Your 2019 Prescription Drug List - Student Resources Traditional Three-Tier - Advantage Four-Tier

 
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Your 2019 Prescription Drug List - Student Resources Traditional Three-Tier - Advantage Four-Tier
Your 2019 Prescription Drug List
Student Resources Traditional Three-Tier

  Effective
Effective   Jan. 1,1,
          January   2019
                      2019

This Prescription Drug List (PDL) is accurate as of Jan.1, 2019 and is subject to change after
this date. The next anticipated update will be July 1, 2019. This PDL applies to members of our
Student Resources medical plans with a pharmacy benefit subject to the Traditional 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.
Table of Contents

Understanding your Prescription                                             Gastrointestinal
Drug List. . . . . . . . . . . . . . . . . . . . . . . . . . . . 3          Acid Suppression. . . . . . . . . . . . . . . . . . . . . 16
                                                                            Nausea/Vomiting. . . . . . . . . . . . . . . . . . . . . 16
Medication tips . . . . . . . . . . . . . . . . . . . . . . 5
                                                                            Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Reading your PDL. . . . . . . . . . . . . . . . . . . . 6
                                                                            Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . 8
                                                                            Hepatitis C. . . . . . . . . . . . . . . . . . . . . . . . . 17
Drugs by category . . . . . . . . . . . . . . . . . . . 9
                                                                            HIV/AIDS. . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Anti-Infectives                                                             Infertility. . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Antifungals. . . . . . . . . . . . . . . . . . . . . . . . . . . 9          Inflammatory Conditions: Rheumatoid
Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9        Arthritis, Crohn’s Disease, Psoriasis,
                                                                            Ulcerative Colitis. . . . . . . . . . . . . . . . . . . . 18
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
                                                                            Men’s Health
Cardiovascular/Heart Disease                                                Prostate. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Coagulation Therapy. . . . . . . . . . . . . . . . . .             10       Testosterone Therapy. . . . . . . . . . . . . . . . . 19
High Blood Pressure. . . . . . . . . . . . . . . . . .             10
                                                                            Miscellaneous. . . . . . . . . . . . . . . . . . . . . . 19
High Cholesterol . . . . . . . . . . . . . . . . . . . . .         11
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   11       Musculoskeletal
                                                                            Muscle Spasms. . . . . . . . . . . . . . . . . . . . . . 19
Central Nervous System
                                                                            Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . 19
Attention Deficit Disorder. . . . . . . . . . . . . . .            11
                                                                            Pain Relief. . . . . . . . . . . . . . . . . . . . . . . . . . 20
Depression . . . . . . . . . . . . . . . . . . . . . . . . .       12
Migraine. . . . . . . . . . . . . . . . . . . . . . . . . . . .    12       Overactive Bladder. . . . . . . . . . . . . . . . . . 20
Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . .        12
                                                                            Respiratory
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   12
                                                                            Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Sedatives/Hypnotics . . . . . . . . . . . . . . . . . .            13
                                                                            Asthma/COPD. . . . . . . . . . . . . . . . . . . . . . . 20
Seizure Disorders . . . . . . . . . . . . . . . . . . . .          13
                                                                            Pulmonary Arterial Hypertension. . . . . . . . 21
Dermatology . . . . . . . . . . . . . . . . . . . . . . . 13
                                                                            Smoking Cessation. . . . . . . . . . . . . . . . . . 21
Diabetes
                                                                            Transplant . . . . . . . . . . . . . . . . . . . . . . . . . 21
Blood Glucose Monitoring. . . . . . . . . . . . . . 14
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15        Vitamins/Electrolytes. . . . . . . . . . . . . . . . 21
Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . 15            Women’s Health
Endocrine                                                                   Contraceptives. . . . . . . . . . . . . . . . . . . . . . .    22
Growth Hormone. . . . . . . . . . . . . . . . . . . . . 15                  Hormone Replacement. . . . . . . . . . . . . . . .             24
Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16         Miscellaneous. . . . . . . . . . . . . . . . . . . . . . .     24
Thyroid Hormone Replacement. . . . . . . . . . 16                           Prenatal Vitamins . . . . . . . . . . . . . . . . . . . .      24

Eye Conditions                                                              Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Allergies. . . . . . . . . . . . . . . . . . . . . . . . . . . .   16
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . .    16
Dry Eye Disease. . . . . . . . . . . . . . . . . . . . .           16
Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . .       16
                                                                        2
Understanding your Prescription Drug List (PDL)

What is a PDL?
This document is a list of the most commonly                      About this PDL
prescribed medications. It includes both brand-name               Where differences exist between
and generic prescription medications approved by the              this PDL and your benefit plan
Food and Drug Administration (FDA). Medications are               documents, the benefit plan
listed by common categories or classes and placed                 documents rule. This PDL is not
in tiers that represent the cost you pay out-of-pocket.           a complete list of medications,
They are then listed in alphabetical order.                       and not all medications listed
                                                                  may be covered by your plan.
How do I use my PDL?                                              Please look at the benefit plan
You and your doctor can consult the PDL to help you               documents provided by your
select the most cost-effective prescription medications.          employer or health plan to see
This guide tells you if a medication is generic or a              which medications are covered
brand-name, and if there are coverage requirements or             under your plan.
limits. Bring this list with you when you see your doctor.
If your medication is not listed here, please visit your
plan’s member website or call the toll-free member
phone number on your health plan 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 benefit plan. This is how much you will pay when
you fill a prescription. See page 6 for additional information.

When does the PDL change?
PDL changes typically occur twice per year. However, changes that have a positive impact for
you — such as coverage for new medications or cost savings — may occur at any time. 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.

                                                  3
Understanding your Prescription Drug List (continued)

Why are some medications excluded from coverage?
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
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.

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.

                                                 4
Medication tips

What is the difference between brand-name and
generic medications?                                               Over-the-counter
Generic medications contain the same active                        (OTC) medications
ingredients (what makes the medication work) as                    An OTC medication may be
brand-name medications, but they often cost less.                  the right treatment option for
Once the patent for a brand-name medication ends,                  some conditions. Talk to your
the FDA can approve a generic version with the same                doctor about available OTC
active ingredients. These types of medications are                 options. Even though these
known as generic medications. Sometimes, the same                  medications may not be
company that makes a brand-name medication also                    covered by your pharmacy
makes the generic version.                                         benefit, they may cost less
                                                                   than a prescription medication.
What if my doctor writes a brand-name prescription?
If your doctor gives you a prescription for a brand-name
medication, ask if a generic equivalent or lower-cost
option is available and could 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.

What if I am taking a specialty medication?
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 ID card to talk with a pharmacist about
finding lower-cost options or a financial assistance program.

                                                   5
Reading your PDL

The PDL gives you choices so you and your doctor can determine your best course of treatment.
In this PDL, brand-name medications are shown in bold type and generic medications in plain type.

Tier information.
Using lower-tier 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 may apply
once you hit your deductible.

Drug Tier       Includes                                         Helpful Tips
Tier 1      $	
              Lower-cost                                         Use Tier 1 drugs for the
              Medications that provide the highest               lowest out-of-pocket costs.
              overall value. Mostly generic drugs. Some
              brand-name drugs may also be included.
Tier 2      $$	
               Mid-range cost                                    Use Tier 2 drugs, instead of
               Medications that provide good overall value.      Tier 3, to help reduce your
               Mainly preferred brand-name drugs.                out-of-pocket costs.
Tier 3      $$$	Highest-cost                                    Ask your doctor if a Tier 1 or Tier 2
                 Medications that provide the lowest             option could work for you.
                 overall value.

                                                  6
Reading your PDL (continued)

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.

 E              ay be excluded from coverage or subject to prior authorization and/or trial/
               M
               failure of another medication(s). (Referred to as First Start in New Jersey)
               Lower-cost options are available and covered.
 H              ealth 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.
 H-PA           ealth Care Reform Preventive with Prior Authorization
               H
               May be part of health care reform preventive and available at no additional
               cost to you if prior authorization criteria is met.
 PA	
    Prior Authorization
    Requires your doctor to provide information about why you are taking
    a medication to determine how it may be covered by your plan.
 SP	
    Specialty Medication
    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.
 SL            Supply Limits
                Specifies the largest quantity of medication covered per copayment
                or in a defined period of time.

