54, 160 mg Tablet............. 10 Halobetasol Ointment............................ 12
Jardiance................................................... 13
Fentanyl 12, 25, 50, 75, 100 mcg Harvoni....................................................... 16
Jencycla.....................................................20
Patch....................................................... 18 Heather......................................................20
Jentadueto................................................ 14
Fentanyl Citrate Lozenge....................... 18 Humalog KwikPens................................. 13
Jentadueto XR.......................................... 14
Fetzima....................................................... 10 Humalog Vials.......................................... 13
Jolessa.......................................................20
Finacea....................................................... 12 Humira........................................................ 16
Jolivette......................................................20
Finasteride Tablet.................................... 17 Humulin KwikPens.................................. 13
Juleber........................................................20
Flecainide.................................................. 10 Humulin Vials............................................ 13
Junel...........................................................20
Flovent Diskus/HFA................................ 19 Hydralazine................................................. 9
Junel Fe......................................................20
Fluconazole Tablet.................................... 8 Hydrochlorothiazide.................................. 9
Fluocinolone Cream, Oil, Solution....... 12 Hydrocodone/Acetaminophen 5/325, K
Fluocinolone Ointment........................... 12 7.5/325, 10/325 mg Tablet............... 18 Kaletra Tablet............................................ 16
Fluocinonide 0.05% Cream.................. 12 Hydrocodone/Chlorpheniramine Kazano....................................................... 14
Fluoride......................................................20 Suspension........................................... 17 Kelnor 1/35...............................................20
Fluorouracil 0.5% Cream....................... 12 Hydrocodone/Ibuprofen Tablet........... 18 Ketoconazole Cream................................ 8
Fluoxetine Capsule.................................. 10 Hydrocortisone 2.5% Cream, Ketorolac Tablet....................................... 18
Fluticasone Nasal Spray........................ 19 Ointment................................................ 12 Kevzara...................................................... 17
Fluticasone/Salmeterol RespiClick..... 19 Hydromorphone Immediate-Release Klor-Con M10...........................................20
Fluvastatin Extended-Release Tablet...................................................... 18 Klor-Con M20...........................................20
Tablet...................................................... 10 Hydroxychloroquine Sulfate.................. 16 Kombiglyze XR......................................... 14
Fluvoxamine Tablet................................. 11 Hydroxyurea Capsule............................... 8 Kurvelo.......................................................20
Folic Acid...................................................20 Hydroxyzine Capsule, Tablet................ 19
Hyoscyamine Tablet................................ 15 L
Forteo......................................................... 18
FreeStyle Test Strips............................... 13 Labetalol...................................................... 9
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