YOUR 2019 FORMULARY - OPTUMRX
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Your 2019 Formulary
Effective January 1, 2019
For the most current list of covered medications or if you have questions:
Call the member phone number on your ID card.
Visit your plan’s member website listed on your ID card to:
• Locate a participating retail pharmacy by ZIP code.
• Look up possible lower-cost medication alternatives.
• Compare medication pricing and options.
Select StandardUnderstanding your formulary
What is a formulary?
A formulary is a list of prescribed medications chosen About this formulary
by your plan for their safety, cost and effectiveness. Where differences exist between
Medications are listed by categories or classes and are this formulary and your benefit
placed into cost levels known as tiers. It includes both brand plan documents, the benefit plan
and generic prescription medications approved by the documents rule. This may not be
U.S. Food and Drug Administration (FDA). a complete list of medications,
and not all medications listed
How do I use my formulary? may be covered by your plan.
You and your doctor can consult the formulary to help you Please look at the benefit plan
select the most cost-effective prescription medications. documents provided by your
This guide tells you if a medication is generic or brand, and employer or plan sponsor for
if special rules apply. Bring this list with you when you see full details.
your doctor. If your medication is not listed here, please
visit your plan’s member website or call the member phone
number on your ID card.
What are tiers?
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost,
determined by your employer or plan sponsor. This is how much you will pay when
you fill a prescription.
When does the formulary change?
• Medications may move to a lower tier at any time.
•M
edications may move to a higher tier when a generic equivalent becomes available.
•M
edications may move to a higher tier or be excluded from coverage on January 1
or July 1 of each year.
When a medication changes tiers, you may have to pay a different amount for that medication.
Why are some medications excluded from coverage?
A medication may be excluded from coverage under your pharmacy benefit when it works the
same as or similar to another prescription or over-the-counter (OTC) medication.
What if I don’t agree with a decision about an excluded medication?
You (or your authorized representative) and your doctor can ask for a coverage request
by calling the member phone number on your ID card.
2Medication tips
What is the difference between brand-name and
generic medications? Over-the-counter medications
Generic medications contain the same active ingredients An OTC medication may be
(what makes the medication work) as brand-name the right treatment option for
medications, but they often cost less. Once the patent for some conditions. Talk to your
a brand-name medication ends, the FDA can approve a doctor about available OTC
generic version with the same active ingredients. options. Even though these
medications may not be
What if my doctor writes a brand-name prescription? covered by your pharmacy
If your doctor gives you a prescription for a brand-name benefit, they may cost less
medication, ask if a generic equivalent or lower-cost option than a prescription medication.
is available and could be right for you. Generic medications
are usually your lowest-cost option.
What if I am taking a specialty medication?
Specialty medications treat rare or complex conditions and are typically higher cost medications.
Please note, not all specialty medications are listed in the formulary. BriovaRx®, the OptumRx®
specialty pharmacy, can provide most of your specialty medications along with helpful programs and
services. Call BriovaRx at 1-855-4BRIOVA (1-855-427-4682) and have your prescriptions delivered
right to your home or doctor’s office.
3Reading 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,
CLOBEX) and generic medications in lowercase (for example, clobetasol).
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 hit your deductible.
Drug Tier Includes Helpful Tips
Tier 1 $
Lower-cost generics Use Tier 1 drugs for the lowest out-of-pocket costs.
and some brand-name
Tier 2 $$
Mid-range cost Use Tier 2 drugs, instead of Tier 3, to help reduce your
preferred brand-name out-of-pocket costs.
Tier 3 $$$ Highest-cost Many Tier 3 drugs have lower-cost options in Tier 1 or 2.
non-preferred Ask your doctor if they could work for you.
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.
PA Prior Authorization – Your doctor is required to provide additional information to
determine coverage.
QL Quantity Limit – Medication may be limited to a certain quantity.
SP Specialty Medication – Medication is designated as specialty.
ST
Step Therapy – Trial of lower-cost medication(s) is required before a higher-cost
medication can be covered.
3P Tier 3 preferred
4Table of Contents
Analgesics - Drugs for Pain.............................. 6 Genitourinary Agents - Drugs for Prostate
Analgesics - Drugs for Pain and Inflammation. 6 Conditions.................................................... 19
Anesthetics....................................................... 6 Hormonal Agents - Adrenal............................ 19
Anti-Addiction / Substance Abuse Treatment Hormonal Agents - Men's Health....................19
Agents............................................................ 7 Hormonal Agents - Osteoporosis................... 20
Antibacterials.................................................... 7 Hormonal Agents - Pituitary............................20
Anticoagulants.................................................. 8 Hormonal Agents - Sex Hormones and Birth
Anticonvulsants - Drugs for Seizures............... 8 Control..........................................................20
Antidementia Agents - Drugs for Alzheimer's Hormonal Agents - Thyroid.............................21
Disease and Dementia................................... 8 Immunological Agents - Drugs for Immune
Antidepressants................................................8 System Stimulation or Suppression............. 21
Antiemetics - Drugs for Nausea and Vomiting..9 Immunological Agents - Drugs for