                                                7
Questions

For the most current list of covered medications or if you have questions:

          all the toll-free member phone number
         C
         on your health plan ID card.

          isit your plan’s member website listed
         V                                                  And, if home delivery services
         on your health plan ID card to:                    are included in your pharmacy
                                                            benefit, you can also:
         • View your pharmacy benefit and coverage
            information, including prescription history     • Refill prescriptions

         • View medication interactions and side effects   • Check the status of your order

         • Locate a participating retail pharmacy          • Set up reminders for refills
            by ZIP code
                                                            • Manage your account
         • Look up possible lower-cost medication
            alternatives
         • Compare medication pricing and options

                                                 8
Drug 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                        1          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                    1                        Nystatin Cream, Ointment               1
Cefprozil Tablet                       1                        Terbinafine Tablet                     1          SL
Cefuroxime Tablet                      1                        Anti-Infectives: Antivirals
Cephalexin Capsule                     1                        Acyclovir Ointment                     1          SL
Ciprodex                               3                        Acyclovir Tablet                       1
Ciprofloxacin Tablet                   1                        Famciclovir Tablet                     1
Clarithromycin Tablet                  1                        Oseltamivir Capsule, Suspension        1          SL
Clindamycin Capsule                    1                        Valacyclovir Tablet                    1          SL
Dificid                                3          SL            Valganciclovir                         1          SL
Doxycycline Capsule, Tablet            1                        Cancer
Levofloxacin Tablet                    1                        Alunbrig                               2     PA, SL, SP
Minocycline Capsule                    1                        Bexarotene Capsule                     3        E, SP
Moxifloxacin Tablet                    1                        Bicalutamide                           1
Nitrofurantoin Capsule                 1                        Bosulif                                2     PA, SL, SP
Nitrofurantoin Macrocrystal                                     Braftovi                               3     PA, SL, SP
                                       1
Capsule
                                                                Calquence                              2     PA, SL, SP
Ofloxacin Otic Solution                1
                                                                Cyclophosphamide Capsule               1
Ofloxacin Tablet                       1
                                                                Erleada                                3     PA, SL, SP
Penicillin V Potassium Tablet          1
                                                                Calquence                              2     PA, SL, SP
Sulfamethoxazole-Trimethoprim
                                       1
Tablet                                                          Ibrance                                2     PA, SL, SP
Suprax Capsule, Chewable                                        Idhifa                                 2     PA, SL, SP
                                       3
Tablet, Tablet
                                                                Imantinib Tablet                       1     PA, SL, SP
                                                                Imbruvica                              2     PA, SL, SP

Bold type = Brand-name drug
[Plain type = Generic drug]
E = May be excluded from coverage                                                      PA = Prior authorization required
H = May be part of health care reform preventive                                       SL = Supply limit
H-PA = May be part of health care reform preventive with prior authorization           SP = Specialty medication
                                                            9
Drug Requirements                                         Drug Requirements
Drug Name                                                 Drug Name
                                 Tier & Limits                                             Tier & Limits
Leucovorin Calcium Tablet         1                       Bisoprolol                        1
Mektovi                           3     PA, SL, SP        Bisoprolol-Hydrochlorothiazide    1
Mercaptopurine Tablet             1                       Bystolic                          2
Nerlynx                           2     PA, SL, SP        Byvalson                          2        SL
Revlimid                          2     PA, SL, SP        Cartia XT                         1
Rydapt                            2     PA, SL, SP        Carvedilol Immediate-Release
                                                                                            1
                                                          Tablet
Sutent                            2     PA, SL, SP
                                                          Chlorthalidone                    1
Targretin Capsule                 1        SP
                                                          Clonidine Tablet                  1
Targretin Gel                     3        SL
                                                          Diltiazem 24 Hour CD              1
Tasigna                           2     PA, SL, SP
                                                          Diltiazem Sustained-Release
                                                                                            1
Verzenio                          2     PA, SL, SP        Capsule
Xeloda                            1      SL, SP           Diltiazem Sustained-Release
                                                                                            1
                                                          Tablet
Zykadia                           2     PA, SL, SP
                                                          Doxazosin                         1
Zytiga                            2     PA, SL, SP
                                                          Edarbi                            3        SL
Cardiovascular/Heart Disease: Coagulation Therapy
                                                          Edarbyclor                        3        SL
Bevyxxa                           3        SL
                                                          Enalapril                         1
Brilinta                          3        SL
                                                          Furosemide                        1
Clopidogrel                       1
                                                          Guanfacine                        1
Eliquis                           3        SL
                                                          Hydralazine                       1
Enoxaparin Sodium                 1        SL
                                                          Hydrochlorothiazide               1
Pradaxa                           2        SL
                                                          Irbesartan                        1
Prasugrel                         1        SL
                                                          Labetalol                         1
Savaysa                           3        SL
                                                          Lisinopril                        1
Warfarin Sodium                   1
                                                          Lisinopril-Hydrochlorothiazide    1
Xarelto                           2        SL
                                                          Losartan                          1
Cardiovascular/Heart Disease: High Blood Pressure
                                                          Losartan-Hydrochlorothiazide      1
Amlodipine                        1
                                                          Metoprolol Succinate Extended-
                                                                                            1
Amlodipine-Benazepril             1                       Release
Amlodipine-Valsartan              1                       Metoprolol Tartrate 25, 50,
                                                                                            1
                                                          100 mg
Atenolol                          1
                                                          Nadolol                           1
Atenolol-Chlorthalidone           1
                                                          Nifedipine Extended-Release       1
Benazepril                        1
                                                          Olmesartan                        1        SL
Benazepril-Hydrochlorothiazide    1
                                                          Olmesartan-Hydrochlorothiazide    1        SL
Bidil                             2

                                                     10
Drug Requirements                                              Drug Requirements
Drug Name                                                       Drug Name
                                    Tier & Limits                                                  Tier & Limits
Propranolol Extended-Release                                    Rosuvastatin                          1          SL
                                       1
Capsule
                                                                Simvastatin                           1        H-PA
Propranolol Tablet                     1
                                                                Vascepa                               3
Quinapril                              1
                                                                Welchol Packet for Suspension,
Ramipril                               1                                                              1
                                                                Tablet
Spironolactone                         1                        Cardiovascular/Heart Disease: Other
Telmisartan                            1                        Amiodarone                            1
Telmisartan-Hydrochlorothiazide        1                        Corlanor                              3          SL
Terazosin                              1                        Digoxin                               1
Triamterene-Hydrochlorothiazide        1                        Entresto                              3          SL
Valsartan                              1                        Flecainide                            1
Valsartan-Hydrochlorothiazide          1                        Isosorbide Mononitrate ER             1
Verapamil                              1                        Multaq                                3
Verapamil Sustained-Release            1                        Nitroglycerin Sublingual Tablet       1
Cardiovascular/Heart Disease: High Cholesterol                  Ranexa                                2
Atorvastatin                           1      H-PA, SL          Sotalol                               1
Colesevelam Packet for                                          Central Nervous System: Attention Deficit Disorder
Suspension, Tablet                     3          E
(generic Welchol)                                               Adderall XR                           1          SL

Ezetimibe Tablet                       1          SL            Amphetamine Salt Combo                1

Ezetimibe/Simvastatin                  1          SL            Atomoxetine                           1          SL

Fenofibrate 54, 160 mg Tablet          1                        Concerta                              1          SL
Fluvastatin Extended-Release                                    Dexmethylphenidate Immediate-
                                       1          SL                                                  1
Tablet                                                          Release Tablet
Gemfibrozil                            1                        Dextroamphetamine-
                                                                Amphetamine Immediate-Release         1
Lovastatin                             1          H             Tablet
Niacin Extended-Release Tablet         1                        Dextroamphetamine Sulfate
                                                                                                      1
                                                                Immediate-Release Tablet
Niaspan                                3
                                                                Guanfacine Extended-Release           1          SL
Omega-3-Acid Ethyl Esters
                                       1                        Methylphenidate Chewable Tablet       1
Capsule
Praluent                               2     PA, SL, SP         Methylphenidate Extended-
                                                                Release Capsule (generic              1          SL
Pravastatin                            1                        Metadate CD, Ritalin LA)
Repatha                                3     PA, SL, SP

