Your 2020 Formulary - Princeton University ...

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Your 2020 Formulary - Princeton University ...
Your 2020 Formulary

Effective July 1, 2020

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

        Call the number on your member ID card.

        Visit your plan’s website on your member ID card to:
         • Find a participating retail pharmacy by ZIP code.
         • Look up possible lower-cost medication alternatives.
         • Compare medication pricing and options.

                                                                  Premium Standard
Understanding your formulary

What is a formulary?
A formulary is a list of prescribed medications or other                 About this formulary
pharmacy care products, services or supplies chosen                      Where differences between
for their safety, cost, and effectiveness. Medications are               this formulary and your benefit
listed by categories or classes and are placed into cost                 plan exist, the benefit plan
levels known as tiers. It includes both brand and generic                documents rule. This may not be
prescription medications.                                                a complete list of medications
                                                                         that are covered by your plan.
To create the list, OptumRx® is guided by the Pharmacy and
                                                                         Please review your benefit plan
Therapeutics Committee. This group of doctors, nurses, and
                                                                         for full details.
pharmacists reviews which medications will be covered,
how well the drugs work, and overall value. They also make
sure there are safe and covered options.

How do I use my formulary?
You and your doctor can use the formulary to help you choose the most cost-effective prescription
medications. This guide tells you if a medication is generic or brand, and if special rules apply.
Bring this list with you when you see your doctor. If your medication is not listed here, please visit
your plan’s website or call the number on your member ID card.
What are tiers?
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by
your employer or plan sponsor. This is how much you will pay when you fill a prescription.

When does the formulary change?
• Medications may move to a lower tier at any time.
•M
  edications may move to a higher tier when a generic equal becomes available.
•M
  edications may move to a higher tier or be excluded from coverage on January 1 or July 1 of
 each year.
When a medication changes tiers, you may have to pay a different amount for that medication.

Why are some medications excluded from coverage?
A medication may be excluded from coverage under your pharmacy benefit when it works the
same as or similar to another prescription or over-the-counter (OTC) medication.

What if I don’t agree with a decision about an excluded medication?
You or your authorized representative and your doctor can ask for a coverage request by calling
the number on your member ID card.

                                                  2
Medication tips

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

What if I am taking a specialty medication?
Specialty medications are for rare or complex conditions and are usually higher-cost medications.
Please note, not all specialty medications are listed in the formulary. Our specialty pharmacy can
provide most of your specialty medications along with helpful programs and services.
Call 1-855-427-4682 and have your prescriptions delivered right to your home or doctor’s office.

                                                  3
Reading your formulary

The formulary gives you choices so you and your doctor can decide your best course of treatment.
In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX).
Generic medications are shown in lowercase (for example, clobetasol).

Tier information
Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your
plan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost
levels will apply once you meet your deductible.

Drug Tier       Includes                 Helpful Tips
Tier 1      $	
              Lower-cost generics Use Tier 1 drugs for the lowest out-of-pocket costs.
              and some brand name
Tier 2      $$	
               Mid-range cost            Use Tier 2 drugs instead of Tier 3 to help reduce your
               preferred brand name      out-of-pocket costs.
Tier 3      $$$	Highest-cost            Many Tier 3 drugs have lower-cost options in Tier 1 or 2.
                non-preferred            Ask your doctor if they could work for you.
Tier E          Excluded                 May not be covered or need prior authorization. Lower-cost
                                         options are available and covered.

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 decides how these medications may
be covered.
 M              Authorized generic or cobranded product
 PA             Prior Authorization – Your doctor is required to give OptumRx more information
                 to determine coverage.
 QL             Quantity Limit – Medication may be limited to a certain quantity.
 SP             Specialty Medication – Medication is designated as specialty.
 ST             Step Therapy – Must try lower-cost medication(s) before a higher-cost medication
                 can be covered.
 3P             Tier 3 preferred

                                                  4
Table of Contents
Analgesics - Drugs for Pain.................................................................................................................................7
Analgesics - Drugs for Pain and Inflammation.................................................................................................... 8
Anesthetics..........................................................................................................................................................8
Anti-Addiction / Substance Abuse Treatment Agents......................................................................................... 8
Antibacterials.......................................................................................................................................................8
Anticoagulants.....................................................................................................................................................9
Anticonvulsants - Drugs for Seizures................................................................................................................ 10
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.............................................................. 10
Antidepressants.................................................................................................................................................10
Antiemetics - Drugs for Nausea and Vomiting.................................................................................................. 11
Antifungals.........................................................................................................................................................11
Antigout Agents................................................................................................................................................. 12
Antimigraine Agents.......................................................................................................................................... 12
Antineoplastics - Drugs for Cancer....................................................................................................................12
Antiparasitics..................................................................................................................................................... 13
Antiparkinson Agents........................................................................................................................................ 13
Antiplatelets.......................................................................................................................................................13
Antipsychotics - Drugs for Mood Disorders....................................................................................................... 13
Antivirals............................................................................................................................................................14
Anxiolytics - Drugs for Anxiety...........................................................................................................................14
Bipolar Agents - Drugs for Mood Disorders.......................................................................................................14
Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders..............................................14
Cardiovascular Agents - Drugs for Heart and Circulation Conditions............................................................... 15
Central Nervous System Agents - Drugs for Attention Deficit Disorder........................................................... 17
Central Nervous System Agents - Drugs for Multiple Sclerosis........................................................................ 18
Central Nervous System Agents - Miscellaneous............................................................................................. 18
Dental and Oral Agents - Drugs for Mouth and Throat Conditions....................................................................19
Dermatological Agents - Drugs for Skin Conditions.......................................................................................... 19
Diabetes - Antidiabetic Agents.......................................................................................................................... 21
Diabetes - Glucose Monitoring.......................................................................................................................... 22
Diabetes - Glycemic Agents.............................................................................................................................. 23
Diabetes - Insulins.............................................................................................................................................23
Electrolytes / Minerals / Metals / Vitamins.........................................................................................................24
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer................................................................................25
Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions.................................................25
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment............................................. 26
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.......................................................26
Genitourinary Agents - Drugs for Prostate Conditions...................................................................................... 26
Hormonal Agents - Adrenal............................................................................................................................... 26
Hormonal Agents - Men's Health.......................................................................................................................27
Hormonal Agents - Osteoporosis...................................................................................................................... 27
Hormonal Agents - Pituitary.............................................................................................................................. 27
Hormonal Agents - Sex Hormones and Birth Control........................................................................................28
Hormonal Agents - Thyroid............................................................................................................................... 29
Immunological Agents - Drugs for Immune System Stimulation or Suppression.............................................. 30
Inflammatory Bowel Disease Agents.................................................................................................................31
Metabolic Bone Disease Agents - Drugs for Osteoporosis............................................................................... 31
Metabolic Bone Disease Agents - Other........................................................................................................... 31
Miscellaneous Therapeutic Agents................................................................................................................... 31
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...........................................................32
Ophthalmic Agents - Drugs for Glaucoma.........................................................................................................32
                                                                                   5
Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions......................................................................... 33
Otic Agents - Drugs for Ear Conditions............................................................................................................. 33
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold........................................................33
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions................................... 34
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis.................................................................... 35
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension.................................................... 35
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm...................................................................... 36
Sleep Disorder Agents...................................................................................................................................... 36