Antifungals........................................................9 Vaccination...................................................23
Antigout Agents................................................ 9 Inflammatory Bowel Disease Agents..............23
Antimigraine Agents......................................... 9 Metabolic Bone Disease Agents - Drugs for
Antineoplastics - Drugs for Cancer...................9 Osteoporosis................................................ 23
Antiparasitics.................................................... 9 Miscellaneous Therapeutic Agents.................23
Antiparkinson Agents......................................10 Ophthalmic Agents - Drugs for Eye Allergy,
Antiplatelets.................................................... 10 Infection and Inflammation........................... 23
Antipsychotics - Drugs for Mood Disorders.... 10 Ophthalmic Agents - Drugs for Glaucoma......24
Antivirals......................................................... 10 Ophthalmic Agents - Drugs for Miscellaneous
Anxiolytics - Drugs for Anxiety........................11 Eye Conditions............................................. 24
Bipolar Agents - Drugs for Mood Disorders....11 Otic Agents - Drugs for Ear Conditions.......... 24
Blood Products / Modifiers / Volume Respiratory Tract / Pulmonary Agents -
Expanders - Drugs for Bleeding Disorders...11 Drugs for Allergies, Cough, Cold..................24
Cardiovascular Agents - Drugs for Heart and Respiratory Tract / Pulmonary Agents -
Circulation Conditions.................................. 11 Drugs for Asthma and Other Lung
Central Nervous System Agents - Drugs for Conditions 25
Attention Deficit Disorder..............................13 Respiratory Tract / Pulmonary Agents -
Central Nervous System Agents - Drugs for Drugs for Cystic Fibrosis.............................. 26
Multiple Sclerosis......................................... 14 Respiratory Tract / Pulmonary Agents -
Central Nervous System Agents - Drugs for Pulmonary Hypertension.............. 26
Miscellaneous...............................................14 Skeletal Muscle Relaxants - Drugs for
Dental and Oral Agents - Drugs for Mouth Muscle Pain and Spasm...............................26
and Throat Conditions.................................. 14 Sleep Disorder Agents....................................26
Dermatological Agents - Drugs for Skin Index of Drugs................................................ 27
Conditions.................................................... 14
Diabetes - Antidiabetic Agents....................... 15
Diabetes - Glucose Monitoring....................... 16
Diabetes - Glycemic Agents........................... 17
Diabetes - Insulins.......................................... 17
Electrolytes / Minerals / Metals / Vitamins...... 17
Gastrointestinal Agents - Drugs for Acid
Reflux and Ulcer...........................................18
Gastrointestinal Agents - Drugs for Bowel,
Intestine and Stomach Conditions................18
Genetic or Enzyme Disorder: Drugs for
Replacement, Modifiers, Treatment............. 18
Genitourinary Agents - Drugs for Bladder,
Genital and Kidney Conditions..................... 18
5Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Analgesics - Drugs for Pain tramadol hcl ir 1 QL
acetaminophen-codeine tramadol-acetaminophen 1 QL
1 QL
#2 ZOHYDRO ER ORAL
acetaminophen-codeine CAPSULE ER 12 HOUR 3 PA; QL
1 QL
#3 ABUSE-DETERRENT
acetaminophen-codeine Analgesics - Drugs for Pain and
1 QL
#4 Inflammation
acetaminophen-codeine celecoxib oral 1 QL
1 QL
oral tablet diclofenac potassium 1
BELBUCA 3 PA; QL 1
diclofenac sodium oral
butalbital-apap-caffeine diclofenac sodium
1 1 QL
oral capsule transdermal gel 1 %
butalbital-apap-caffeine etodolac oral tablet 1
1
oral tablet 50-325-40 mg
FLECTOR 3 QL
EMBEDA 2 PA; QL
ibuprofen oral tablet 400
fentanyl 1 PA; QL 1
mg, 600 mg, 800 mg
hydrocodone- indomethacin oral 1
acetaminophen oral
tablet 10-300 mg, 10-325 ketorolac tromethamine
1 QL 1 QL
mg, 2.5-325 mg, 5-300 oral
mg, 5-325 mg, 7.5-300 meloxicam oral tablet 1
mg, 7.5-325 mg nabumetone oral 1
hydromorphone hcl oral naproxen oral tablet 1
1 QL
tablet
naproxen sodium oral 1
HYSINGLA ER 2 PA; QL
tablet 275 mg, 550 mg
morphine sulfate er oral SPRIX 3 PA; QL
1 PA; QL
tablet extended release
sulindac oral 1
NUCYNTA 3 QL
Anesthetics
oxycodone hcl oral tablet 1 QL
lidocaine external 1
oxycodone- ointment
acetaminophen oral
tablet 10-325 mg, 2.5- 1 QL lidocaine external patch 5
1
325 mg, 5-325 mg, 7.5- %
325 mg lidocaine-prilocaine
1
OXYCONTIN ORAL external cream
TABLET ER 12 HOUR 2 PA; QL
ABUSE-DETERRENT
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
6Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Anti-Addiction / Substance Abuse cephalexin oral capsule 1
Treatment Agents
cephalexin oral 1
BUNAVAIL 3 QL suspension reconstituted
buprenorphine hcl ciprofloxacin hcl oral 1
1 QL
sublingual clarithromycin oral tablet 1
buprenorphine hcl- clindamycin hcl oral 1
naloxone hcl sublingual 1 QL
tablet sublingual CLINDESSE 3
CHANTIX STARTING doxycycline hyclate oral 1
3 QL capsule
MONTH PAK
naltrexone hcl oral 1 doxycycline hyclate oral
tablet 100 mg, 150 mg, 1
NARCAN 2
20 mg, 50 mg, 75 mg
SUBOXONE doxycycline monohydrate
2 QL 1
SUBLINGUAL FILM oral capsule
ZUBSOLV 2 QL
doxycycline monohydrate
1
Antibacterials oral tablet
amoxicillin oral capsule 1 levofloxacin oral tablet 1
amoxicillin oral metronidazole oral tablet 1
1
suspension reconstituted metronidazole vaginal 1
amoxicillin oral tablet 1
minocycline hcl oral 1
amoxicillin-potassium capsule
clavulanate oral mupirocin external 1
suspension reconstituted 1
200-28.5 mg/5ml, 250- nitrofurantoin 1
62.5 mg/5ml, 400-57 macrocrystal oral
mg/5ml, 600-42.9 mg/5ml nitrofurantoin
amoxicillin-potassium monohydrate 1
clavulanate oral tablet macrocrystals
1
250-125 mg, 500-125 penicillin v potassium
1
mg, 875-125 mg oral tablet
azithromycin oral 1 SOLODYN ORAL
suspension reconstituted TABLET EXTENDED
azithromycin oral tablet RELEASE 24 HOUR 105 3
1 MG, 115 MG, 55 MG, 65
250 mg, 500 mg, 600 mg
MG, 80 MG
cefdinir 1
cefuroxime axetil oral
1
tablet
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
7Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
sulfamethoxazole- zonisamide oral 1