Bold type = Brand-name drug
[Plain type = Generic drug]
E = May be excluded from coverage                                                     PA = Prior authorization required
H = May be part of health care reform preventive                                      SL = Supply limit
H-PA = May be part of health care reform preventive with prior authorization          SP = Specialty medication
                                                           11
Drug Requirements                                          Drug Requirements
Drug Name                                                   Drug Name
                                   Tier & Limits                                              Tier & Limits
Methylphenidate Extended-                                   Central Nervous System: Migraine
Release Capsule (Metadate ER,       1        SL
                                                            Acetaminophen/Butalbital/
generic Ritalin SR)                                                                            1         SL
                                                            Caffeine 325 mg/50 mg/40 mg
Methylphenidate Extended-
Release Tablet (generic             3       E, SL           Eletriptan                         1         SL
Concerta)                                                   Frovatriptan                       1         SL
Methylphenidate Immediate-
                                    1                       Naratriptan                        1         SL
Release Tablet
Vyvanse                             2        SL             Rizatriptan ODT, Tablet            1         SL

Central Nervous System: Depression                          Sumatriptan Nasal Spray            1         SL
                                                            Sumatriptan Succinate Tablet,
Amitriptyline Tablet                1                                                          1         SL
                                                            Injection
Bupropion Extended-Release
                                    1                       Central Nervous System: Multiple Sclerosis
Tablet
Bupropion Sustained-Release                                 Ampyra                             2     PA, SL, SP
                                    1
Tablet                                                      Aubagio                            3     PA, SL, SP
Bupropion Tablet                    1                       Avonex                             2     PA, SL, SP
Citalopram Tablet                   1                       Betaseron                          2     PA, SL, SP
Desvenlafaxine Extended-
                                    1        SL             Gilenya                            3     PA, SL, SP
Release Tablet (generic Pristiq)
                                                            Glatiramer (generic Copaxone)
Doxepin                             1                                                          1     PA, SL, SP
                                                            [Mylan version only]
Duloxetine Capsule                  1        SL             Plegridy                           3     PA, SL, SP
Escitalopram Tablet                 1                       Rebif                              3     PA, SL, SP
Fetzima                             3        SL             Tecfidera                          2     PA, SL, SP
Fluoxetine Capsule (generic
                                    1                       Central Nervous System: Other
Prozac)
                                                            Alprazolam Extended-Release
Fluvoxamine Tablet                  1                                                          1
                                                            Tablet
Mirtazapine Tablet                  1                       Alprazolam Tablet                  1
Nortriptyline Capsule               1                       Aripiprazole Tablet                1         SL
Paroxetine Tablet                   1                       Armodafinil                        1         SL
Sertraline Tablet                   1                       Austedo                            2     PA, SL, SP
Trazodone Tablet                    1                       Buprenorphine Sublingual Tablet    1
Trintellix                          3        SL             Buspirone Tablet                   1
Venlafaxine Extended-Release
                                    1                       Carbidopa-Levodopa                 1
Capsule
Venlafaxine Tablet                  1                       Diazepam Tablet                    1

Viibryd                             3        SL             Donepezil ODT, 5, 10 mg Tablet     1
                                                            Latuda                             3         SL
                                                            Lithium Capsule                    1

                                                       12
Drug Requirements                                               Drug Requirements
Drug Name                                                       Drug Name
                                    Tier & Limits                                                   Tier & Limits
Lorazepam Tablet                       1                        Divalproex Delayed-Release
                                                                                                       1
                                                                Tablet
Memantine Immediate-Release
                                       1                        Divalproex Extended-Release
Tablet                                                                                                 1
                                                                Tablet
Modafinil                              1          SL
                                                                Gabapentin Capsule, Tablet             1
Naloxone Vial                          1
                                                                Lamotrigine Immediate-Release
                                                                                                       1
Narcan Nasal Spray                     2          SL            Tablet
Olanzapine Tablet                      1          SL            Levetiracetam Extended-Release
                                                                                                       1
                                                                Tablet
Pramipexole Tablet                     1
                                                                Levetiracetam Immediate-Release
Quetiapine Extended-Release                                                                            1
                                       1          SL            Tablet
Tablet
                                                                Lyrica                                 3          SL
Quetiapine Immediate-Release
                                       1                        Lyrica CR                              3        E, SL
Tablet
Risperidone Tablet                     1                        Oxcarbazepine Tablet                   1
Ropinirole Tablet                      1                        Phenytoin Capsule, Suspension          1
Suboxone Film                          3        E, SL           Topiramate Immediate-Release
                                                                                                       1
                                                                Tablet
Tolcapone                              1
                                                                Zonisamide Capsule                     1
Xyrem                                  3        PA, SL
                                                                Dermatology
Zelapar                                3
                                                                Aczone                                 1          SL
Ziprasidone Capsule                    1          SL
                                                                Betamethasone Dipropionate
Zubsolv                                1          SL            0.05% Augmented Lotion,                1
                                                                Ointment
Central Nervous System: Sedatives/Hypnotics
                                                                Betamethasone Dipropionate
Eszopiclone Tablet                     1          SL                                                   1
                                                                0.05% Cream, Ointment
Temazepam Capsule                      1                        Calcipotriene/Betamethasone
                                                                                                       1          SL
                                                                Ointment
Triazolam Tablet                       1
                                                                Carac                                  2
Zaleplon Capsule                       1          SL
                                                                Ciclopirox Cream, Gel, Lotion,
Zolpidem Immediate-Release                                                                             1
                                       1          SL            Solution
Tablet
                                                                Claravis                               1
Central Nervous System: Seizure Disorders
                                                                Clindamycin 1.2%/Benzoyl
Carbamazepine Extended-                                                                                1          SL
                                       1                        Peroxide 5% Gel
Release Capsule, Tablet
                                                                Clindamycin Gel                        1          SL
Carbamazepine Immediate-
                                       1                        Clindamycin Lotion, Swabs              1
Release Tablet
Clonazepam Tablet                      1                        Clindamycin Solution                   1          SL
Diazepam Tablet                        1

Bold type = Brand-name drug
[Plain type = Generic drug]
E = May be excluded from coverage                                                      PA = Prior authorization required
H = May be part of health care reform preventive                                       SL = Supply limit
H-PA = May be part of health care reform preventive with prior authorization           SP = Specialty medication
                                                           13
Drug Requirements                                         Drug Requirements
Drug Name                                                  Drug Name
                                  Tier & Limits                                             Tier & Limits
Clobetasol Propionate Cream,                               Regranex                          2        SL
                                   1        SL
Ointment, Solution
                                                           Rhofade                           3        SL
Clotrimazole-Betamethasone
                                   1        SL
Cream                                                      Taclonex Suspension               3        SL
Clotrimazole-Betamethasone                                 Tacrolimus Ointment               1        SL
                                   1
Lotion
                                                           Tazarotene 0.1% Cream (generic
Dapsone 5% Gel                     3       E, SL                                             3     E, PA, SL
                                                           Tazorac)
Desonide 0.05% Cream, Lotion,                              Tazorac 0.1% Cream                1      PA, SL
                                   1        SL
Ointment
                                                           Tazorac Gel, 0.05% Cream          3      PA, SL
Desoximetasone Cream, Gel,
                                   1        SL
Ointment                                                   Tretinoin Cream                   1      PA, SL
Diflorasone Diacetate 0.05%                                Triamcinolone Acetonide Cream,
                                   1        SL                                               1
Cream, Ointment                                            Lotion, Ointment
Dupixent                           3     PA, SL, SP        Vectical                          3        SL
Elidel                             3        SL             Diabetes: Blood Glucose Monitoring
Enstilar Foam                      3        SL             Accu-Chek Test Strips             3       E, SL
Eucrisa                            3        SL             Contour Next EZ Meter             2
Finacea                            3                       Contour Next Meter                2
Fluocinonide 0.05% Cream           1                       Contour Next One Meter            2
Fluocinolone Cream, Oil,                                   Contour Next Test Strips          2        SL
                                   1        SL
Ointment, Solution
                                                           Contour Test Strips               3       E, SL
Fluorouracil 0.5% Cream            3        SL
                                                           FreeStyle Test Strips             3       E, SL
Halobetasol Ointment               1        SL
Hydrocortisone 2.5% Cream,                                 OneTouch Ultra 2 Meter            1
                                   1
Ointment                                                   OneTouch Ultra Test Strips        1        SL
Imiquimod 5% Cream                 1        SL             OneTouch UltraMini Meter          1
Metronidazole 0.75% Topical Gel    1                       OneTouch Verio Flex Meter         1
Minocycline Extended-Release                               OneTouch Verio IQ Meter           1
                                   1         E
(generic Solodyn)
                                                           OneTouch Verio Meter              1
Mirvaso                            3        SL
Mometasone Furoate Cream,                                  OneTouch Verio Sync Meter         1
                                   1
Lotion, Ointment                                           OneTouch Verio Test Strips        1        SL
Mupirocin Ointment                 1        SL
Oracea                             3
Oxsoralen-Ultra                    2
Picato                             3        SL