                                                                              6
Drug Name                  Drug Tier Notes                 Drug Name                  Drug Tier Notes
Analgesics - Drugs                                         FIORICET/CODEINE              E
for Pain                                                   hydrocodone-
ABSTRAL                       E                            acetaminophen oral            1     QL
acetaminophen-                                             tablet
                              1       QL
codeine #2                                                 hydromorphone hcl oral
                                                                                         1     QL
acetaminophen-                                             tablet
                              1       QL
codeine #3                                                 HYSINGLA ER                   2     PA; QL
acetaminophen-                                             KADIAN                        E
                              1       QL
codeine #4                                                 LAZANDA                       E
acetaminophen-                                             morphine sulfate er oral
                              1       QL                                                 1     PA; QL
codeine oral tablet                                        tablet extended release
APADAZ                        E                            MS CONTIN                     E
apap-caff-                                                 NORCO                         E
dihydrocodeine oral           1       QL
capsule                                                    NUCYNTA                       E
ARYMO ER                      E                            NUCYNTA ER                    E
BELBUCA                       2       PA; QL               OXYCODONE HCL                 E
BENZHYDROCODON                                             OXYCODONE HCL ER              E     M
                              E
E-ACETAMINOPHEN                                            oxycodone hcl oral
                                                                                         1     QL
butalbital-apap-caffeine      1                            tablet
BUTRANS                                                    oxycodone-
TRANSDERMAL                                                acetaminophen oral
PATCH WEEKLY 10                                            tablet 10-325 mg, 2.5-        1     QL
                              E                            325 mg, 5-325 mg, 7.5-
MCG/HR, 15 MCG/HR,
20 MCG/HR, 5                                               325 mg
MCG/HR                                                     OXYCONTIN                     2     PA; QL
CONZIP                        E                            PERCOCET                      E
DILAUDID ORAL                 E                            ROXICODONE                    E
DURAGESIC-100                 E                            SUBSYS                        E
DURAGESIC-12                  E                            TRAMADOL HCL ER
DURAGESIC-25                  E                            ORAL CAPSULE
                                                           EXTENDED RELEASE              E     M
DURAGESIC-50                  E                            24 HOUR 100 MG, 200
DURAGESIC-75                  E                            MG, 300 MG
fentanyl                      1       PA; QL               tramadol hcl oral tablet
                                                                                         1     QL
FENTANYL CITRATE                                           50 mg
                              E       M
BUCCAL TABLET                                              TREZIX                        3     QL
FENTORA                       E                            TYLENOL WITH
                                                                                         E
FIORICET                      E                            CODEINE #3

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                       7
Drug Name                 Drug Tier Notes                  Drug Name                  Drug Tier Notes
TYLENOL WITH                                               PENNSAID                      E
CODEINE #4 ORAL               E                            QMIIZ ODT                     E
TABLET 300-60 MG
                                                           SPRIX                         E
ULTRACET                      E
                                                           VIMOVO                        E
ULTRAM                        E
                                                           VOLTAREN                      E
XTAMPZA ER                    E
                                                           ZIPSOR                        E
ZOHYDRO ER                    E
                                                           ZORVOLEX                      E
Analgesics - Drugs
for Pain and                                               Anesthetics
Inflammation                                               lidocaine external
                                                                                         1
ARTHROTEC                     E                            ointment
CAMBIA                        E                            lidocaine external patch
                                                                                         1
                                                           5%
CELEBREX                      E
                                                           lidocaine-prilocaine
celecoxib oral                1       QL                                                 1
                                                           external cream
diclofenac sodium oral        1                            LIDODERM                      E
diclofenac sodium                                          ZTLIDO                        E
                              1       QL
transdermal gel 1 %
                                                           Anti-Addiction /
DUEXIS                        E                            Substance Abuse
etodolac oral tablet          1                            Treatment Agents
FLECTOR                       E                            BUNAVAIL                      3     QL
ibuprofen oral tablet         1                            buprenorphine hcl
                                                                                         1     QL
indomethacin oral                                          sublingual
                              1
capsule 25 mg, 50 mg                                       buprenorphine hcl-
                                                                                         1     QL
KETOROLAC                                                  naloxone hcl
TROMETHAMINE                                               CHANTIX                       3     QL
                              E       M
NASAL SOLUTION                                             CHANTIX
15.75 MG/SPRAY                                             CONTINUING MONTH              3     QL
ketorolac tromethamine                                     PAK
                              1       QL
oral                                                       CHANTIX STARTING
                                                                                         3     QL
meloxicam oral                1                            MONTH PAK
MOBIC                         E                            naltrexone hcl oral           1
nabumetone oral               1                            NARCAN                        2
NALFON                        E                            SUBOXONE                      E
NAPRELAN                      3                            ZUBSOLV                       2     QL
naproxen oral tablet          1                            Antibacterials
naproxen sodium oral                                       ACTICLATE                     E
                              1
tablet                                                     amoxicillin oral capsule      1