trimethoprim oral 1 Antidementia Agents - Drugs for
suspension 200-40 Alzheimer's Disease and Dementia
mg/5ml
donepezil hcl oral tablet 1
sulfamethoxazole- 1
trimethoprim oral tablet memantine hcl oral tablet 1
10 mg, 5 mg
XIFAXAN 3 PA
NAMZARIC ORAL
Anticoagulants CAPSULE EXTENDED 2 QL
ELIQUIS 2 QL RELEASE 24 HOUR 14-
enoxaparin sodium 1 SP; QL 10 MG, 28-10 MG
2 QL Antidepressants
PRADAXA
3 QL amitriptyline hcl oral 1
SAVAYSA
1 bupropion hcl er (sr) 1 QL
warfarin sodium oral
2 QL bupropion hcl er (xl) 1 QL
XARELTO
bupropion hcl oral 1
XARELTO STARTER
2 QL
PACK citalopram hydrobromide
1
Anticonvulsants - Drugs for Seizures oral tablet
carbamazepine oral desvenlafaxine succinate 1 QL
1 er
tablet
divalproex sodium er oral doxepin hcl oral capsule 1
tablet extended release 1 duloxetine hcl oral 1 QL
24 hour escitalopram oxalate oral 1
divalproex sodium oral 1 tablet
tablet delayed release fluoxetine hcl oral 1
gabapentin oral capsule 1 capsule
gabapentin oral tablet 1 fluoxetine hcl oral tablet 1
lamotrigine oral tablet 1 fluvoxamine maleate 1
levetiracetam oral tablet 1 FORFIVO XL 2 QL
oxcarbazepine oral tablet 1 mirtazapine oral tablet 1
OXTELLAR XR 3 ST nortriptyline hcl oral
1
phenytoin sodium capsule
1
extended paroxetine hcl er 1
topiramate er 1 ST paroxetine hcl oral tablet 1
topiramate oral tablet 1 sertraline hcl oral tablet 1
VIMPAT 3 trazodone hcl oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
8Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
TRINTELLIX 3 ST; QL Antigout Agents
venlafaxine hcl 1 allopurinol oral 1
venlafaxine hcl er 1 COLCHICINE ORAL 3 ST
VIIBRYD ORAL TABLET 3 QL TABLET
COLCRYS 2
VIIBRYD STARTER 3 QL
PACK DUZALLO 3 ST
Antiemetics - Drugs for Nausea and ULORIC 2 ST
Vomiting ZURAMPIC 3 ST
meclizine hcl oral tablet 1 Antimigraine Agents
metoclopramide hcl oral 1 eletriptan hydrobromide 1 QL
tablet
MIGRANAL 3 QL
ondansetron hcl oral
1 QL ONZETRA XSAIL 3 ST; QL
tablet 24 mg
rizatriptan benzoate 1 QL
ondansetron hcl oral
1
tablet 4 mg, 8 mg sumatriptan succinate 1 QL
ondansetron odt 1 oral
Antineoplastics - Drugs for Cancer
prochlorperazine maleate
1
oral anastrozole oral 1
scopolamine 1 CABOMETYX 2 PA; SP
VARUBI ORAL 3 QL capecitabine 1 PA; SP
Antifungals IBRANCE 3 PA; SP
fluconazole oral tablet 1 letrozole oral 1
GYNAZOLE-1 3 mercaptopurine oral 1 SP
JUBLIA 3 PA REVLIMID 3 PA; SP
KERYDIN 3 PA SPRYCEL 2 PA; SP
ketoconazole external tamoxifen citrate oral 1
1
cream XTANDI 3 PA; SP
ketoconazole external 1 ZYTIGA 3 PA; SP
shampoo
Antiparasitics
nystatin external cream 1
EMVERM 2
nystatin mouth/throat 1
hydroxychloroquine 1
terbinafine hcl oral 1 QL sulfate oral
terconazole vaginal permethrin external
1 1
cream cream
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
9Drug Drug
Drug Name Notes Drug Name Notes
Tier Tier
Antiparkinson Agents SAPHRIS 2 QL
benztropine mesylate VRAYLAR 3 ST; QL
1
oral ziprasidone hcl 1 QL
carbidopa-levodopa oral 1 Antivirals
tablet
abacavir sulfate- 1 SP
pramipexole 1 lamivudine
dihydrochloride
acyclovir oral tablet 1
ropinirole hcl 1
ATRIPLA 3 ST; SP
ZELAPAR 3
CIMDUO 2 SP
Antiplatelets
COMPLERA 2 SP
BRILINTA 2
DESCOVY 3 SP
cilostazol 1
entecavir 1 SP; QL
clopidogrel bisulfate oral 1
EPCLUSA 2 PA; SP; QL
Antipsychotics - Drugs for Mood Disorders
GENVOYA 3 SP
ABILIFY MAINTENA
INTRAMUSCULAR 3 HARVONI 2 PA; SP; QL
PREFILLED SYRINGE INTELENCE 2 SP
ABILIFY MAINTENA ISENTRESS 2 SP
INTRAMUSCULAR 3 ISENTRESS HD 2 SP
SUSPENSION
RECONSTITUTED ER JULUCA 2 SP
aripiprazole oral tablet 1 QL MAVYRET 2 PA; SP; QL
ARISTADA NORVIR ORAL TABLET 3 SP
INTRAMUSCULAR ODEFSEY 3 SP
PREFILLED SYRINGE oseltamivir phosphate
3 1 QL
441 MG/1.6ML, 662 oral
MG/2.4ML, 882
MG/3.2ML PREZCOBIX 2 SP
haloperidol oral 1 PREZISTA ORAL
TABLET 150 MG, 600 2 SP
INVEGA SUSTENNA 3
MG, 75 MG, 800 MG
INVEGA TRINZA 3
REYATAZ ORAL
LATUDA 3 QL CAPSULE 150 MG, 200 3 SP
olanzapine oral tablet 1 QL MG, 300 MG
quetiapine fumarate 1 QL STRIBILD 3 SP
REXULTI 3 QL SYMFI 2 SP
risperidone oral tablet 1 QL SYMFI LO 2 SP
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
TAMIFLU ORAL ARANESP (ALBUMIN
3 QL
CAPSULE 75 MG FREE) INJECTION
TAMIFLU ORAL SOLUTION 100
SUSPENSION MCG/ML, 200 MCG/ML, 2 PA; SP
3 QL 25 MCG/ML, 300
RECONSTITUTED 6
MG/ML MCG/ML, 40 MCG/ML,
60 MCG/ML
tenofovir disoproxil 1 SP
fumarate ARANESP (ALBUMIN
FREE) INJECTION
TIVICAY 2 SP 2 PA; SP
SOLUTION PREFILLED
TRIUMEQ 2 SP SYRINGE
TRUVADA 2 SP GRANIX 2 PA; SP
valacyclovir hcl oral 1 QL NEUPOGEN INJECTION
VOSEVI 2 PA; SP; QL SOLUTION 300 2 PA; SP
MCG/ML, 480
ZOVIRAX EXTERNAL MCG/1.6ML
2
CREAM
NEUPOGEN INJECTION
ZOVIRAX EXTERNAL SOLUTION PREFILLED 2 PA; SP
3
OINTMENT SYRINGE
Anxiolytics - Drugs for Anxiety 3 SP
NUWIQ
alprazolam oral tablet 1 QL 2 PA; SP
PROCRIT
buspirone hcl oral 1 2 PA; SP
ZARXIO
clonazepam oral tablet 1 QL Cardiovascular Agents - Drugs for Heart
diazepam oral tablet 1 and Circulation Conditions
hydroxyzine hcl oral amiodarone hcl oral 1
1
tablet amlodipine besylate oral 1
hydroxyzine pamoate 1 amlodipine besylate-
oral 1
benazepril hcl
lorazepam oral tablet 1 QL amlodipine besylate- 1
triazolam 1 QL valsartan
Bipolar Agents - Drugs for Mood Disorders amlodipine-olmesartan 1
lithium carbonate er 1 atenolol oral 1
lithium carbonate oral atenolol-chlorthalidone 1
1
capsule atorvastatin calcium oral 1
Blood Products / Modifiers / Volume 1
benazepril hcl oral
Expanders - Drugs for Bleeding Disorders
benazepril-
AFSTYLA 3 SP 1
hydrochlorothiazide
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
bisoprolol fumarate 1 fenofibric acid oral
1
bisoprolol- capsule delayed release
1
hydrochlorothiazide flecainide acetate 1
bumetanide oral 1 furosemide oral tablet 1
BYSTOLIC 2 gemfibrozil oral 1
BYVALSON 2 guanfacine hcl oral 1
cartia xt 1 hydralazine hcl oral 1
carvedilol 1 hydrochlorothiazide oral 1
chlorthalidone oral tablet irbesartan 1
1
25 mg, 50 mg irbesartan- 1
choline fenofibrate 1 hydrochlorothiazide
clonidine hcl oral 1 isosorbide mononitrate er 1
CORLANOR 3 PA; QL labetalol hcl oral 1
digoxin oral tablet 1 LIPOFEN 3
diltiazem hcl er beads 1 lisinopril oral 1
diltiazem hcl er coated lisinopril-
1
beads oral capsule 1 hydrochlorothiazide
extended release 24 hour LIVALO 3 ST
diltiazem hcl oral 1 losartan potassium 1
doxazosin mesylate oral 1 losartan potassium-hctz 1