                                                      14
Drug Requirements                                                Drug Requirements
Drug Name                                                       Drug Name
                                    Tier & Limits                                                    Tier & Limits
Diabetes: Insulin                                               Januvia                                 3          SL
Admelog SoloStar, Vials                3        E, SL           Jardiance                               2          SL
Apidra SoloStar, Vials                 3        E, SL           Jentadueto, Jentadueto XR               2          SL
Basaglar                               1          SL            Kazano                                  2          SL
Fiasp FlexTouch, Vials                 3        E, SL           Kombiglyze XR                           2          SL
Humalog KwikPens                                                Metformin                               1
                                       2          SL
(all formulations)
                                                                Metformin Extended-Release
Humalog Vials (all formulations)       1          SL                                                    1
                                                                Tablet (generic Glucophage XR)
Humulin KwikPens                                                Nesina                                  2          SL
                                       2          SL
(all formulations)
                                                                Onglyza                                 2          SL
Humulin Vials (all formulations)       1          SL
                                                                Oseni                                   2          SL
Lantus SoloStar                        3        E, SL
                                                                Ozempic                                 3          SL
Lantus Vials                           3        E, SL
                                                                Pioglitazone                            1          SL
Levemir FlexTouch, Vials               3          SL
                                                                Qtern                                   3        E, SL
Novolin Vials (all formulations)       3        E, SL
                                                                Segluromet                              3        E, SL
Novolog FlexPen, Vials
                                       3        E, SL
(all formulations)                                              Soliqua                                 2          SL
Tresiba FlexTouch                      2        E, SL           Steglatro                               3        E, SL
Diabetes: Non-Insulin                                           Steglujan                               3        E, SL
Adlyxin                                3          SL            Synjardy, Synjardy XR                   2          SL
Bydureon, Bydureon Bcise               2          SL            Tradjenta                               2          SL
Byetta                                 2          SL            Trulicity                               3          SL
Farxiga                                3        E, SL           Victoza 2-Pak                           2          SL
Glimepiride                            1                        Victoza 3-Pak                           3          SL
Glipizide                              1                        Xigduo XR                               3        E, SL
Glipizide Extended-Release             1                        Endocrine: Growth Hormone        1

Glyburide                              1                        Nutropin, Nutropin AQ                   2     PA, SL, SP
Glyxambi                               2          SL            1
                                                                    Coverage is determined by the consumer’s prescription
                                                                    drug benefit plan. Please consult plan documents
Invokamet, Invokamet XR                2          SL                regarding benefit coverage and cost-share.
Invokana                               2          SL
Janumet                                3          SL

Bold type = Brand-name drug
[Plain type = Generic drug]
E = May be excluded from coverage                                                       PA = Prior authorization required
H = May be part of health care reform preventive                                        SL = Supply limit
H-PA = May be part of health care reform preventive with prior authorization            SP = Specialty medication
                                                           15
Drug Requirements                                          Drug Requirements
Drug Name                                                   Drug Name
                                   Tier & Limits                                              Tier & Limits
Endocrine: Other                                            Eye Conditions: Dry Eye Disease
Calcitriol Capsule                  1                       Restasis Single Use Vial            3       SL
Desmopressin Tablet                 1                       Xiidra                              3       SL
Dexamethasone Tablet                1                       Eye Conditions: Glaucoma
Methylprednisolone Tablet           1                       Alphagan P 0.1%                      2      SL
Prenisolone Oral Solution           1                       Azopt                                2      SL
Prednisone Tablet                   1                       Combigan                             2      SL
Endocrine: Thyroid Hormone Replacement                      Latanoprost 0.005% Ophthalmic
                                                                                                 1
                                                            Solution
Armour Thyroid                      3
                                                            Lumigan                              2      SL
Levothyroxine Sodium Tablet         1
                                                            Timolol 0.25%, 0.5% Ophthalmic
                                                                                                 1
Liothyronine Sodium Tablet          1                       Solution
Methimazole Tablet                  1                       Travatan Z                           2      SL
NP Thyroid Tablet                   1                       Gastrointestinal: Acid Suppression
Synthroid                           2                       Dexilant                             3      SL
Eye Conditions: Allergies                                   Omeclamox-Pak                        3      SL
Azelastine 0.05% Ophthalmic                                 Omeprazole Capsule                   1
                                    1
Solution
                                                            Pantoprazole Tablet                  1
Lastacaft                           3        SL
                                                            Pylera                               3      SL
Olopatadine 0.1% Ophthalmic
                                    1        SL             Rabeprazole Tablet                   1      SL
Solution
Eye Conditions: Antibiotics                                 Ranitadine Syrup                     1
Erythromycin 0.5% Ophthalmic                                Sucralfate Tablet                    1
                                    1
Ointment
                                                            Gastrointestinal: Nausea/Vomiting
Gentamicin Ophthalmic Ointment,
                                    1
Solution                                                    Akynzeo                              3      SL
Moxeza                              3                       Aprepitant Capsule                   1      SL
Moxifloxacin Ophthalmic Solution    1                       Emend Suspension                     2      SL
Ofloxacin 0.3% Ophthalmic                                   Ondansetron                          1
                                    1
Solution
                                                            Ondansetron ODT                      1
Tobramycin/Dexamethasone
0.3%-0.1% Ophthalmic                1                       Scopolamine Transdermal Patch        1
Suspension
                                                            Varubi                               2      SL
Tobramycin Ophthalmic Solution      1

                                                       16
Drug Requirements                                              Drug Requirements
Drug Name                                                       Drug Name
                                    Tier & Limits                                                  Tier & Limits
Gastrointestinal: Other                                         Gout
Amitiza                                3          SL            Allopurinol Tablet                    1
Apriso                                 2                        Duzallo                               3          SL
Budesonide Extended-Release                                     Mitigare                              2
                                       3          E
Tablet (generic Uceris)
                                                                Uloric                                3          SL
Canasa                                 2
                                                                Zurampic                              3          SL
Clenpiq                                3
                                                                Hepatitis C
Cortifoam                              2
                                                                Daklinza                              3     PA, SL, SP
Creon                                  2
                                                                Epclusa                               2     PA, SL, SP
Diphenoxylate-Atropine Tablet          1
                                                                Harvoni                               2     PA, SL, SP
Golytely                               2
                                                                Mavyret                               2     PA, SL, SP
Hyoscyamine Tablet                     1
                                                                Ribavirin Tablet                      1         SP
Lialda                                 1
                                                                Sovaldi                               3     PA, SL, SP
Linzess                                2          SL
                                                                Technivie                             3     PA, SL, SP
Mesalmine Delayed-Release
                                       3          E
Tablet (generic Lialda)                                         Viekira Pak                           3     PA, SL, SP
Metoclopramide Tablet                  1                        Viekira XR                            3     PA, SL, SP
Movantik                               3        E, SL           Vosevi                                2     PA, SL, SP
Moviprep                               3                        Zepatier                              3     PA, SL, SP
Polyethylene Glycol 3350               1                        HIV/AIDS
Prepopik                               3                        Abacavir-Lamivudine                   1         SP
Sulfasalazine Tablet                   1                        Atazanavir Capsule                    1         SP
Suprep                                 3                        Atripla                               3        E, SP
Symproic                               2          SL            Cimduo                                2         SP
Uceris Foam                            2                        Complera                              3         SP
Uceris Tablet                          1                        Descovy                               3         SP
Viberzi                                3          SL            Efavirenz                             1         SP
Zenpep                                 2                        Evotaz                                2         SP
                                                                Genvoya                               3         SP