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                       8
Drug Name                  Drug Tier Notes                 Drug Name                  Drug Tier Notes
amoxicillin oral                                           levofloxacin oral tablet      1
suspension                    1                            metronidazole oral
reconstituted                                                                            1
                                                           tablet
amoxicillin oral tablet       1                            metronidazole vaginal         1
amoxicillin-potassium                                      minocycline hcl oral
clavulanate oral                                                                         1
                              1                            capsule
suspension
reconstituted                                              MINOLIRA                      E
amoxicillin-potassium                                      mupirocin external            1
                              1
clavulanate oral tablet                                    nitrofurantoin
                                                                                         1
azithromycin oral                                          macrocrystal oral
suspension                    1                            nitrofurantoin
reconstituted                                              monohydrate                   1
azithromycin oral tablet      1                            macrocrystals
cefdinir                      1                            NUZYRA ORAL                   3
cefuroxime axetil             1                            penicillin v potassium
                                                                                         1
                                                           oral tablet
cephalexin oral capsule       1
                                                           SEYSARA                       3     ST
cephalexin oral
suspension                    1                            SILVADENE                     E
reconstituted                                              SOLODYN                       E
ciprofloxacin hcl oral                                     SOLOSEC                       3
                              1
tablet 250 mg, 500 mg                                      sulfamethoxazole-
                                                                                         1
clarithromycin oral                                        trimethoprim oral
                              1
tablet                                                     TARGADOX                      E
clindamycin hcl oral          1                            XENLETA                       3
CLINDESSE                     3                            XEPI                          3
DIFICID                       3                            XIMINO                        3
DORYX                         E                            Anticoagulants
DORYX MPC                     E                            BEVYXXA                       3     QL
doxycycline hyclate oral                                   ELIQUIS                       2     QL
                              1
capsule
                                                           ELIQUIS DVT/PE
doxycycline hyclate oral                                                                 2     QL
                              1                            STARTER PACK
tablet
                                                           enoxaparin sodium             1     SP; QL
doxycycline
monohydrate oral              1                            PRADAXA                       2     QL
capsule                                                    warfarin sodium oral          1
doxycycline                                                XARELTO                       2     QL
                              1
monohydrate oral tablet

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                       9
Drug Name                 Drug Tier Notes                  Drug Name                   Drug Tier Notes
XARELTO STARTER                                            oxcarbazepine oral
                              2       QL                                                  1
PACK                                                       tablet
Anticonvulsants -                                          OXTELLAR XR                    E
Drugs for Seizures                                         QUDEXY XR                      E
carbamazepine oral                                         SABRIL                         E     SP
                              1
tablet
                                                           SYMPAZAN                       3     PA
CARBATROL                     E
                                                           TEGRETOL                       E
DEPAKOTE                      E
                                                           TEGRETOL-XR                    E
DEPAKOTE ER                   E
                                                           TOPAMAX                        E
DEPAKOTE
                              E                            TOPAMAX SPRINKLE               E
SPRINKLES
DILANTIN INFATABS             E                            topiramate oral tablet         1
DILANTIN ORAL                                              TRILEPTAL                      E
                              E
CAPSULE 100 MG                                             TROKENDI XR                    E
DILANTIN ORAL                                              VIMPAT                         3
                              E
SUSPENSION                                                 ZONEGRAN                       E
divalproex sodium er          1                            zonisamide oral                1
divalproex sodium oral                                     Antidementia Agents
                              1
tablet delayed release                                     - Drugs for
EPIDIOLEX                     3       PA; SP               Alzheimer's Disease
gabapentin oral                                            and Dementia
                              1
capsule                                                    donepezil hcl oral tablet
                                                                                          1
gabapentin oral tablet        1                            10 mg, 23 mg
KEPPRA ORAL                   E                            memantine hcl oral
                                                                                          1
                                                           tablet 10 mg, 5 mg
KEPPRA XR                     E
                                                           NAMZARIC                       2     QL
LAMICTAL                      E
                                                           Antidepressants
LAMICTAL ODT                  E
                                                           amitriptyline hcl oral         1
LAMICTAL STARTER              E
                                                           BRISDELLE                      E
LAMICTAL XR ORAL
TABLET EXTENDED               E                            bupropion hcl er (sr)          1     QL
RELEASE 24 HOUR                                            bupropion hcl er (xl)
lamotrigine er                1                            oral tablet extended
                                                                                          1     QL
                                                           release 24 hour 150
lamotrigine oral tablet       1                            mg, 300 mg
levetiracetam oral                                         BUPROPION HCL ER
                              1
tablet                                                     (XL) ORAL TABLET
                                                                                          2     QL
NEURONTIN                     E                            EXTENDED RELEASE
ONFI                          E                            24 HOUR 450 MG

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      10
Drug Name                    Drug Tier Notes               Drug Name                   Drug Tier Notes
bupropion hcl oral              1                          VIIBRYD STARTER
                                                                                          3     QL
CELEXA                          E                          PACK
citalopram                                                 WELLBUTRIN SR                  E
hydrobromide oral               1                          WELLBUTRIN XL                  E
tablet                                                     ZOLOFT                         E
CYMBALTA                        E                          Antiemetics - Drugs
desvenlafaxine                                             for Nausea and
                                1     QL
succinate er                                               Vomiting
doxepin hcl oral                                           meclizine hcl oral tablet      1
capsule 10 mg, 100                                         metoclopramide hcl
                                1                                                         1
mg, 150 mg, 50 mg, 75                                      oral tablet 10 mg
mg
                                                           ondansetron hcl oral
duloxetine hcl oral             1     QL                                                  1
                                                           tablet 4 mg, 8 mg
EFFEXOR XR                      E                          ondansetron odt                1
escitalopram oxalate                                       prochlorperazine
                                1                                                         1
oral tablet                                                maleate oral
fluoxetine hcl oral                                        SANCUSO                        E
                                1
capsule
                                                           scopolamine                    1
fluoxetine hcl oral tablet      1
                                                           VARUBI ORAL
fluvoxamine maleate             1                                                         3     QL
                                                           TABLET 90 MG
FORFIVO XL                      3     QL                   Antifungals
LEXAPRO                         E                          ciclopirox external
                                                                                          1
mirtazapine oral tablet         1                          solution
nortriptyline hcl oral                                     clotrimazole external
                                1                                                         1
capsule                                                    cream
paroxetine hcl                  1                          clotrimazole-
PAXIL CR                        E                          betamethasone                  1
                                                           external cream
PAXIL ORAL TABLET               E
                                                           CRESEMBA ORAL                  3
PRISTIQ                         E
                                                           fluconazole oral tablet        1
PROZAC                          E
                                                           GYNAZOLE-1                     3
sertraline hcl oral tablet      1
                                                           JUBLIA                         E
trazodone hcl oral              1
                                                           KERYDIN                        3     PA
TRINTELLIX                      3     ST; QL
                                                           ketoconazole external
venlafaxine hcl                 1                                                         1
                                                           cream
venlafaxine hcl er              1                          ketoconazole external
                                                                                          1
VIIBRYD                         3     QL                   shampoo