EDARBI 3 ST lovastatin 1
EDARBYCLOR 3 ST metoprolol succinate er 1
enalapril maleate oral 1 metoprolol tartrate oral 1
ENTRESTO 2 QL MULTAQ 3
ezetimibe 1 nadolol oral tablet 20 mg,
1
ezetimibe-simvastatin 40 mg, 80 mg
oral tablet 10-10 mg, 10- 1 niacin er
20 mg, 10-40 mg 1
(antihyperlipidemic)
ezetimibe-simvastatin 1 PA nifedipine er 1
oral tablet 10-80 mg
nifedipine er osmotic 1
fenofibrate micronized release
oral capsule 134 mg, 200 1
mg, 67 mg nitroglycerin sublingual 1
fenofibrate oral tablet 1 olmesartan medoxomil 1
oral
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
olmesartan medoxomil- valsartan 1
1
hctz valsartan- 1
omega-3-acid ethyl 1 hydrochlorothiazide
esters VASCEPA 2
pentoxifylline er 1 verapamil hcl er oral
PRALUENT tablet extended release 1
SUBCUTANEOUS 2 PA; SP; QL 120 mg, 180 mg, 240 mg
SOLUTION PEN- verapamil hcl oral 1
INJECTOR
ZYPITAMAG 3 ST
pravastatin sodium 1
Central Nervous System Agents - Drugs for
prazosin hcl oral 1 Attention Deficit Disorder
propranolol hcl er 1 ADDERALL XR 3 PA; ST; QL
propranolol hcl oral tablet 1 ADZENYS ER 3 PA; ST; QL
quinapril hcl 1 ADZENYS XR-ODT 3 PA; ST; QL
ramipril 1 amphetamine-
1 PA; QL
RANEXA 2 ST dextroamphetamine
REPATHA 2 PA; SP; QL amphetamine-
1 PA; QL
REPATHA dextroamphetamine er
2 PA; SP; QL
PUSHTRONEX SYSTEM atomoxetine hcl 1 QL
REPATHA SURECLICK 2 PA; SP; QL COTEMPLA XR-ODT 3 PA; ST; QL
rosuvastatin calcium 1 dexmethylphenidate hcl 1 PA; QL
simvastatin oral tablet 10 dexmethylphenidate hcl 1 PA; QL
1
mg, 20 mg, 40 mg, 5 mg er
simvastatin oral tablet 80 guanfacine hcl er 1
1 PA
mg methylphenidate hcl er
sotalol hcl oral 1 oral tablet extended
1 release 10 mg, 18 mg, 20 1 PA; QL
spironolactone oral
mg, 27 mg, 36 mg, 54
TEKTURNA 2 ST mg
TEKTURNA HCT 2 ST methylphenidate hcl er
telmisartan 1 oral tablet extended 1 PA; QL
torsemide oral 1 release 24 hour
triamterene-hctz oral methylphenidate hcl oral 1 PA; QL
1 tablet
capsule 37.5-25 mg
VYVANSE 2 PA; QL
triamterene-hctz oral
1
tablet
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
Central Nervous System Agents - Drugs for Central Nervous System Agents -
Multiple Sclerosis Miscellaneous
AMPYRA 2 PA; SP; QL ADDYI 3 PA; QL
AUBAGIO 3 PA; SP; QL CONTRAVE 2 PA
AVONEX PEN GRALISE 3 ST; QL
INTRAMUSCULAR 2 PA; SP; QL GRALISE STARTER 3 ST; QL
AUTO-INJECTOR KIT
LYRICA ORAL 2 QL
AVONEX PREFILLED CAPSULE
INTRAMUSCULAR
2 PA; SP; QL phentermine hcl oral
PREFILLED SYRINGE 1 PA
KIT tablet
Dental and Oral Agents - Drugs for Mouth
AVONEX VIAL
2 PA; SP; QL and Throat Conditions
INTRAMUSCULAR KIT
BETASERON chlorhexidine gluconate
2 PA; SP; QL 1
SUBCUTANEOUS KIT mouth/throat
lidocaine viscous 1
COPAXONE
SUBCUTANEOUS Dermatological Agents - Drugs for Skin
2 PA; SP; QL
SOLUTION PREFILLED Conditions
SYRINGE ABSORICA 3 PA
PA; 3P; ACZONE EXTERNAL
3 3
GILENYA SP; QL GEL 5 %
REBIF REBIDOSE ACZONE EXTERNAL
SUBCUTANEOUS 2
3 PA; SP; QL GEL 7.5 %
SOLUTION AUTO-
adapalene external gel 1 PA
INJECTOR
ATRALIN 3 PA
REBIF REBIDOSE
TITRATION PACK claravis 1 PA
SUBCUTANEOUS 3 PA; SP; QL CLINDAGEL 3 ST
SOLUTION AUTO-
INJECTOR clindamycin phosphate-
benzoyl peroxide 1
REBIF external gel 1-5 %
SUBCUTANEOUS
3 PA; SP; QL clindamycin phosphate
SOLUTION PREFILLED 1
SYRINGE external lotion
REBIF TITRATION clindamycin phosphate
1
PACK SUBCUTANEOUS external solution
3 PA; SP; QL
SOLUTION PREFILLED CLINDAMYCIN
SYRINGE PHOSPHATE GEL 1 % 3 ST
TECFIDERA 2 PA; SP; QL EXTERNAL
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
clindamycin phosphate TAZORAC 3
1
gel 1 % external tretinoin external cream 1 PA
clotrimazole- VECTICAL 3
betamethasone external 1
cream ZYCLARA 3
DIFFERIN EXTERNAL ZYCLARA PUMP 3
3 PA
GEL 0.3 % Diabetes - Antidiabetic Agents
DIFFERIN EXTERNAL BYDUREON BCISE 2 ST; QL
3 PA
LOTION AUTOINJECTOR
DUPIXENT 2 PA; SP; QL BYDUREON PEN 2 ST; QL
ELIDEL 2 ST BYDUREON VIAL 2 ST; QL
ENSTILAR 3 QL BYETTA 10 MCG PEN 2 ST; QL
EPIDUO 3 BYETTA 5 MCG PEN 2 ST; QL
EPIDUO FORTE 3 FARXIGA 3 ST
EUCRISA 2 ST glimepiride 1
FLUOROPLEX 3 glipizide er 1
METROGEL EXTERNAL glipizide ir 1
3
GEL glipizide xl 1
metronidazole external 1 glyburide oral 1
gel
glyburide-metformin 1
MIRVASO 2
GLYXAMBI 2 ST
myorisan 1 PA
INVOKAMET 2 ST
ONEXTON 3
INVOKAMET XR 2 ST
ORACEA 3
INVOKANA 2 ST
OXSORALEN ULTRA 2
JANUMET 2 ST
RETIN-A MICRO GEL 3 PA JANUMET XR 2 ST
0.04 %, 0.1 %
JANUVIA 2 ST
RETIN-A MICRO PUMP
EXTERNAL GEL 0.04 %, 3 PA JARDIANCE 2 ST
0.1 % JENTADUETO 2 ST
RETIN-A MICRO PUMP JENTADUETO XR 2 ST
EXTERNAL GEL 0.06 %, 2 PA
metformin hcl er 1
0.08 %
2 metformin hcl er (mod) 1 PA
SOOLANTRA
TACLONEX 3 QL
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
metformin hcl er (osm) ACCU-CHEK
oral tablet extended MULTICLIX LANCET 2
1
release 24 hour 1000 DEVICE KIT
mg, 500 mg ACCU-CHEK 2
metformin hcl oral tablet 1 MULTICLIX LANCETS
ONGLYZA 3 ST ACCU-CHEK NANO
OZEMPIC 2 ST; QL SMARTVIEW KIT 2
W/DEVICE
pioglitazone hcl 1
ACCU-CHEK
QTERN 3 ST SMARTVIEW TEST 2 QL
SOLIQUA 2 ST; QL STRIPS
SYNJARDY 2 ST ACCU-CHEK SOFT
2
SYNJARDY XR 2 ST TOUCH LANCETS
TRADJENTA 2 ST ACCU-CHEK SOFTCLIX 2
LANCET DEVICE KIT
TRULICITY 2 ST; QL
ACCU-CHEK SOFTCLIX 2
VICTOZA 2 ST; QL LANCETS
Diabetes - Glucose Monitoring
DEXCOM G4 PLATINUM
ACCU-CHEK AVIVA PEDIATRIC RECEIVER 3
CONNECT KIT 2 DEVICE
W/DEVICE DEXCOM G4 PLATINUM
ACCU-CHEK AVIVA RECEIVER, SENSOR, 3
2
PLUS TRANSMITTER DEVICE
ACCU-CHEK AVIVA 2 QL DEXCOM G5 SENSOR,
PLUS TEST STRIPS TRANSMITTER, 3
ACCU-CHEK COMPACT MOBILE RECEIVER
2
PLUS CARE KIT ONETOUCH ULTRA 2 2
ACCU-CHEK COMPACT KIT W/DEVICE
2 QL
PLUS TEST STRIPS ONETOUCH ULTRA 2 QL
ACCU-CHEK FASTCLIX BLUE TEST STRIPS
2
LANCET KIT ONETOUCH ULTRA
2
ACCU-CHEK FASTCLIX MINI KIT W/DEVICE
2
LANCETS ONETOUCH VERIO 2
ACCU-CHEK GUIDE 2 ONETOUCH VERIO
ACCU-CHEK GUIDE FLEX SYSTEM KIT 2
2 QL W/DEVICE
TEST STRIPS
ONETOUCH VERIO IQ 2
SYSTEM KIT W/DEVICE
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
ONETOUCH VERIO LEVEMIR U-100
2 QL 2
STRIP IN VITRO FLEXTOUCH
V-GO 20 2 LEVEMIR U-100 VIAL 2
V-GO 30 2 NOVOFINE
V-GO 40 2 AUTOCOVER PEN 2
NEEDLE
Diabetes - Glycemic Agents
NOVOFINE PEN 2
GLUCAGON 2 NEEDLE 32G X 6 MM
EMERGENCY
NOVOFINE PLUS PEN
Diabetes - Insulins 2
NEEDLE
HUMALOG U-100 AND 2 NOVOLIN 70/30 VIAL 2
U-200 KWIKPEN
NOVOLIN N VIAL 2
HUMALOG MIX 50/50
2 NOVOLIN R VIAL 2
KWIKPEN
HUMALOG MIX 50/50 NOVOLOG U-100
2 2
VIAL FLEXPEN
HUMALOG MIX 75/25 NOVOLOG MIX 70/30