Bold type = Brand-name drug
[Plain type = Generic drug]
E = May be excluded from coverage                                                     PA = Prior authorization required
H = May be part of health care reform preventive                                      SL = Supply limit
H-PA = May be part of health care reform preventive with prior authorization          SP = Specialty medication
                                                           17
Drug Requirements                                            Drug Requirements
Drug Name                                                        Drug Name
                                     Tier & Limits                                                Tier & Limits
Intelence                              2          SP             Inflammatory Conditions: Rheumatoid Arthritis,
                                                                 Crohn’s Disease, Psoriasis, Ulcerative Colitis
Isentress                              2          SP
                                                                 Actemra                          3     PA, SL, SP
Juluca                                 2          SP
                                                                 Cimzia                           2     PA, SL, SP
Kaletra Tablet                         2          SP
                                                                 Cosentyx                         3     PA, SL, SP
Lamivudine-Zidovudine                  1          SP
                                                                 Enbrel                           3     PA, SL, SP
Lopinavir-Ritonavir Oral Solution      1          SP
                                                                 Humira                           2     PA, SL, SP
Nevirapine                             1          SP
                                                                 Hydroxychloroquine Sulfate       1
Nevirapine Extended-Release            1        E, SP
                                                                 Kevzara                          3     PA, SL, SP
Odefsey                                3          SP
                                                                 Leflunomide                      1
Prezcobix                              2          SP
                                                                 Methotrexate Tablet              1
Prezista                               2          SP
                                                                 Orencia                          3     PA, SL, SP
Ritonavir Tablet                       1          SP
                                                                 Otezla                           2     PA, SL, SP
Selzentry                              2        PA, SP
                                                                 Rasuvo                           3        SL
Stribild                               3          SP
                                                                 Siliq                            3     PA, SL, SP
Symfi                                  2          SP
                                                                 Simponi                          2     PA, SL, SP
Symfi Lo                               2          SP
                                                                 Stelara                          2     PA, SL, SP
Tenofovir Tablet                       1          SP
                                                                 Taltz                            3     PA, SL, SP
Tivicay                                3          SP
                                                                 Tremfya                          2     PA, SL, SP
Triumeq                                2          SP
                                                                 Xeljanz, Xeljanz XR              3     PA, SL, SP
Truvada                                3          SP
                                                                 Men’s Health: Prostate
Tybost                                 2          SP
                                                                 Alfuzosin Tablet                 1
Vitekta                                2          SP
                                                                 Doxazosin Tablet                 1
Infertility1
                                                                 Dutasteride Capsule              1
Cetrotide                              2          SP
                                                                 Finasteride Tablet               1
Clomiphene                             1
                                                                 Rapaflo                          3
Endometrin                             2
                                                                 Tamsulosin Capsule               1
Gonal-F                                2          SP
                                                                 Terazosin Capsule, Tablet        1
Gonal-F RFF                            2          SP
Ovidrel                                3          SP
1
    Coverage is determined by the consumer’s prescription
    drug benefit plan. Please consult plan documents
    regarding benefit coverage and cost-share.

                                                            18
Drug Requirements                                              Drug Requirements
Drug Name                                                       Drug Name
                                    Tier & Limits                                                  Tier & Limits
Men’s Health: Testosterone Therapy                              Promethazine/Codeine                  1          SL
Androderm                              2          SL            Promethazine/Dextromethorphan         1
Androgel                               3        E, SL           Pulmozyme                             2     PA, SL, SP
Methyltestosterone Capsule             1                        Rectiv                                3          SL
Testim                                 1          SL            Rezira                                3
Testosterone 1% Topical Gel            1        E, SL           Sevelamer                             1
Testosterone Cypionate Injection       1                        Syprine                               1       PA, SP
Miscellaneous                                                   Tobi Podhaler                         3     PA, SL, SP
Anastrozole Tablet                     1                        Trientine (generic Syprine)           3      E, PA, SP
Aranesp                                2       SL, SP           Velphoro                              2
Auryxia                                3                        Veltassa                              3          SL
Bethkis                                1     PA, SL, SP         Zarxio                                2         SP
Cayston                                2     PA, SL, SP         Musculoskeletal: Muscle Spasms
Cerdelga                               2       PA, SP           Baclofen Tablet                       1
Chlorhexidine Gluconate                1                        Carisoprodol 350 mg Tablet            1
Chlorpheniramine/Hydrocodone/                                   Cyclobenzaprine                       1
                                       1          SL
Pseudoephedrine Solution
                                                                Metaxalone Tablet                     1
Epinephrine (generic EpiPen/
                                       2          SL
EpiPen-Jr.)                                                     Methocarbamol Tablet                  1
EpiPen/EpiPen Jr.                      3        E, SL           Tizanidine Tablet                     1
Hydrocodone/Chlorpheniramine                                    Musculoskeletal: Osteoporosis
                                       1          SL
Suspension
                                                                Alendronate Sodium Tablet             1
Lanthanum Chewable Tablet              1
                                                                Forteo                                3       PA, SP
Letrozole                              1
                                                                Ibandronate Tablet                    1          SL
Lidocaine Transdermal Patch
                                       1          SL
(generic Lidoderm)                                              Raloxifene Tablet                     1
Nityr                                  2       PA, SP           Risedronate Sodium Tablet             1          SL
Nuedexta                               2                        Tymlos                                3       PA, SP
Obredon                                3          SL
Pegasys                                2     PA, SL, SP
Phenazopyridine                        1
Procrit                                2       SL, SP

Bold type = Brand-name drug
[Plain type = Generic drug]
E = May be excluded from coverage                                                     PA = Prior authorization required
H = May be part of health care reform preventive                                      SL = Supply limit
H-PA = May be part of health care reform preventive with prior authorization          SP = Specialty medication
                                                           19
Drug Requirements                                            Drug Requirements
Drug Name                                                   Drug Name
                                   Tier & Limits                                                Tier & Limits
Musculoskeletal: Pain Relief                                Tramadol Immediate-Release
                                                                                                 1
                                                            Tablet
Acetaminophen/Codeine Tablet        1        SL
                                                            Tramadol Sustained-Release
                                                                                                 1        SL
Belbuca                             3        SL             Tablet
Celecoxib                           1        SL             Trezix                               1        SL
Diclofenac Tablet                   1                       Vicodin 5/300, 7.5/300, 10/300
                                                                                                 1       E, SL
                                                            mg Tablet
Etodolac Capsule                    1
                                                            Voltaren Gel                         2
Fentanyl 12, 25, 50, 75, 100 mcg
                                    1        SL             Xtampza ER                           2        SL
Patch
Fentanyl Citrate Lozenge            1        SL             Zohydro ER                           3        SL
Hydrocodone/Acetaminophen                                   Overactive Bladder
                                    1        SL
5/325, 7.5/325, 10/325 mg Tablet
                                                            Dicyclomine Tablet                   1
Hydrocodone/Ibuprofen Tablet        1
                                                            Oxybutynin Extended-Release
Hydromorphone Immediate-                                                                         1
                                    1                       Tablet
Release Tablet
                                                            Oxybutynin Tablet                    1
Ibuprofen Tablet                    1
                                                            Toviaz                               3
Indomethacin Capsule                1
                                                            Respiratory: Allergies
Ketorolac Tablet                    1
                                                            Azelastine 0.1% Nasal Spray          1
Lazanda                             3        SL
                                                            Fluticasone Nasal Spray              1        SL
Meloxicam Tablet                    1
                                                            Zetonna                              3        SL
Methadone Tablet, Oral Solution,
                                    1        SL             Respiratory: Asthma/COPD
Concentrate Solution
Morphine Sulfate Extended-                                  Advair Diskus/HFA                    3        SL
                                    1        SL
Release Tablet
                                                            Albuterol Nebs                       1
Morphine Sulfate Oral Solution      1
                                                            Alvesco                              1        SL
Nabumetone Tablet                   1
                                                            Anoro Ellipta                        3        SL
Naproxen Tablet                     1
                                                            Arnuity Ellipta                      3        SL
Nucynta                             3        SL
                                                            Asmanex TwistHaler, HFA              1        SL
Nucynta ER                          3        SL
                                                            Bevespi Aerosphere                   2        SL
Oxycodone/Acetaminophen
                                    1        SL
5/325, 7.5/325, 10/325 mg Tablet                            Breo Ellipta                         3        SL
Oxycodone Tablet                    1                       Budesonide Nebs                      1        SL
Oxycontin                           3       E, SL           Combivent Respimat                   3        SL
Sprix                               3                       Flovent Diskus/HFA                   3        SL
Tramadol-Acetaminophen              1        SL             Fluticasone/Salmeterol RespiClick
                                                                                                 1        SL
                                                            (generic AirDuo RespiClick)