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      11
Drug Name                  Drug Tier Notes                 Drug Name               Drug Tier Notes
nystatin external cream       1                            rizatriptan benzoate        1       QL
nystatin mouth/throat         1                            sumatriptan succinate
                                                                                       1       QL
terbinafine hcl oral          1       QL                   oral
terconazole vaginal                                        TOSYMRA                     E
                              1
cream                                                      TREXIMET                    E
TOLSURA                       E                            ZEMBRACE
                                                                                       E
Antigout Agents                                            SYMTOUCH
allopurinol oral              1                            ZOMIG ORAL                  E
COLCHICINE ORAL                                            ZOMIG ZMT                   E
                              E
CAPSULE                                                    Antineoplastics -
colchicine tablet 0.6 mg                                   Drugs for Cancer
                              1       Made by Mylan
oral                                                       AFINITOR ORAL
colchicine tablet 0.6 mg                                   TABLET 2.5 MG, 5            E       SP
                              E       Made by Par          MG, 7.5 MG
oral
colchicine tablet 0.6 mg              Made by              anastrozole oral            1
                              E
oral                                  Prasco               ARIMIDEX                    E
COLCRYS                       2                            BELRAPZO                    E       SP
MITIGARE                      E                            BENDAMUSTINE HCL            E       SP
Antimigraine Agents                                        CABOMETYX                   2       PA; SP
AIMOVIG                       2       PA; QL               capecitabine                1       PA; SP
AJOVY                                                      ERLEADA                     E       SP
SUBCUTANEOUS                                               GLEEVEC                     E       SP
                              E
SOLUTION
PREFILLED SYRINGE                                          IBRANCE ORAL
                                                                                       3       PA; SP
                                                           CAPSULE
eletriptan hydrobromide       1       QL
                                                           IDHIFA                      3       PA; SP; QL
EMGALITY                      2       PA; QL
                                                           imatinib mesylate           1       PA; SP
EMGALITY (300 MG
                              2       PA; QL               IMBRUVICA ORAL
DOSE)                                                                                  3       PA; SP
                                                           TABLET
IMITREX                       E
                                                           KANJINTI                    2       PA; SP
IMITREX STATDOSE
                              E                            letrozole oral              1
REFILL
IMITREX STATDOSE                                           LYNPARZA                    2       PA; SP
                              E
SYSTEM                                                     MVASI                       2       PA; SP
MAXALT                        E                            NUBEQA                      3       PA; SP
MAXALT-MLT                    E                            OGIVRI                      E       SP
ONZETRA XSAIL                 E                            REVLIMID                    2       PA; SP
RELPAX                        E                            RUBRACA                     2       PA; SP

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      12
Drug Name                 Drug Tier Notes                  Drug Name                  Drug Tier Notes
RUXIENCE                      2       PA; SP               OSMOLEX ER                    E
SPRYCEL                       2       PA; SP               pramipexole
                                                                                         1
tamoxifen citrate oral        1                            dihydrochloride
TARGRETIN ORAL                E       SP                   ropinirole hcl                1
temozolomide                  1       PA; SP               RYTARY                        3     ST
TRAZIMERA                     2       PA; SP               Antiplatelets

TREANDA                       E       SP                   ASPIRIN-
                                                                                         E     M
                                                           OMEPRAZOLE
TRUXIMA                       E       SP
                                                           BRILINTA                      2
XPOVIO (100 MG
                              3       PA; SP               clopidogrel bisulfate
ONCE WEEKLY)                                                                             1
                                                           oral
XPOVIO (60 MG
                              3       PA; SP               PLAVIX                        E
ONCE WEEKLY)
XPOVIO (80 MG                                              prasugrel hcl                 1
                              3       PA; SP
ONCE WEEKLY)                                               YOSPRALA                      E
XPOVIO (80 MG                                              Antipsychotics -
                              3       PA; SP               Drugs for Mood
TWICE WEEKLY)
XTANDI                        3       PA; SP               Disorders

YONSA                         E       SP                   ABILIFY                       E
ZEJULA                        2       PA; SP               ABILIFY MAINTENA              3
ZIRABEV                       2       PA; SP               aripiprazole oral tablet      1     QL
ZYTIGA                        E       SP                   ARISTADA                      3
Antiparasitics                                             ARISTADA INITIO               3
ARAKODA                       3                            INVEGA SUSTENNA               3
EMVERM                        2                            INVEGA TRINZA                 3
hydroxychloroquine                                         LATUDA                        3     QL
                              1
sulfate oral                                               olanzapine oral tablet        1     QL
NATROBA                       E                            PERSERIS                      3
permethrin external           1                            quetiapine fumarate           1     QL
PLAQUENIL                     E                            quetiapine fumarate er        1     QL
Antiparkinson Agents                                       REXULTI                       3     QL
benztropine mesylate                                       RISPERDAL                     E
                              1
oral                                                       risperidone oral tablet       1     QL
carbidopa-levodopa                                         SAPHRIS                       2     QL
                              1
oral tablet
                                                           SEROQUEL                      E
GOCOVRI                       E
                                                           SEROQUEL XR                   E
INBRIJA                       3       PA; SP