2 2
KWIKPEN FLEXPEN
HUMALOG MIX 75/25 NOVOLOG MIX 70/30 2
2 VIAL
VIAL
HUMALOG U-100 NOVOLOG U-100 2
2 PENFILL
JUNIOR KWIKPEN
HUMALOG U-100 VIAL NOVOLOG U-100 VIAL 2
2
AND CARTRIDGE NOVOTWIST PEN 2
HUMULIN 70/30 NEEDLE 32G X 5 MM
2
KWIKPEN TOUJEO SOLOSTAR 2
HUMULIN 70/30 VIAL 2 TRESIBA FLEXTOUCH 2
HUMULIN N KWIKPEN 2 Electrolytes / Minerals / Metals / Vitamins
HUMULIN N VIAL 2 cyanocobalamin injection 1
HUMULIN R U-500 folic acid oral tablet 1 mg 1
2
KWIKPEN klor-con m20 1
HUMULIN R U-500 VIAL potassium chloride crys
2 1
(CONCENTRATED) er
HUMULIN R VIAL 2 1
potassium chloride er
LANTUS U-100 2 potassium citrate er 1
SOLOSTAR
VELTASSA 3
LANTUS U-100 VIAL 2
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
vitamin d (ergocalciferol) polyethylene glycol 3350
1 1
oral capsule 50000 unit oral powder
Gastrointestinal Agents - Drugs for Acid PREPOPIK 3
Reflux and Ulcer 2
PYLERA
DEXILANT 2 QL 3 PA; QL
RELISTOR ORAL
esomeprazole 1 QL RELISTOR
magnesium SUBCUTANEOUS 3 PA; QL
famotidine oral tablet 20 1 SOLUTION 12
mg, 40 mg MG/0.6ML, 8 MG/0.4ML
lansoprazole oral capsule SUPREP BOWEL PREP
1 QL 3
delayed release KIT
omeprazole oral capsule SYMPROIC 2 ST; QL
1 QL
delayed release TRULANCE 3 ST; QL
pantoprazole sodium oral 1 QL 3 PA; QL
VIBERZI
rabeprazole sodium 1 QL Genetic or Enzyme Disorder: Drugs for
ranitidine hcl oral capsule 1 Replacement, Modifiers, Treatment
ranitidine hcl oral syrup 1 CERDELGA 3 PA; SP
ranitidine hcl oral tablet CREON 2
1
150 mg, 300 mg NITYR 3 PA; SP
sucralfate oral tablet 1 ZENPEP ORAL
Gastrointestinal Agents - Drugs for Bowel, CAPSULE DELAYED
Intestine and Stomach Conditions RELEASE PARTICLES
AMITIZA 3 ST; QL 10000-32000 UNIT,
15000-47000 UNIT,
CLENPIQ 3 2
20000-63000 UNIT,
dicyclomine hcl oral 1 25000-79000 UNIT,
capsule 3000-14000 UNIT,
dicyclomine hcl oral 40000-126000 UNIT,
1 5000-24000 UNIT
tablet
diphenoxylate-atropine Genitourinary Agents - Drugs for Bladder,
1 Genital and Kidney Conditions
oral tablet
1 AURYXIA 3
gavilyte-g
2 ST; QL CIALIS 2 QL
LINZESS
2 ST; QL DEPEN TITRATABS 2 SP
MOVANTIK
3 MYRBETRIQ 2
MOVIPREP
2 oxybutynin chloride er 1
OMECLAMOX-PAK
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
oxybutynin chloride oral fluocinonide external
1 1
tablet cream
phenazopyridine hcl oral 1 hydrocortisone external 1
tablet 100 mg, 200 mg cream 1 %, 2.5 %
RENVELA 3 hydrocortisone external 1
sildenafil citrate oral ointment 2.5 %
tablet 100 mg, 25 mg, 50 1 QL hydrocortisone in 1
mg absorbase
tolterodine tartrate er 1 hydrocortisone oral 1
TOVIAZ 3 methylprednisolone oral 1
VELPHORO 3 mometasone furoate
1
VESICARE 2 external cream
Genitourinary Agents - Drugs for Prostate prednisolone oral
1
Conditions solution
alfuzosin hcl er 1 prednisolone sodium
phosphate oral solution
finasteride oral tablet 5 10 mg/5ml, 15 mg/5ml, 1
1
mg 20 mg/5ml, 25 mg/5ml,
RAPAFLO 2 6.7 (5 base) mg/5ml
tamsulosin hcl 1 prednisone oral tablet 1
terazosin hcl oral 1 prednisone oral tablet 1
Hormonal Agents - Adrenal therapy pack
ala-cort external cream 1 triamcinolone acetonide
1 1
% external cream
betamethasone valerate triamcinolone acetonide
1 1
external cream external ointment
clobetasol propionate Hormonal Agents - Men's Health
1
external cream ANDRODERM
clobetasol propionate TRANSDERMAL PATCH 2 PA
1 24 HOUR
external ointment
clobetasol propionate ANDROGEL PUMP
1 TRANSDERMAL GEL 2 PA
external solution
20.25 MG/ACT (1.62%)
CLOBEX SPRAY 3
ANDROGEL
dexamethasone oral TRANSDERMAL GEL
1
solution 20.25 MG/1.25GM 2 PA
dexamethasone oral 1 (1.62%), 40.5 MG/2.5GM
tablet (1.62%)
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
testosterone cypionate NUTROPIN AQ NUSPIN
2 PA; SP
intramuscular solution 1 PA 5
100 mg/ml, 200 mg/ml OMNITROPE 2 PA; SP
Hormonal Agents - Osteoporosis 3 SP
OVIDREL
OSPHENA 3 Hormonal Agents - Sex Hormones and
raloxifene hcl 1 Birth Control
Hormonal Agents - Pituitary apri 1
CETROTIDE aviane 1
SUBCUTANEOUS KIT 2 PA; SP 1
blisovi 24 fe
0.25 MG
blisovi fe 1.5/30 1
GONAL-F 2 PA; SP
blisovi fe 1/20 1
GONAL-F RFF 2 PA; SP
CLIMARA PRO 2
GONAL-F RFF
2 PA; SP cryselle-28 1
REDIJECT
HP ACTHAR 2 PA; SP DIVIGEL 3
LUPRON DEPOT (1- drospirenone-ethinyl
1
MONTH) estradiol
2 PA; SP
INTRAMUSCULAR KIT DUAVEE 2
7.5 MG ELESTRIN 3
LUPRON DEPOT (3- ENDOMETRIN 2
MONTH) 2 PA; SP
INTRAMUSCULAR KIT enskyce oral tablet 0.15-
1
22.5 MG 30 mg-mcg
LUPRON DEPOT (4- estradiol oral 1
MONTH) estradiol transdermal 1
2 PA; SP
INTRAMUSCULAR KIT estradiol vaginal cream 1
30MG
gianvi 1
LUPRON DEPOT (6-
MONTH) junel 1/20 1
2 PA; SP
INTRAMUSCULAR KIT junel fe 1.5/30 1
45MG junel fe 1/20 1
NORDITROPIN 2 PA; SP levonorgestrel-ethinyl
FLEXPRO estrad oral tablet 0.1-20 1
NUTROPIN AQ NUSPIN mg-mcg, 0.15-30 mg-
2 PA; SP
10 mcg
NUTROPIN AQ NUSPIN LO LOESTRIN FE 3
2 PA; SP
20 loryna 1
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
low-ogestrel 1 progesterone micronized
1
MAKENA oral
3 PA; SP
INTRAMUSCULAR sprintec 28 1
medroxyprogesterone tri-estarylla 1
1 QL
acetate intramuscular tri-linyah 1
medroxyprogesterone 1 tri-lo-marzia 1
acetate oral
trinessa (28) 1
MENEST ORAL TABLET
0.3 MG, 0.625 MG, 1.25 2 trinessa lo 1
MG tri-previfem 1
microgestin 1.5/30 1 tri-sprintec 1
microgestin 1/20 1 vienva 1
microgestin fe 1/20 1 viorele 1
MINIVELLE 3 xulane 1
mono-linyah 1 yuvafem 1
mononessa 1 Hormonal Agents - Thyroid
NATAZIA 2 ARMOUR THYROID 3
nikki 1 levo-t 1
norethindrone acet- levothyroxine sodium oral 1
1
ethinyl est oral tablet levoxyl 1
norethindrone oral 1 liothyronine sodium oral 1
norgestimate-eth methimazole oral 1
estradiol oral tablet 0.25- 1
35 mg-mcg NATURE-THROID ORAL
TABLET 113.75 MG, 130
norgestimate-ethinyl 1 MG, 146.25 MG, 16.25
estradiol triphasic MG, 195 MG, 260 MG, 3
nortrel 1/35 (21) 1 32.5 MG, 325 MG, 48.75
nortrel 1/35 (28) 1 MG, 65 MG, 81.25 MG,
97.5 MG
NUVARING 2
SYNTHROID 3
ocella 1
TIROSINT 3
portia-28 1
Immunological Agents - Drugs for Immune
PREMARIN ORAL 2 System Stimulation or Suppression
PREMARIN VAGINAL 2 azathioprine oral 1
PREMPHASE 2 CIMZIA PREFILLED KIT 2 PA; SP
PREMPRO 2 CIMZIA STARTER KIT 2 PA; SP
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
CIMZIA VIAL KIT 2 PA; SP HUMIRA
COSENTYX 150 MG/ML 3 PA; 3P; SP SUBCUTANEOUS 2 PA; SP
PREFILLED SYRINGE
COSENTYX 300 DOSE 3 PA; 3P; SP KIT
COSENTYX KEVZARA
SENSOREADY 300 3 PA; 3P; SP SUBCUTANEOUS