                                                       20
Drug Requirements                                            Drug Requirements
Drug Name                                                       Drug Name
                                      Tier & Limits                                                Tier & Limits
Incruse Ellipta                        2          SL            Smoking Cessation
Ipratropium-Albuterol Nebs             1                        Bupropion Sustained-Release
                                                                                                      1        H-PA
                                                                Tablet
Ipratropium Nebs                       1
                                                                Chantix Tablet                        3        H-PA
Montelukast                            1
                                                                Nicoderm CQ                           3        H-PA
Perforomist                            3          SL
                                                                Nicorette Gum                         3        H-PA
ProAir HFA/RespiClick                  3          SL
                                                                Nicorette Lozenge                     2        H-PA
Proventil HFA                          3          SL
                                                                Nicorette Mini-Lozenge                2        H-PA
Pulmicort Flexhaler                    3          SL
                                                                Nicotine Gum                          1        H-PA
QVAR Redihaler                         1          SL
                                                                Nicotine Lozenge                      1        H-PA
Seebri Neohaler                        3          SL
                                                                Nicotine Patch                        1        H-PA
Serevent Diskus                        3          SL
                                                                Nicotrol Inhaler                      3        H-PA
Spiriva Handihaler/Respimat            2          SL
                                                                Nicotrol Nasal Spray                  3        H-PA
Striverdi Respimat                     2          SL
                                                                Transplant
Symbicort                              3          SL
                                                                Azathioprine Tablet                   1
Trelegy Ellipta                        3          SL
                                                                Cyclosporine Modified Capsule         1         SP
Tudorza                                2          SL
                                                                Mycophenolate Capsule,
                                                                                                      1         SP
Ventolin HFA                           2          SL            Suspension
Xopenex HFA                            3          SL            Mycophenolic Acid Tablet              1         SP
Respiratory: Pulmonary Arterial Hypertension                    Sirolimus Tablet                      1         SP
Adempas                                2     PA, SL, SP         Tacrolimus Capsule                    1         SP
Letairis                               2     PA, SL, SP         Vitamins/Electrolytes
Opsumit                                2     PA, SL, SP         Fluoride                              1
Orenitram                              3     PA, SL, SP         Folic Acid                            1
Sildenafil Tablet (generic Revatio)    1     PA, SL, SP         Klor-Con M10                          1
Tadalafil (generic Adcirca)            1     PA, SL, SP         Klor-Con M20                          1
Tracleer                               2     PA, SL, SP         Potassium Chloride                    1
Tyvaso                                 2       PA, SP           Potassium Citrate                     1
Uptravi                                3     PA, SL, SP

Bold type = Brand-name drug
[Plain type = Generic drug]
E = May be excluded from coverage                                                     PA = Prior authorization required
H = May be part of health care reform preventive                                      SL = Supply limit
H-PA = May be part of health care reform preventive with prior authorization          SP = Specialty medication
                                                           21
Drug Requirements                                Drug Requirements
Drug Name                                                 Drug Name
                                 Tier & Limits                                    Tier & Limits
Women’s Health: Contraceptives                            Elinest                  1        H
Aftera                            1        H              Ella                     1       H, SL
Altavera                          1        H              Emoquette                1        H
Alyacen 7/7/7, 1/35               1        H              Enpresse                 1        H
Amethia                           1        H              Enskyce                  1        H
Amethia Lo                        1        H              Errin                    1        H
Amethyst                          1        H              Estarylla                1        H
Apri                              1        H              Fallback                 1        H
Aranelle                          1        H              Falmina                  1        H
Ashlyna                           1        H              Gianvi                   1        H
Aubra                             1        H              Gildagia                 1        H
Aviane                            1        H              Heather                  1        H
Azurette                          1        H              Introvale                1        H
Balziva                           1        H              Isibloom                 1        H
Bekyree                           1        H              Jencycla                 1        H
Blisovi Fe                        1        H              Jolessa                  1        H
Blisovi 24 Fe                     1        H              Jolivette                1        H
Briellyn                          1        H              Juleber                  1        H
Camila                            1        H              Junel                    1        H
Camrese                           1        H              Junel 24 Fe              1        H
Camrese Lo                        1        H              Junel Fe                 1        H
Caziant                           1        H              Kariva                   1        H
Chateal                           1        H              Kelnor 1/35              1        H
Cryselle                          1        H              Kimidess                 1        H
Cyclafem 7/7/7, 1/35              1        H              Kurvelo                  1        H
Cyred                             1        H              Larin                    1        H
Dasetta 7/7/7, 1/35               1        H              Larin 24 Fe              1        H
Daysee                            1        H              Larin Fe                 1        H
Deblitane                         1        H              Larissia                 1        H
Delyla                            1        H              Leena                    1        H
Desogestrel-Ethinyl Estradiol     1        H              Lessina                  1        H
Drospirenone-Ethinyl Estradiol    1        H              Levonest                 1        H
Econtra EZ                        1        H              Levonorgestrel 1.5 mg    1        H

                                                     22
Drug Requirements                                               Drug Requirements
Drug Name                                                       Drug Name
                                    Tier & Limits                                                   Tier & Limits
Levonorgestrel-Ethinyl Estradiol       1          H             Ocella                                 1          H
Levora-28                              1          H             Ogestrel                               1          H
Lillow                                 1          H             Opcicon One Step                       1          H
Lo Loestrin Fe                         3                        Option 2                               1          H
LoMedia 24 Fe                          1          H             Orsythia                               1          H
Loryna                                 1          H             Philith                                1          H
Low-Ogestrel                           1          H             Pimtrea                                1          H
Lutera                                 1          H             Pirmella 7/7/7, 1/35                   1          H
Lyza                                   1          H             Plan B One Step                        1          H
Marlissa                               1          H             Portia                                 1          H
Medroxyprogesterone Acetate            1          H             Previfem                               1          H
Microgestin                            1          H             Quasense                               1          H
Microgestin Fe                         1          H             Reclipsen                              1          H
Mono-Linyah                            1          H             Setlakin                               1          H
Mononessa                              1          H             Sharobel                               1          H
My Choice                              1          H             Solia                                  1          H
My Way                                 1          H             Sprintec                               1          H
Myzilra                                1          H             Sronyx                                 1          H
Natazia                                2                        Syeda                                  1          H
Necon 7/7/7, 0.5/35, 1/35, 1/50,                                Take Action                            1          H
                                       1          H
10/11
                                                                Tarina Fe                              1          H
Next Choice One Dose                   1          H
                                                                Tilia Fe                               1          H
Nikki                                  1          H
                                                                Tri Femynor                            1          H
Nora BE                                1          H
                                                                Tri-Estarylla                          1          H
Norethindrone 0.35 mg                  1          H
                                                                Tri-Legest Fe                          1          H
Norethindrone-Ethinyl Estradiol-
                                       1          H
Ferrous Fumarate                                                Tri-Linyah                             1          H
Norgestimate-Ethinyl Estradiol         1          H             Tri-Lo-Estarylla                       1          H
Norlyda                                1          H             Tri-Lo-Marzia                          1          H
Norlyroc                               1          H             Tri-Lo-Sprintec                        1          H
Nortrel 7/7/7, 0.5/35, 1/35            1          H             Tri-Previfem                           1          H
Nuvaring                               2          H             Tri-Sprintec                           1          H