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      13
Drug Name                 Drug Tier Notes                  Drug Name                Drug Tier Notes
VRAYLAR                       3       ST; QL               VEMLIDY                     3       SP
ziprasidone hcl               1       QL                   VOSEVI                      2       PA; SP; QL
ZYPREXA                       E                            XOFLUZA (40 MG
                                                                                       3       QL
Antivirals                                                 DOSE)
acyclovir oral tablet         1                            XOFLUZA (80 MG
                                                                                       3       QL
                                                           DOSE)
ATRIPLA                       E
                                                           ZOVIRAX                     E
BARACLUDE ORAL
                              E       SP                   Anxiolytics - Drugs
TABLET
                                                           for Anxiety
BIKTARVY                      3
                                                           alprazolam oral tablet      1       QL
CIMDUO                        2
                                                           ATIVAN ORAL                 E
DESCOVY                       3       PA
                                                           buspirone hcl oral          1
DOVATO                        2
                                                           clonazepam oral tablet      1       QL
entecavir                     1       SP; QL
                                                           diazepam oral tablet        1
EPCLUSA                       2       PA; SP; QL
                                                           hydroxyzine hcl oral
GENVOYA                       3                                                        1
                                                           tablet
HARVONI                       2       PA; SP; QL           hydroxyzine pamoate
                                                                                       1
JULUCA                        2                            oral
LEDIPASVIR-                                                KLONOPIN                    E
                              E       M; SP
SOFOSBUVIR                                                 lorazepam oral tablet       1       QL
MAVYRET                       2       PA; SP; QL           triazolam                   1       QL
ODEFSEY                       3                            VALIUM                      E
oseltamivir phosphate                                      XANAX                       E
                              1       QL
oral
                                                           XANAX XR                    E
PREZCOBIX                     2
                                                           Bipolar Agents -
SOFOSBUVIR-                                                Drugs for Mood
                              E       M; SP
VELPATASVIR                                                Disorders
SYMFI                         2                            lithium carbonate er        1
SYMFI LO                      2                            lithium carbonate oral
                                                                                       1
TAMIFLU                       E                            capsule
TEMIXYS                       E                            Blood Products /
                                                           Modifiers / Volume
TIVICAY                       2
                                                           Expanders - Drugs for
TRIUMEQ                       2                            Bleeding Disorders
TRUVADA                       2                            ADYNOVATE                   3       SP
valacyclovir hcl oral         1       QL                   AFSTYLA                     3       SP
VALTREX                       E

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      14
Drug Name                 Drug Tier Notes                  Drug Name               Drug Tier Notes
ARANESP (ALBUMIN                                           atorvastatin calcium
                              2       PA; SP                                           1
FREE)                                                      oral
ELOCTATE                      3       SP                   AVAPRO                      E
EPOGEN                        E       SP                   AZOR                        E
FULPHILA                      E       SP                   benazepril hcl oral         1
GRANIX                        E       SP                   BENICAR                     E
JIVI                          3       SP                   BENICAR HCT                 E
MULPLETA                      2       PA; SP               bisoprolol fumarate         1
NEULASTA                      3       PA; SP               bisoprolol-
                                                                                       1
NEULASTA ONPRO                3       PA; SP               hydrochlorothiazide
NEUPOGEN                      E       SP                   bumetanide oral             1
NIVESTYM                      2       PA; SP               BYSTOLIC                    2
NOVOEIGHT                     3       SP                   candesartan cilexetil       1
NUWIQ                         3       SP                   CARDIZEM LA ORAL
                                                           TABLET EXTENDED
PROCRIT                       E       SP                   RELEASE 24 HOUR             E
RETACRIT                      2       PA; SP               180 MG, 240 MG, 300
UDENYCA                       3       PA; SP               MG, 360 MG, 420 MG

ULTOMIRIS                     3       PA; SP               cartia xt                   1

ZARXIO                        2       PA; SP               carvedilol                  1
Cardiovascular                                             CATAPRES-TTS-1              E
Agents - Drugs for                                         CATAPRES-TTS-2              E
Heart and Circulation                                      CATAPRES-TTS-3              E
Conditions
                                                           chlorthalidone              1
ALTACE                        E
                                                           clonidine hcl oral          1
amiodarone hcl oral           1
                                                           COLESTID                    E
amlodipine besylate
                              1                            COLESTID
oral                                                                                   E
                                                           FLAVORED
amlodipine besylate-
                              1                            COREG                       E
benazepril hcl
amlodipine besylate-                                       COREG CR                    E
                              1
valsartan                                                  CORLANOR ORAL
                                                                                       3       PA; QL
amlodipine-olmesartan         1                            TABLET
ATACAND                       E                            COZAAR                      E

atenolol oral                 1                            CRESTOR                     E

atenolol-chlorthalidone       1                            digoxin oral tablet         1

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      15
Drug Name                 Drug Tier Notes                  Drug Name                  Drug Tier Notes
diltiazem hcl er coated                                    INNOPRAN XL                   E
beads oral capsule                                         irbesartan                    1
                              1
extended release 24
hour                                                       irbesartan-
                                                                                         1
                                                           hydrochlorothiazide
dilt-xr                       1
                                                           isosorbide mononitrate
DIOVAN                        E                                                          1
                                                           er
DIOVAN HCT                    E                            KAPSPARGO
                                                                                         E
doxazosin mesylate                                         SPRINKLE
                              1
oral                                                       KATERZIA                      E
DYAZIDE                       E                            labetalol hcl oral            1
EDARBI                        3       ST                   LASIX                         E
EDARBYCLOR                    3       ST                   LESCOL XL                     E
enalapril maleate oral        1                            LIPITOR                       E
ENTRESTO                      2       QL                   lisinopril oral               1
EXFORGE                       E                            lisinopril-
                                                                                         1
EXFORGE HCT                   E                            hydrochlorothiazide
ezetimibe                     1                            LIVALO                        3     ST
ezetimibe-simvastatin         1                            losartan potassium            1
fenofibrate micronized                                     losartan potassium-hctz       1
oral capsule 134 mg,          1                            LOTREL                        E
200 mg, 67 mg
                                                           lovastatin                    1
fenofibrate oral tablet       1
                                                           LOVAZA                        E
fenofibric acid oral
capsule delayed               1                            metoprolol succinate er       1
release                                                    metoprolol tartrate oral      1
flecainide acetate            1                            MICARDIS                      E
furosemide oral tablet        1                            MICARDIS HCT                  E
gemfibrozil oral              1                            MULTAQ                        3
guanfacine hcl                1                            nadolol oral                  1
HEMANGEOL                     3                            NIASPAN                       E
hydralazine hcl oral          1                            nifedipine er                 1
hydrochlorothiazide                                        nifedipine er osmotic
                              1                                                          1
oral                                                       release
HYZAAR                        E                            nitroglycerin sublingual      1
INDERAL LA                    E                            NITROSTAT                     E
INDERAL XL                    E                            NORVASC                       E