DOSE 3 PA; 3P; SP
SOLUTION PREFILLED
COSENTYX SYRINGE
SENSOREADY PEN methotrexate oral 1
SUBCUTANEOUS 3 PA; 3P; SP
SOLUTION AUTO- methotrexate sodium oral 1
INJECTOR 150 MG/ML mycophenolate mofetil
1 SP
ENBREL oral capsule
SUBCUTANEOUS 3 PA; SP mycophenolate mofetil
1 SP
SOLUTION PREFILLED oral tablet
SYRINGE mycophenolate sodium 1 SP
ENBREL SURECLICK OTEZLA ORAL TABLET 2 PA; SP
SUBCUTANEOUS 3 PA; SP
SOLUTION AUTO- OTEZLA ORAL TABLET 2 PA; SP
INJECTOR THERAPY PACK
HAEGARDA 3 PA; SP PROGRAF ORAL 3 SP
HUMIRA PEDIATRIC RASUVO
CROHNS START SUBCUTANEOUS
SUBCUTANEOUS 2 PA; SP SOLUTION AUTO-
PREFILLED SYRINGE INJECTOR 10
KIT 40 MG/0.8ML MG/0.2ML, 12.5
MG/0.25ML, 15
HUMIRA PEN MG/0.3ML, 17.5 2 PA; QL
SUBCUTANEOUS PEN- 2 PA; SP MG/0.35ML, 20
INJECTOR KIT MG/0.4ML, 22.5
HUMIRA PEN- MG/0.45ML, 25
CD/UC/HS STARTER MG/0.5ML, 30
SUBCUTANEOUS PEN- 2 PA; SP MG/0.6ML, 7.5
INJECTOR KIT 40 MG/0.15ML
MG/0.8ML REMICADE 2 PA; SP
HUMIRA PEN-PS/UV SIMPONI ARIA 2 PA; SP
STARTER
SUBCUTANEOUS PEN- 2 PA; SP SIMPONI
INJECTOR KIT 40 SUBCUTANEOUS 2 PA; SP
MG/0.8ML SOLUTION AUTO-
INJECTOR
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
SIMPONI UCERIS 3
SUBCUTANEOUS 2 PA; SP Metabolic Bone Disease Agents - Drugs for
SOLUTION PREFILLED Osteoporosis
SYRINGE
alendronate sodium oral
STELARA 2 PA; SP tablet 10 mg, 40 mg, 5 1
INTRAVENOUS mg
STELARA alendronate sodium oral
SUBCUTANEOUS 1 QL
2 PA; SP tablet 35 mg, 70 mg
SOLUTION PREFILLED
BINOSTO 3 QL
SYRINGE
1 SP calcitriol oral capsule 1
tacrolimus oral
TREMFYA 2 PA; SP FORTEO
SUBCUTANEOUS
XELJANZ ORAL 2 PA; SP
3 PA; 3P; SP SOLUTION 600
TABLET 5 MG MCG/2.4ML
XELJANZ XR 3 PA; 3P; SP ibandronate sodium oral 1 QL
Immunological Agents - Drugs for TYMLOS 2 PA; SP
Vaccination
Miscellaneous Therapeutic Agents
AFLURIA
PA; Non-
PRESERVATIVE FREE
3 2 Cosmetic;
INTRAMUSCULAR
BOTOX SP
SUSPENSION
PREFILLED SYRINGE CETYLEV 3
FLUCELVAX EUFLEXXA INTRA-
QUADRIVALENT ARTICULAR SOLUTION 2 PA; SP
INTRAMUSCULAR 3 PREFILLED SYRINGE
SUSPENSION SYNVISC INTRA-
PREFILLED SYRINGE ARTICULAR SOLUTION 2 PA; SP
SHINGRIX 3 PREFILLED SYRINGE
Inflammatory Bowel Disease Agents SYNVISC ONE INTRA-
APRISO 2 ARTICULAR SOLUTION 2 PA; SP
PREFILLED SYRINGE
CANASA 2
Ophthalmic Agents - Drugs for Eye Allergy,
DELZICOL 3 ST Infection and Inflammation
DIPENTUM 3 AZASITE 3
mesalamine oral 1 BESIVANCE 3
PENTASA 3 BROMSITE 3 ST; QL
PROCTOFOAM HC 2 ciprofloxacin hcl 1
sulfasalazine oral tablet 1 ophthalmic
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
erythromycin ophthalmic 1 timolol maleate
1
gentamicin sulfate ophthalmic solution
1
ophthalmic solution TIMOPTIC OCUDOSE 3
ILEVRO 3 ST; QL TRAVATAN Z 2 QL
ketorolac tromethamine ZIOPTAN 3 QL
1
ophthalmic Ophthalmic Agents - Drugs for
MOXEZA 2 Miscellaneous Eye Conditions
moxifloxacin hcl LASTACAFT 3 ST
1
ophthalmic neomycin-polymyxin-
NEVANAC 3 ST; QL dexameth ophthalmic 1
ofloxacin ophthalmic 1 suspension 3.5-10000-
0.1
olopatadine hcl
1 polymyxin b-trimethoprim 1
ophthalmic
2 RESTASIS 2 PA
PAZEO
RESTASIS MULTIDOSE 2 PA
prednisolone acetate
1
ophthalmic tobramycin-
1
PROLENSA 2 QL dexamethasone
1 XIIDRA 2 PA
tobramycin ophthalmic
Ophthalmic Agents - Drugs for Glaucoma Otic Agents - Drugs for Ear Conditions
2 CIPRODEX 2
ALPHAGAN P
AZOPT 2 neomycin-polymyxin-hc 1
otic
BETIMOL 3
ofloxacin otic 1
BETOPTIC-S 3
Respiratory Tract / Pulmonary Agents -
brimonidine tartrate 1 Drugs for Allergies, Cough, Cold
ophthalmic
ASTEPRO NASAL 3 QL
COMBIGAN 2 SOLUTION 0.15 %
COSOPT PF 3 azelastine hcl nasal 1 QL
dorzolamide hcl-timolol 1 benzonatate 1
mal
cetirizine hcl oral solution 1
latanoprost ophthalmic 1 QL
desloratadine oral tablet 1
LUMIGAN
2 QL DYMISTA 2 QL
OPHTHALMIC
SOLUTION 0.01 % fluticasone propionate
1
SIMBRINZA 2 nasal
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
hydrocodone polst-cpm ARMONAIR
3 ST; QL
polst er oral suspension 1 PA; QL RESPICLICK 55
extended release 10-8 ARNUITY ELLIPTA
mg/5ml INHALATION AEROSOL
ipratropium bromide 1 POWDER BREATH 2 QL
nasal ACTIVATED 100
levocetirizine MCG/ACT, 200
dihydrochloride oral 1 MCG/ACT
tablet BEVESPI
3 ST; QL
mometasone furoate AEROSPHERE
1 QL
nasal BREO ELLIPTA 2 QL
OMNARIS 3 QL budesonide inhalation 1 QL
promethazine hcl oral COMBIVENT RESPIMAT 2 QL
1
tablet EPINEPHRINE ST; Made
promethazine-codeine INJECTION SOLUTION 3
1 PA; QL by Impax
oral syrup 0.3 MG/0.3ML
promethazine-dm 1 EPINEPHRINE
pseudoephedrine- INJECTION SOLUTION ST; Made
3
bromphen-dm oral syrup 1 AUTO-INJECTOR 0.15 by Impax
30-2-10 mg/5ml MG/0.15ML
QNASL 3 QL EPINEPHRINE
INJECTION SOLUTION
QNASL CHILDRENS 3 QL Made by
AUTO-INJECTOR 0.15 2
Mylan
XOLAIR 2 PA; SP MG/0.3ML, 0.3
ZETONNA 3 QL MG/0.3ML
Respiratory Tract / Pulmonary Agents - FLOVENT DISKUS 2 QL
Drugs for Asthma and Other Lung FLOVENT HFA 2 QL
Conditions 2 QL
INCRUSE ELLIPTA
ADVAIR DISKUS 2 QL
ipratropium bromide 1 QL
ADVAIR HFA 2 QL inhalation
albuterol sulfate ipratropium-albuterol 1 QL
1 QL
inhalation montelukast sodium oral 1
ANORO ELLIPTA 2 QL tablet
ARMONAIR 3 ST; QL montelukast sodium oral
1
RESPICLICK 113 tablet chewable
ARMONAIR PERFOROMIST 3 QL
3 ST; QL
RESPICLICK 232 PROAIR HFA 2 QL
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
PROAIR RESPICLICK 2 QL carisoprodol oral 1
PROVENTIL HFA 3 ST; QL cyclobenzaprine hcl oral 1
PULMICORT LORZONE 3
2 QL
FLEXHALER metaxalone 1
SEEBRI NEOHALER 3 ST; QL methocarbamol oral 1
SEREVENT DISKUS 2 QL orphenadrine citrate er 1
SPIRIVA HANDIHALER 2 QL tizanidine hcl oral tablet 1
SPIRIVA RESPIMAT Sleep Disorder Agents
INHALATION AEROSOL
2 QL eszopiclone 1 QL
SOLUTION 1.25
MCG/ACT, 2.5 modafinil 1 PA; QL
MCG/ACT SILENOR 3 QL
STIOLTO RESPIMAT temazepam 1 QL
INHALATION AEROSOL
2 QL zolpidem tartrate er 1 QL
SOLUTION 2.5-2.5
MCG/ACT zolpidem tartrate oral 1 QL
SYMBICORT 2 QL
UTIBRON NEOHALER 3 ST; QL
VENTOLIN HFA 2 QL
Respiratory Tract / Pulmonary Agents -
Drugs for Cystic Fibrosis
BETHKIS 2 SP
TOBI PODHALER 3 SP; QL
Respiratory Tract / Pulmonary Agents -
Drugs for Pulmonary Hypertension
ADCIRCA 3 PA; SP; QL
ADEMPAS 2 PA; SP; QL
LETAIRIS 2 PA; SP; QL
OPSUMIT 2 PA; SP; QL
ORENITRAM 3 PA; SP
sildenafil citrate oral
1 PA; SP; QL
tablet 20 mg
TRACLEER 2 PA; SP; QL
Skeletal Muscle Relaxants - Drugs for
Muscle Pain and Spasm
baclofen oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading
your formulary section of this booklet.