Bold type = Brand-name drug
[Plain type = Generic drug]
E = May be excluded from coverage                                                      PA = Prior authorization required
H = May be part of health care reform preventive                                       SL = Supply limit
H-PA = May be part of health care reform preventive with prior authorization           SP = Specialty medication
                                                           23
Drug Requirements                                          Drug Requirements
Drug Name                                                  Drug Name
                                  Tier & Limits                                              Tier & Limits
Tri-Vylibra                        1        H              Estrogen/Methyltestosterone
                                                                                              1
                                                           Tablet
Trinessa                           1        H
                                                           Evamist                            2
Trinessa Lo                        1        H
                                                           Medroxyprogesterone                1
Trivora-28                         1        H
                                                           Minivelle                          3        SL
Velivet                            1        H
                                                           Premarin                           3
Vestura                            1        H
                                                           Premphase                          3
Vienva                             1        H
                                                           Prempro                            3
Viorele                            1        H
                                                           Progesterone Micronized Capsule    1
Vyfemla                            1        H
                                                           Vivelle-Dot                        1        SL
Vylibra                            1        H
                                                           Yuvafem                            1
Wera                               1        H
                                                           Women’s Health: Miscellaneous
Wymza Fe                           1        H
                                                           Raloxifene                         1       H-PA
Xulane                             1        H
                                                           Tamoxifen                          1       H-PA
Yasmin 28                          3
                                                           Women’s Health: Prenatal Vitamins
Yaz                                3
                                                           Brand Prenatal Vitamins            3
Zarah                              1        H
Zenchent                           1        H
Zenchent Fe                        1        H
Zovia 1/35E, 1/50E                 1        H
Women’s Health: Hormone Replacement
Climara Pro                        3        SL
Divigel                            3
Duavee                             3        SL
Estrace Cream                      1
Estradiol Cream (generic
                                   3        E
Estrace)
Estradiol/Norethindrone Acetate
                                   1
Tablet
Estradiol Tablet                   1
Estradiol Twice-Weekly
Transdermal Patch (generic         3       E, SL
Vivelle-Dot)
Estradiol Weekly Transdermal
                                   1        SL
Patch (generic Climara)
Estring                            2        SL

                                                      24
Index
                           A                              Amphetamine Salt Combo..............11                     Benazepril...................................... 10
Abacavir-Lamivudine...................... 17              Ampyra........................................... 12       Benazepril-Hydrochlorothiazide..... 10
Accu-Chek Test Strips.................... 14              Anastrozole Tablet.......................... 19            Betamethasone Dipropionate 0.05%
Acetaminophen/Butalbital/Caffeine                         Androderm...................................... 19           Augmented Lotion, Ointment...... 13
  325 mg/50 mg/40 mg.................. 12                 Androgel......................................... 19       Betamethasone Dipropionate 0.05%
Acetaminophen/Codeine Tablet..... 20                      Anoro Ellipta................................... 20          Cream, Ointment......................... 13
Actemra.......................................... 18      Apidra SoloStar, Vials.................... 15              Betaseron....................................... 12
Acyclovir Ointment........................... 9           Aprepitant Capsule......................... 16             Bethkis............................................ 19
Acyclovir Tablet................................ 9        Apri................................................. 22   Bevespi Aerosphere....................... 20
Aczone........................................... 13      Apriso............................................. 17     Bevyxxa.......................................... 10
Adcirca........................................... 21     Aranelle.......................................... 22      Bexarotene Capsule......................... 9
Adderall XR.....................................11        Aranesp.......................................... 19       Bicalutamide..................................... 9
Adempas........................................ 21        Aripiprazole Tablet.......................... 12           Bidil................................................. 10
Adlyxin............................................ 15    Armodafinil..................................... 12        Bisoprolol........................................ 10
Admelog SoloStar, Vials................. 15               Armour Thyroid............................... 16           Bisoprolol-Hydrochlorothiazide...... 10
Advair Diskus/HFA......................... 20             Arnuity Ellipta................................. 20        Blisovi 24 Fe................................... 22
Aftera.............................................. 22   Ashlyna........................................... 22      Blisovi Fe........................................ 22
AirDuo RespiClick.......................... 20            Asmanex TwistHaler, HFA.............. 20                   Bosulif............................................... 9
Akynzeo.......................................... 16      Atazanavir Capsule........................ 17              Braftovi............................................. 9
Albuterol Nebs................................ 20         Atenolol.......................................... 10      Brand Prenatal Vitamins................ 24
Alendronate Sodium Tablet............ 19                  Atenolol-Chlorthalidone.................. 10               Breo Ellipta..................................... 20
Alfuzosin Tablet.............................. 18         Atomoxetine.....................................11         Briellyn............................................ 22
Allopurinol Tablet............................ 17         Atorvastatin.....................................11        Brilinta............................................ 10
Alphagan P 0.1%............................ 16            Atripla............................................. 17    Budesonide Extended-Release
Alprazolam Extended-Release                               Aubagio.......................................... 12         Tablet........................................... 17
  Tablet........................................... 12    Aubra.............................................. 22     Budesonide Nebs........................... 20
Alprazolam Tablet........................... 12           Auryxia........................................... 19      Buprenorphine Sublingual Tablet... 12
Altavera.......................................... 22     Austedo.......................................... 12       Bupropion Extended-Release
Alunbrig............................................ 9    Aviane............................................. 22       Tablet........................................... 12
Alvesco........................................... 20     Avonex............................................ 12      Bupropion Sustained-Release
Alyacen 7/7/7, 1/35......................... 22           Azathioprine Tablet........................ 21               Tablet......................................12, 21
Amethia.......................................... 22      Azelastine 0.05% Ophthalmic                                Bupropion Tablet............................ 12
Amethia Lo..................................... 22          Solution....................................... 16       Buspirone Tablet............................. 12
Amethyst........................................ 22       Azelastine 0.1% Nasal Spray......... 20                    Bydureon, Bydureon Bcise............. 15
Amiodarone.....................................11         Azithromycin Tablet.......................... 9            Byetta............................................. 15
Amitiza............................................ 17    Azopt.............................................. 16     Bystolic........................................... 10
Amitriptyline Tablet......................... 12          Azurette.......................................... 22      Byvalson......................................... 10
Amlodipine...................................... 10
Amlodipine-Benazepril................... 10                                          B                                                           C
Amlodipine-Valsartan..................... 10              Baclofen Tablet............................... 19          Calcipotriene/Betamethasone
Amoxicillin Capsule, Chewable                             Balziva............................................ 22      Ointment...................................... 13
  Tablet............................................. 9   Basaglar......................................... 15       Calcitriol Capsule........................... 16
Amoxicillin/Potassium Clavulanate                         Bekyree.......................................... 22       Calquence........................................ 9
  Chewable Tablet, Tablet................ 9               Belbuca.......................................... 20       Camila............................................ 22