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      16
Drug Name                 Drug Tier Notes                  Drug Name                 Drug Tier Notes
olmesartan medoxomil                                       TENORMIN                     E
                              1
oral                                                       TIKOSYN                      E
olmesartan medoxomil-                                      TOPROL XL                    E
                              1
hctz
                                                           torsemide                    1
olmesartan-amlodipine-
                              1                            triamterene-hctz             1
hctz
omega-3-acid ethyl                                         TRIBENZOR                    E
                              1       PA
esters                                                     TRICOR                       E
PRALUENT                      2       PA; QL               valsartan                    1
PRAVACHOL                     E                            valsartan-
                                                                                        1
pravastatin sodium            1                            hydrochlorothiazide
prazosin hcl oral             1                            VASCEPA                      3      PA
PRINIVIL                      E                            verapamil hcl er oral
                                                           capsule extended
propranolol hcl er            1                            release 24 hour 120          1
propranolol hcl oral                                       mg, 180 mg, 240 mg,
                              1
tablet                                                     360 mg
QUESTRAN                      E                            verapamil hcl er oral
                                                                                        1
QUESTRAN LIGHT                E                            tablet extended release
quinapril hcl                 1                            VYTORIN                      E
ramipril                      1                            WELCHOL                      E
RANEXA                        E                            ZESTRIL                      E
ranolazine er                 1                            ZETIA                        E
REPATHA                       2       PA; QL               ZOCOR ORAL
                                                           TABLET 10 MG, 20             E
REPATHA                                                    MG, 40 MG, 80 MG
PUSHTRONEX                    2       PA; QL
SYSTEM                                                     ZYPITAMAG                    E
REPATHA                                                    Central Nervous
                              2       PA; QL               System Agents -
SURECLICK
                                                           Drugs for Attention
rosuvastatin calcium          1                            Deficit Disorder
simvastatin oral tablet       1                            ADDERALL                     E
sotalol hcl oral              1                            ADDERALL XR                  E
spironolactone oral           1                            ADHANSIA XR                  E
TEKTURNA                      2                            amphetamine-
                                                                                        1      PA; QL
TEKTURNA HCT                  2       ST                   dextroamphetamine
telmisartan                   1                            amphetamine-
                                                                                        1      PA; QL
telmisartan-hctz              1                            dextroamphetamine er

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      17
Drug Name                 Drug Tier Notes                  Drug Name               Drug Tier Notes
atomoxetine hcl               1       QL                   glatiramer acetate          1       PA; SP; QL
CONCERTA                      E                            MAVENCLAD (10
                                                                                       3       PA; 3P; SP
dexmethylphenidate hcl                                     TABS)
                              1       PA; QL
er                                                         MAVENCLAD (4
                                                                                       3       PA; 3P; SP
dexmethylphenidate hcl                                     TABS)
                              1       PA; QL
oral tablet 10 mg, 5 mg                                    MAVENCLAD (5
                                                                                       3       PA; 3P; SP
EVEKEO                        E                            TABS)
FOCALIN                       E                            MAVENCLAD (6
                                                                                       3       PA; 3P; SP
                                                           TABS)
FOCALIN XR                    E
                                                           MAVENCLAD (7
guanfacine hcl er             1                                                        3       PA; 3P; SP
                                                           TABS)
INTUNIV                       E                            MAVENCLAD (8
                                                                                       3       PA; 3P; SP
JORNAY PM                     3       PA; ST; QL           TABS)
methylphenidate hcl er        1       PA; QL               MAVENCLAD (9
                                                                                       3       PA; 3P; SP
methylphenidate hcl er                                     TABS)
(la) oral capsule                                                                              PA; 3P; SP;
                                                           MAYZENT                     3
extended release 24           1       PA; QL                                                   QL
hour 10 mg, 20 mg, 30                                      MAYZENT STARTER                     PA; 3P; SP;
mg, 40 mg                                                                              3
                                                           PACK                                QL
methylphenidate hcl                                        PLEGRIDY                    E       SP
                              1       PA; QL
oral tablet
                                                           PLEGRIDY STARTER
RITALIN                       E                                                        E       SP
                                                           PACK
RITALIN LA                    E                            REBIF                       3       PA; SP; QL
STRATTERA                     E                            REBIF REBIDOSE              3       PA; SP; QL
VYVANSE                       2       PA; QL               REBIF REBIDOSE
                                                                                       3       PA; SP; QL
Central Nervous                                            TITRATION PACK
System Agents -                                            REBIF TITRATION
Drugs for Multiple                                                                     3       PA; SP; QL
                                                           PACK
Sclerosis
                                                           TECFIDERA                   2       PA; SP; QL
AMPYRA                        3       PA; SP; QL
                                                           Central Nervous
AUBAGIO                       3       PA; SP; QL           System Agents -
AVONEX PEN                    2       PA; SP; QL           Miscellaneous
AVONEX PREFILLED              2       PA; SP; QL           ADDYI                       3       PA; QL
BETASERON                     2       PA; SP; QL           ADIPEX-P                    E
COPAXONE                      2       PA; SP; QL           AUSTEDO                     3       PA; SP; QL
EXTAVIA                       E       SP                   CONTRAVE                    2       PA
                                      PA; 3P; SP;          GRALISE                     3       ST; QL
GILENYA                       3
                                      QL                   GRALISE STARTER             3       ST; QL