26Index of Drugs
abacavir sulfate-lamivudine 10 allopurinol............................. 9 AZASITE.............................23
ABILIFY MAINTENA...........10 ALPHAGAN P.....................24 azathioprine........................ 21
ABSORICA......................... 14 alprazolam.......................... 11 azelastine hcl...................... 24
ACCU-CHEK AVIVA amiodarone hcl................... 11 azithromycin..........................7
CONNECT KIT W/DEVICE.16 AMITIZA..............................18 AZOPT................................24
ACCU-CHEK AVIVA PLUS 16 amitriptyline hcl..................... 8 baclofen.............................. 26
ACCU-CHEK COMPACT amlodipine besylate............ 11 BELBUCA............................. 6
PLUS CARE KIT.................16 amlodipine besylate- benazepril hcl......................11
ACCU-CHEK COMPACT benazepril hcl......................11 benazepril-
PLUS TEST STRIPS.......... 16 amlodipine besylate- hydrochlorothiazide.............11
ACCU-CHEK FASTCLIX valsartan............................. 11 benzonatate........................ 24
LANCET KIT....................... 16 amlodipine-olmesartan....... 11 benztropine mesylate..........10
ACCU-CHEK FASTCLIX amoxicillin............................. 7 BESIVANCE....................... 23
LANCETS........................... 16 amoxicillin-potassium betamethasone valerate..... 19
ACCU-CHEK GUIDE.......... 16 clavulanate............................7 BETASERON......................14
ACCU-CHEK MULTICLIX amphetamine- BETHKIS............................ 26
LANCET DEVICE KIT.........16 dextroamphetamine............ 13 BETIMOL............................ 24
ACCU-CHEK MULTICLIX amphetamine- BETOPTIC-S...................... 24
LANCETS........................... 16 dextroamphetamine er........13 BEVESPI AEROSPHERE.. 25
ACCU-CHEK NANO AMPYRA.............................14 BINOSTO............................23
SMARTVIEW KIT anastrozole........................... 9 bisoprolol fumarate............. 12
W/DEVICE.......................... 16 ANDRODERM.................... 19 bisoprolol-
ACCU-CHEK ANDROGEL........................19 hydrochlorothiazide.............12
SMARTVIEW TEST ANDROGEL PUMP............ 19 blisovi 24 fe.........................20
STRIPS...............................16 ANORO ELLIPTA............... 25 blisovi fe 1.5/30...................20
ACCU-CHEK SOFT apri......................................20 blisovi fe 1/20......................20
TOUCH LANCETS............. 16 APRISO.............................. 23 BOTOX............................... 23
ACCU-CHEK SOFTCLIX ARANESP (ALBUMIN BREO ELLIPTA.................. 25
LANCET DEVICE KIT.........16 FREE)................................. 11 BRILINTA............................10
ACCU-CHEK SOFTCLIX aripiprazole......................... 10 brimonidine tartrate.............24
LANCETS........................... 16 ARISTADA..........................10 BROMSITE......................... 23
acetaminophen-codeine....... 6 ARMONAIR RESPICLICK budesonide......................... 25
acetaminophen-codeine #2.. 6 113......................................25 bumetanide......................... 12
acetaminophen-codeine #3.. 6 ARMONAIR RESPICLICK BUNAVAIL............................ 7
acetaminophen-codeine #4.. 6 232......................................25 buprenorphine hcl................. 7
acyclovir..............................10 ARMONAIR RESPICLICK buprenorphine hcl-
ACZONE.............................14 55........................................25 naloxone hcl..........................7
adapalene........................... 14 ARMOUR THYROID...........21 bupropion hcl........................ 8
ADCIRCA............................26 ARNUITY ELLIPTA.............25 bupropion hcl er (sr)..............8
ADDERALL XR...................13 ASTEPRO...........................24 bupropion hcl er (xl).............. 8
ADDYI.................................14 atenolol............................... 11 buspirone hcl...................... 11
ADEMPAS.......................... 26 atenolol-chlorthalidone........11 butalbital-apap-caffeine........ 6
ADVAIR DISKUS................ 25 atomoxetine hcl...................13 BYDUREON....................... 15
ADVAIR HFA...................... 25 atorvastatin calcium............ 11 BYDUREON BCISE
ADZENYS ER.....................13 ATRALIN.............................14 AUTOINJECTOR................15
ADZENYS XR-ODT............ 13 ATRIPLA.............................10 BYETTA 10 MCG PEN....... 15
AFLURIA AUBAGIO........................... 14 BYETTA 5 MCG PEN......... 15
PRESERVATIVE FREE......23 AURYXIA............................ 18 BYSTOLIC.......................... 12
AFSTYLA............................11 aviane................................. 20 BYVALSON........................ 12
ala-cort................................19 AVONEX PEN.................... 14 CABOMETYX....................... 9
albuterol sulfate.................. 25 AVONEX PREFILLED........ 14 calcitriol...............................23
alendronate sodium............ 23 AVONEX VIAL CANASA............................. 23
alfuzosin hcl er....................19 INTRAMUSCULAR KIT..... 14 capecitabine..........................9
27carbamazepine..................... 8 CORLANOR....................... 12 drospirenone-ethinyl
carbidopa-levodopa............ 10 COSENTYX 150 MG/ML.... 22 estradiol.............................. 20
carisoprodol........................ 26 COSENTYX 300 DOSE......22 DUAVEE............................. 20
cartia xt............................... 12 COSENTYX duloxetine hcl........................8
carvedilol.............................12 SENSOREADY 300 DOSE.22 DUPIXENT..........................15
cefdinir.................................. 7 COSENTYX DUZALLO............................. 9
cefuroxime axetil...................7 SENSOREADY PEN.......... 22 DYMISTA............................24
celecoxib...............................6 COSOPT PF....................... 24 EDARBI.............................. 12
cephalexin.............................7 COTEMPLA XR-ODT......... 13 EDARBYCLOR................... 12
CERDELGA........................ 18 CREON...............................18 ELESTRIN.......................... 20
cetirizine hcl........................ 24 cryselle-28.......................... 20 eletriptan hydrobromide........ 9
CETROTIDE....................... 20 cyanocobalamin..................17 ELIDEL............................... 15
CETYLEV........................... 23 cyclobenzaprine hcl............ 26 ELIQUIS................................8
CHANTIX STARTING DELZICOL.......................... 23 EMBEDA...............................6
MONTH PAK........................ 7 DEPEN TITRATABS...........18 EMVERM.............................. 9
chlorhexidine gluconate...... 14 DESCOVY.......................... 10 enalapril maleate................ 12
chlorthalidone..................... 12 desloratadine...................... 24 ENBREL............................. 22
choline fenofibrate.............. 12 desvenlafaxine succinate ENBREL SURECLICK........22
CIALIS................................ 18 er...........................................8 ENDOMETRIN....................20
cilostazol............................. 10 dexamethasone.................. 19 enoxaparin sodium............... 8
CIMDUO............................. 10 DEXCOM G4 PLATINUM enskyce...............................20
CIMZIA................................22 PEDIATRIC RECEIVER..... 16 ENSTILAR.......................... 15
CIMZIA PREFILLED KIT.... 21 DEXCOM G4 PLATINUM entecavir............................. 10
CIMZIA STARTER KIT....... 21 RECEIVER, SENSOR, ENTRESTO........................ 12
CIPRODEX......................... 24 TRANSMITTER.................. 16 EPCLUSA........................... 10
ciprofloxacin hcl.............. 7, 23 DEXCOM G5 SENSOR, EPIDUO.............................. 15
citalopram hydrobromide...... 8 TRANSMITTER, MOBILE EPIDUO FORTE.................15
claravis................................14 RECEIVER......................... 16 EPINEPHRINE................... 25