                                                                                    25
Camrese......................................... 22      Clindamycin Solution...................... 13            Desoximetasone Cream, Gel,
Camrese Lo.................................... 22        Clobetasol Propionate Cream,                               Ointment...................................... 14
Canasa........................................... 17       Ointment, Solution...................... 14            Desvenlafaxine Extended-Release
Carac.............................................. 13   Clomiphene.................................... 18          Tablet........................................... 12
Carbamazepine Extended-Release                           Clonazepam Tablet........................ 13             Dexamethasone Tablet................... 16
  Capsule, Tablet........................... 13          Clonidine Tablet.............................. 10        Dexilant........................................... 16
Carbamazepine Immediate-Release                          Clopidogrel..................................... 10      Dexmethylphenidate Immediate-
  Tablet........................................... 13   Clotrimazole-Betamethasone                                 Release Tablet.............................11
Carbidopa-Levodopa...................... 12                Cream......................................... 14      Dextroamphetamine Sulfate
Carisoprodol 350 mg Tablet........... 19                 Clotrimazole-Betamethasone                                 Immediate-Release Tablet...........11
Cartia XT........................................ 10       Lotion.......................................... 14    Dextroamphetamine-Amphetamine
Carvedilol Immediate-Release                             Colesevelam Packet for Suspension,                         Immediate-Release Tablet...........11
  Tablet........................................... 10     Tablet............................................11   Diazepam Tablet........................12, 13
Cayston.......................................... 19     Combigan....................................... 16       Diclofenac Tablet............................ 20
Caziant........................................... 22    Combivent Respimat...................... 20              Dicyclomine Tablet......................... 20
Cefadroxil Capsule, Tablet............... 9              Complera........................................ 17      Dificid................................................ 9
Cefdinir Capsule............................... 9        Concerta....................................11, 12       Diflorasone Diacetate 0.05% Cream,
Cefixime Suspension....................... 9             Contour Next EZ Meter.................. 14                 Ointment...................................... 14
Cefprozil Tablet................................. 9      Contour Next Meter........................ 14            Digoxin............................................11
Cefuroxime Tablet............................ 9          Contour Next One Meter................ 14                Diltiazem 24 Hour CD..................... 10
Celecoxib........................................ 20     Contour Next Test Strips................ 14              Diltiazem Sustained-Release
Cephalexin Capsule......................... 9            Contour Test Strips......................... 14            Capsule....................................... 10
Cerdelga......................................... 19     Copaxone....................................... 12       Diltiazem Sustained-Release
Cetrotide......................................... 18    Corlanor...........................................11      Tablet........................................... 10
Chantix Tablet................................. 21       Cortifoam........................................ 17     Diphenoxylate-Atropine Tablet....... 17
Chateal........................................... 22    Cosentyx........................................ 18      Divalproex Delayed-Release
Chlorhexidine Gluconate................ 19               Creon.............................................. 17     Tablet........................................... 13
Chlorpheniramine/Hydrocodone/                            Cresemba......................................... 9      Divalproex Extended-Release
  Pseudoephedrine Solution.......... 19                  Cryselle.......................................... 22      Tablet........................................... 13
Chlorthalidone................................ 10        Cyclafem 7/7/7, 1/35....................... 22           Divigel............................................. 24
Ciclopirox Cream, Gel, Lotion,                           Cyclobenzaprine............................ 19           Donepezil ODT, 5, 10 mg Tablet.... 12
  Solution....................................... 13     Cyclophosphamide Capsule............ 9                   Doxazosin..................................10, 18
Cimduo........................................... 17     Cyclosporine Modified Capsule..... 21                    Doxazosin Tablet............................ 18
Cimzia............................................ 18    Cyred.............................................. 22   Doxepin.......................................... 12
Ciprodex........................................... 9                                                             Doxycycline Capsule, Tablet............ 9
Ciprofloxacin Tablet.......................... 9                                   D                              Drospirenone-Ethinyl Estradiol....... 22
Citalopram Tablet........................... 12          Daklinza.......................................... 17    Duavee........................................... 24
Claravis.......................................... 13    Dapsone 5% Gel............................ 14            Duloxetine Capsule........................ 12
Clarithromycin Tablet........................ 9          Dasetta 7/7/7, 1/35.......................... 22         Dupixent......................................... 14
Clenpiq........................................... 17    Daysee........................................... 22     Dutasteride Capsule....................... 18
Climara........................................... 24    Deblitane........................................ 22     Duzallo........................................... 17
Climara Pro.................................... 24       Delyla............................................. 22
Clindamycin 1.2%/Benzoyl Peroxide                        Descovy.......................................... 17                                 E
  5% Gel........................................ 13      Desmopressin Tablet...................... 16             Econazole Cream............................. 9
Clindamycin Capsule........................ 9            Desogestrel-Ethinyl Estradiol......... 22                Econtra EZ..................................... 22
Clindamycin Gel............................. 13          Desonide 0.05% Cream, Lotion,                            Edarbi............................................. 10
Clindamycin Lotion, Swabs............ 13                  Ointment...................................... 14       Edarbyclor...................................... 10

                                                                                  26
Efavirenz......................................... 17                                 F                              Glipizide Extended-Release........... 15
Eletriptan........................................ 12       Fallback.......................................... 22    Glucophage XR.............................. 15
Elidel............................................... 14    Falmina........................................... 22    Glyburide........................................ 15
Elinest............................................. 22     Famciclovir Tablet............................. 9        Glyxambi........................................ 15
Eliquis............................................. 10     Farxiga........................................... 15    Golytely.......................................... 17
Ella.................................................. 22   Fenofibrate 54, 160 mg Tablet.........11                 Gonal-F.......................................... 18
Emend Suspension........................ 16                 Fentanyl 12, 25, 50, 75, 100 mcg                         Gonal-F RFF.................................. 18
Emoquette...................................... 22            Patch........................................... 20    Guanfacine................................10, 11
Enalapril......................................... 10       Fentanyl Citrate Lozenge............... 20               Guanfacine Extended-Release.......11
Enbrel............................................. 18      Fetzima........................................... 12
Endometrin..................................... 18          Fiasp FlexTouch, Vials.................... 15                                        H
Enoxaparin Sodium........................ 10                Finacea........................................... 14    Halobetasol Ointment..................... 14
Enpresse........................................ 22         Finasteride Tablet........................... 18         Harvoni........................................... 17
Enskyce.......................................... 22        Flecainide........................................11     Heather........................................... 22
Enstilar Foam................................. 14           Flovent Diskus/HFA........................ 20            Humalog KwikPens........................ 15
Entresto...........................................11       Fluconazole Tablet........................... 9          Humalog Vials................................ 15
Epclusa........................................... 17       Fluocinolone Cream, Oil, Ointment,                       Humira............................................ 18
Epinephrine.................................... 19            Solution....................................... 14     Humulin KwikPens.......................... 15
EpiPen/EpiPen Jr........................... 19              Fluocinonide 0.05% Cream............ 14                  Humulin Vials................................. 15
EpiPen/EpiPen-Jr........................... 19              Fluoride.......................................... 21    Hydralazine.................................... 10
Erleada............................................. 9      Fluorouracil 0.5% Cream................ 14               Hydrochlorothiazide....................... 10
Errin................................................ 22    Fluoxetine Capsule......................... 12           Hydrocodone/Acetaminophen 5/325,
Erythromycin 0.5% Ophthalmic                                Fluticasone Nasal Spray................ 20                7.5/325, 10/325 mg Tablet........... 20
  Ointment...................................... 16         Fluticasone/Salmeterol                                   Hydrocodone/Chlorpheniramine
Escitalopram Tablet........................ 12                RespiClick................................... 20        Suspension................................. 19
Estarylla......................................... 22       Fluvastatin Extended-Release                             Hydrocodone/Ibuprofen Tablet....... 20
Estrace........................................... 24         Tablet............................................11   Hydrocortisone 2.5% Cream,
Estrace Cream............................... 24             Fluvoxamine Tablet........................ 12             Ointment...................................... 14
Estradiol Cream.............................. 24            Folic Acid........................................ 21    Hydromorphone Immediate-Release
Estradiol Tablet............................... 24          Forteo............................................. 19    Tablet........................................... 20
Estradiol Twice-Weekly                                      FreeStyle Test Strips...................... 14           Hydroxychloroquine Sulfate........... 18
  Transdermal Patch...................... 24                Frovatriptan.................................... 12      Hyoscyamine Tablet....................... 17
Estradiol Weekly Transdermal                                Furosemide..................................... 10
  Patch........................................... 24                                                                                            I
Estradiol/Norethindrone Acetate                                                       G                              Ibandronate Tablet.......................... 19
  Tablet........................................... 24
                                                            Gabapentin Capsule, Tablet........... 13                 Ibrance............................................. 9
Estring............................................ 24
                                                            Gemfibrozil......................................11      Ibuprofen Tablet.............................. 20
Estrogen/Methyltestosterone
                                                            Gentamicin Ophthalmic Ointment,                          Idhifa................................................. 9
  Tablet........................................... 24
                                                              Solution....................................... 16     Imantinib Tablet................................ 9
Eszopiclone Tablet......................... 13
                                                            Genvoya......................................... 17      Imbruvica.......................................... 9
Etodolac Capsule........................... 20
                                                            Gianvi............................................. 22   Imiquimod 5% Cream..................... 14
Eucrisa........................................... 14
                                                            Gildagia.......................................... 22    Incruse Ellipta................................. 21
Evamist........................................... 24
                                                            Gilenya........................................... 12    Indomethacin Capsule.................... 20
Evotaz............................................. 17
                                                            Glatiramer....................................... 12     Intelence......................................... 18
Ezetimibe Tablet..............................11
                                                            Glimepiride..................................... 15      Introvale.......................................... 22
Ezetimibe/Simvastatin.....................11
                                                            Glipizide.......................................... 15   Invokamet, Invokamet XR.............. 15

                                                                                     27
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