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      18
Drug Name                 Drug Tier Notes                  Drug Name                Drug Tier Notes
HORIZANT                      3       PA; QL               BRYHALI                     3
LYRICA                        E                            CALCIPOTRIENE
                                                                                       E       M
phentermine hcl oral                                       EXTERNAL FOAM
                              1       PA
capsule 30 mg                                              CAPEX                       E
phentermine hcl oral                                       claravis                    1       PA
                              1       PA
tablet                                                     CLINDAGEL                   E
pregabalin oral capsule       1       QL                   clindamycin phosphate-
SAXENDA                       3       PA                   benzoyl peroxide            1
TEGSEDI                       3       PA; SP               external gel 1-5 %
TIGLUTIK                      3       PA; SP; QL           clindamycin phosphate
                                                                                       1
                                                           external lotion
VYLEESI                       3       PA; QL
                                                           clindamycin phosphate
Dental and Oral                                                                        1
                                                           external solution
Agents - Drugs for
Mouth and Throat                                           clindamycin phosphate
                                                                                       1
Conditions                                                 external swab
chlorhexidine gluconate                                    CLINDAMYCIN
                              1                            PHOSPHATE GEL 1 %           E       M
mouth/throat
                                                           EXTERNAL
lidocaine viscous hcl         1
                                                           clindamycin phosphate
Dermatological                                                                         1
                                                           gel 1 % external
Agents - Drugs for
Skin Conditions                                            clobetasol propionate
                                                                                       1
                                                           external cream
ABSORICA                      3       PA
                                                           clobetasol propionate
ABSORICA LD                   3       PA                                               1
                                                           external ointment
ACANYA                        E                            clobetasol propionate
                                                                                       1
ACZONE EXTERNAL                                            external solution
                              E
GEL 5 %                                                    CLOBEX                      E
ACZONE EXTERNAL                                            CLOBEX SPRAY                E
                              2
GEL 7.5 %
                                                           CLODERM                     E
ALA SCALP                     E
                                                           CORDRAN
APEXICON E                    E                                                        E
                                                           EXTERNAL TAPE
BENZACLIN                     E                            DESONATE                    E
BENZACLIN WITH                                             DIFFERIN EXTERNAL
                              E                                                        E
PUMP                                                       CREAM
BENZAMYCIN                    E                            DIFFERIN EXTERNAL
                                                                                       E
betamethasone                                              GEL 0.3 %
dipropionate external         1                            DIFFERIN EXTERNAL
cream                                                                                  E
                                                           LOTION

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      19
Drug Name                 Drug Tier Notes                  Drug Name                  Drug Tier Notes
DUOBRII                       E                            MICORT-HC
DUPIXENT                      2       PA; SP; QL           EXTERNAL CREAM                E
                                                           2.5 %
ELIDEL                        E
                                                           MIRVASO                       2
ENSTILAR                      3       QL
                                                           mometasone furoate
EPIDUO                        E                                                          1
                                                           external cream
EPIDUO FORTE                  3                            NORITATE                      E
EUCRISA                       2       ST                   ONEXTON                       3
FINACEA EXTERNAL                                           ORACEA                        E
                              E
GEL
                                                           PANDEL                        E
fluocinonide external
                              1                            PROPECIA                      E
cream
FLUOROPLEX                    3                            PSORCON                       E
FLUOROURACIL                                               QBREXZA                       3     QL
EXTERNAL CREAM                2                            RETIN-A                       E
0.5 %                                                      RETIN-A MICRO GEL
                                                                                         E
fluorouracil external                                      0.04 %, 0.1 %
                              1
cream 5 %                                                  RETIN-A MICRO
HALOBETASOL                                                PUMP EXTERNAL                 E
PROPIONATE                    E       M                    GEL 0.04 %, 0.1 %
EXTERNAL FOAM                                              RETIN-A MICRO
HALOG                         E                            PUMP EXTERNAL                 2     PA
hydrocortisone external                                    GEL 0.06 %, 0.08 %
                              1
cream                                                      SERNIVO                       3
hydrocortisone external                                    SOOLANTRA                     2
                              1
ointment                                                   SORILUX                       E
imiquimod external            1                            TACLONEX
IMIQUIMOD PUMP                E       M                    EXTERNAL                      E
IMPOYZ                        E                            OINTMENT

KENALOG EXTERNAL              E                            TACLONEX
                                                           EXTERNAL                      3     QL
LEXETTE                       E                            SUSPENSION
METROGEL                      E                            tacrolimus external
                                                                                         1
metronidazole external                                     ointment
                              1
cream                                                      TAZORAC EXTERNAL
                                                                                         E
metronidazole external                                     CREAM 0.1 %
                              1
gel                                                        TOPICORT SPRAY                E
                                                           tretinoin external cream      1     PA

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      20
Drug Name                 Drug Tier Notes                  Drug Name                Drug Tier Notes
triamcinolone acetonide                                    GLUCOPHAGE XR
                              1
external cream                                             ORAL TABLET
triamcinolone acetonide                                    EXTENDED RELEASE            E
                              1                            24 HOUR 500 MG, 750
external ointment
                                                           MG
ULTRAVATE                     E
                                                           GLUMETZA                    E
VECTICAL                      E
                                                           glyburide oral              1
VELTIN                        E
                                                           GLYXAMBI                    2       ST
VERDESO                       E
                                                           INVOKAMET                   E
ZIANA                         E
                                                           INVOKAMET XR                E
ZYCLARA                       E
                                                           INVOKANA                    E
ZYCLARA PUMP                  E
                                                           JANUMET                     2       ST
Diabetes -
Antidiabetic Agents                                        JANUMET XR                  2       ST
ADLYXIN                       E                            JANUVIA                     2       ST
ADLYXIN STARTER                                            JARDIANCE                   2       ST
                              E
PACK                                                       JENTADUETO                  2       ST
ALOGLIPTIN                                                 JENTADUETO XR               2       ST
                              E       M
BENZOATE                                                   KAZANO                      E
ALOGLIPTIN-                                                KOMBIGLYZE XR               E
                              E       M
METFORMIN HCL
                                                           metformin hcl er            1
ALOGLIPTIN-
                              E       M                    metformin hcl er (mod)      E
PIOGLITAZONE
BYDUREON                      2       ST; QL               metformin hcl er (osm)      E
BYDUREON BCISE                                             metformin hcl oral
                              2       ST; QL                                           1
AUTOINJECTOR                                               tablet
BYETTA 10 MCG PEN             2       ST; QL               NESINA                      E
BYETTA 5 MCG PEN              2       ST; QL               ONGLYZA                     E
FARXIGA                       2       ST                   OSENI                       E
FORTAMET                      E                            OZEMPIC                     2       ST; QL
glimepiride                   1                            pioglitazone hcl            1
glipizide er                  1                            QTERN                       E
glipizide ir                  1                            RYBELSUS                    2       QL
GLUCOPHAGE ORAL                                            SEGLUROMET                  E
TABLET 1000 MG, 500           E                            SOLIQUA                     2       ST; QL
MG, 850 MG                                                 STEGLATRO                   E
                                                           STEGLUJAN                   E