clarithromycin........................7 DEXILANT.......................... 18 erythromycin....................... 24
CLENPIQ............................ 18 dexmethylphenidate hcl...... 13 escitalopram oxalate.............8
CLIMARA PRO................... 20 dexmethylphenidate hcl er..13 esomeprazole magnesium..18
CLINDAGEL....................... 14 diazepam............................ 11 estradiol.............................. 20
clindamycin hcl..................... 7 diclofenac potassium............ 6 eszopiclone.........................26
clindamycin phos-benzoyl diclofenac sodium................. 6 etodolac................................ 6
perox...................................14 dicyclomine hcl................... 18 EUCRISA............................15
clindamycin phosphate. 14, 15 DIFFERIN........................... 15 EUFLEXXA......................... 23
CLINDAMYCIN digoxin................................ 12 ezetimibe............................ 12
PHOSPHATE......................14 diltiazem hcl........................ 12 ezetimibe-simvastatin......... 12
CLINDESSE......................... 7 diltiazem hcl er beads......... 12 famotidine........................... 18
clobetasol propionate..........19 diltiazem hcl er coated FARXIGA............................ 15
CLOBEX SPRAY................ 19 beads.................................. 12 fenofibrate...........................12
clonazepam........................ 11 DIPENTUM......................... 23 fenofibrate micronized........ 12
clonidine hcl........................ 12 diphenoxylate-atropine....... 18 fenofibric acid......................12
clopidogrel bisulfate............ 10 divalproex sodium.................8 fentanyl................................. 6
clotrimazole- divalproex sodium er.............8 finasteride........................... 19
betamethasone................... 15 DIVIGEL..............................20 flecainide acetate................12
COLCHICINE........................9 donepezil hcl.........................8 FLECTOR............................. 6
COLCRYS............................ 9 dorzolamide hcl-timolol mal 24 FLOVENT DISKUS.............25
COMBIGAN........................ 24 doxazosin mesylate............ 12 FLOVENT HFA................... 25
COMBIVENT RESPIMAT... 25 doxepin hcl............................8 FLUCELVAX
COMPLERA........................10 doxycycline hyclate...............7 QUADRIVALENT................23
CONTRAVE........................14 doxycycline monohydrate..... 7 fluconazole............................9
COPAXONE....................... 14 fluocinonide.........................19
28FLUOROPLEX....................15 HUMIRA PEN..................... 22 JENTADUETO....................15
fluoxetine hcl.........................8 HUMIRA PEN-CD/UC/HS JENTADUETO XR..............15
fluticasone propionate.........24 STARTER........................... 22 JUBLIA..................................9
fluvoxamine maleate.............8 HUMIRA PEN-PS/UV JULUCA..............................10
folic acid..............................17 STARTER........................... 22 junel 1/20............................ 20
FORFIVO XL........................ 8 HUMULIN 70/30 junel fe 1.5/30..................... 20
FORTEO.............................23 KWIKPEN........................... 17 junel fe 1/20........................ 20
furosemide.......................... 12 HUMULIN 70/30 VIAL.........17 KERYDIN..............................9
gabapentin............................ 8 HUMULIN N KWIKPEN...... 17 ketoconazole.........................9
gavilyte-g............................ 18 HUMULIN N VIAL............... 17 ketorolac tromethamine.. 6, 24
gemfibrozil.......................... 12 HUMULIN R U-500 KEVZARA........................... 22
gentamicin sulfate...............24 KWIKPEN........................... 17 klor-con m20....................... 17
GENVOYA.......................... 10 HUMULIN R U-500 VIAL labetalol hcl.........................12
gianvi.................................. 20 (CONCENTRATED)........... 17 lamotrigine............................ 8
GILENYA............................ 14 HUMULIN R VIAL............... 17 lansoprazole....................... 18
glimepiride.......................... 15 hydralazine hcl....................12 LANTUS SOLOSTAR......... 17
glipizide...............................15 hydrochlorothiazide.............12 LANTUS U-100 VIAL.......... 17
glipizide er...........................15 hydrocodone polst-cpm LASTACAFT....................... 24
glipizide xl........................... 15 polst er................................ 25 latanoprost.......................... 24
GLUCAGON hydrocodone- LATUDA..............................10
EMERGENCY.....................17 acetaminophen..................... 6 LETAIRIS............................26
glyburide............................. 15 hydrocortisone.................... 19 letrozole................................ 9
glyburide-metformin............ 15 hydrocortisone in LEVEMIR U-100
GLYXAMBI......................... 15 absorbase........................... 19 FLEXTOUCH...................... 17
GONAL-F............................20 hydromorphone hcl............... 6 LEVEMIR U-100 VIAL........ 17
GONAL-F RFF....................20 hydroxychloroquine sulfate... 9 levetiracetam........................ 8
GONAL-F RFF REDIJECT. 20 hydroxyzine hcl................... 11 levocetirizine
GRALISE............................ 14 hydroxyzine pamoate..........11 dihydrochloride................... 25
GRALISE STARTER.......... 14 HYSINGLA ER......................6 levofloxacin........................... 7
GRANIX.............................. 11 ibandronate sodium............ 23 levonorgestrel-ethinyl
guanfacine hcl.....................12 IBRANCE..............................9 estrad..................................20
guanfacine hcl er................ 13 ibuprofen...............................6 levo-t................................... 21
GYNAZOLE-1....................... 9 ILEVRO...............................24 levothyroxine sodium.......... 21
HAEGARDA........................22 INCRUSE ELLIPTA............ 25 levoxyl.................................21
haloperidol.......................... 10 indomethacin........................ 6 lidocaine................................6
HARVONI........................... 10 INTELENCE........................10 lidocaine viscous.................14
HP ACTHAR....................... 20 INVEGA SUSTENNA..........10 lidocaine-prilocaine............... 6
HUMALOG KWIKPEN........ 17 INVEGA TRINZA................ 10 LINZESS.............................18
HUMALOG MIX 50/50 INVOKAMET.......................15 liothyronine sodium.............21
KWIKPEN........................... 17 INVOKAMET XR.................15 LIPOFEN............................ 12
HUMALOG MIX 50/50 INVOKANA......................... 15 lisinopril...............................12
VIAL.................................... 17 ipratropium bromide............25 lisinopril-
HUMALOG MIX 75/25 ipratropium-albuterol...........25 hydrochlorothiazide.............12
KWIKPEN........................... 17 irbesartan............................12 lithium carbonate................ 11
HUMALOG MIX 75/25 irbesartan- lithium carbonate er............ 11
VIAL.................................... 17 hydrochlorothiazide.............12 LIVALO............................... 12
HUMALOG U-100 JUNIOR ISENTRESS....................... 10 LO LOESTRIN FE.............. 20
KWIKPEN........................... 17 ISENTRESS HD................. 10 lorazepam........................... 11
HUMALOG U-100 VIAL isosorbide mononitrate er... 12 loryna.................................. 20
AND CARTRIDGE.............. 17 JANUMET...........................15 LORZONE.......................... 26
HUMIRA..............................22 JANUMET XR.....................15 losartan potassium..............12
HUMIRA PEDIATRIC JANUVIA.............................15 losartan potassium-hctz......12
CROHNS START............... 22 JARDIANCE....................... 15 lovastatin.............................12
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