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      21
Drug Name                 Drug Tier Notes                  Drug Name               Drug Tier Notes
SYMLINPEN 60                  3       PA                   ACCU-CHEK
SYNJARDY                      2       ST                   SMARTVIEW                   E
                                                           CONTROL
SYNJARDY XR                   2       ST
                                                           ACCU-CHEK
TRADJENTA                     2       ST                   SMARTVIEW TEST              E
TRULICITY                     2       ST; QL               STRIPS
VICTOZA                       2       ST; QL               ACCU-CHEK
XIGDUO XR                     2       ST                   SOFTCLIX LANCET             2
                                                           DEVICE KIT
Diabetes - Glucose
Monitoring                                                 DEXCOM G4 / G5 / G6
                                                           RECEIVER,
ACCU-CHEK AVIVA                                            TRANSMITTER,
                              E
DEVICE                                                     SENSOR (INCLUDING           2
ACCU-CHEK AVIVA                                            PLATINUM,
CONNECT KIT                   E                            PLATINUM
W/DEVICE                                                   PEDIATRIC)
ACCU-CHEK AVIVA                                            DEXCOM G4 / G5 / G6
                              E
PLUS KIT W/DEVICE                                          RECEIVER,
ACCU-CHEK                                                  TRANSMITTER,
COMPACT PLUS                  E                            SENSOR (INCLUDING           2
CARE KIT                                                   PLATINUM,
                                                           PLATINUM
ACCU-CHEK                                                  PEDIATRIC) DEVICE
COMPACT PLUS                  E
CONTROL                                                    FREESTYLE LIBRE 14
                                                                                       E
                                                           DAY READER
ACCU-CHEK
COMPACT PLUS                  E                            FREESTYLE LIBRE 14
                                                                                       E
TEST STRIPS                                                DAY SENSOR

ACCU-CHEK                                                  FREESTYLE LIBRE
                                                                                       E
FASTCLIX LANCET               2                            READER
KIT                                                        FREESTYLE LIBRE
                                                                                       E
ACCU-CHEK GUIDE                                            SENSOR SYSTEM
                              E
KIT W/DEVICE                                               LANCETS                     2
ACCU-CHEK GUIDE                                            ONETOUCH ULTRA 2
                              E                                                        2
CONTROL                                                    KIT W/DEVICE
ACCU-CHEK                                                  ONETOUCH ULTRA
                                                                                       2       QL
MULTICLIX LANCET              2                            BLUE TEST STRIPS
DEVICE KIT                                                 ONETOUCH ULTRA
                                                                                       2
ACCU-CHEK NANO                                             MINI KIT W/DEVICE
SMARTVIEW KIT                 E                            ONETOUCH VERIO
W/DEVICE                                                                               2
                                                           KIT W/DEVICE

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      22
Drug Name                 Drug Tier Notes                  Drug Name               Drug Tier Notes
ONETOUCH VERIO                                             FIASP PENFILL               E
FLEX SYSTEM KIT               2                            HUMALOG                     2
W/DEVICE
                                                           HUMALOG KWIKPEN             2
ONETOUCH VERIO
                              2       QL                   HUMALOG MIX 50/50
TEST STRIPS                                                                            2
                                                           KWIKPEN
ONETOUCH VERIO IQ
                              2                            HUMALOG MIX 50/50
SYSTEM                                                                                 2
                                                           VIAL
ONETOUCH VERIO
SYNC SYSTEM KIT               2                            HUMALOG MIX 75/25
                                                                                       2
W/DEVICE                                                   KWIKPEN
V-GO 20                       2                            HUMALOG MIX 75/25
                                                                                       2
                                                           VIAL
V-GO 30                       2
                                                           HUMALOG U-100
V-GO 40                       2                                                        2
                                                           JUNIOR KWIKPEN
Diabetes - Glycemic                                        HUMULIN 70/30
Agents                                                                                 2
                                                           KWIKPEN
BAQSIMI ONE PACK              2                            HUMULIN 70/30 VIAL          2
BAQSIMI TWO PACK              2                            HUMULIN N KWIKPEN           2
GLUCAGON                                                   HUMULIN N VIAL              2
                              2       Made by Lilly
EMERGENCY KIT
                                                           HUMULIN R U-500
GLUCAGON                              Made by                                          2
                              2                            KWIKPEN
EMERGENCY KIT                         Fresenius
                                                           HUMULIN R U-500
GVOKE PFS                     2                            VIAL                        2
Diabetes - Insulins                                        (CONCENTRATED)
ADMELOG                       E                            HUMULIN R VIAL              2
ADMELOG                                                    INSULIN ASP PROT &
                              E                                                        E       M
SOLOSTAR                                                   ASP FLEXPEN
APIDRA SOLOSTAR               E                            INSULIN ASPART              E       M
APIDRA VIAL                   E                            INSULIN ASPART
                                                                                       E       M
BASAGLAR KWIKPEN              E                            FLEXPEN
BD AUTOSHIELD DUO                                          INSULIN ASPART
                              2                                                        E       M
PEN NEEDLES                                                PENFILL
BD ULTRA-FINE                                              INSULIN ASPART
                              2                                                        E       M
INSULIN SYRINGES                                           PROT & ASPART
BD ULTRA-FINE PEN                                          INSULIN LISPRO              E       M
                              2
NEEDLES                                                    INSULIN LISPRO (1
                                                                                       E       M
FIASP                         E                            UNIT DIAL)
FIASP FLEXTOUCH               E                            LANTUS SOLOSTAR             2
                                                           LANTUS U-100 VIAL           2

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      23
Drug Name                 Drug Tier Notes                  Drug Name                  Drug Tier Notes
LEVEMIR U-100                                              TOUJEO SOLOSTAR               2
                              E
FLEXTOUCH                                                  TRESIBA                       E
LEVEMIR U-100 VIAL            E                            TRESIBA
                                                                                         E
NOVOFINE                                                   FLEXTOUCH
AUTOCOVER PEN                 2                            Electrolytes / Minerals
NEEDLE                                                     / Metals / Vitamins
NOVOFINE PEN                                               AZESCO                        E
                              2
NEEDLE
                                                           CARNITOR ORAL                 E
NOVOFINE PLUS PEN
                              2                            CARNITOR SF                   E
NEEDLE
NOVOLIN 70/30                                              cyanocobalamin
                              E                            injection solution 1000       1
FLEXPEN
                                                           mcg/ml
NOVOLIN 70/30
                              E                            ergocalciferol oral
FLEXPEN RELION                                                                           1
                                                           capsule
NOVOLIN 70/30
                              E                            folic acid oral tablet 1
RELION                                                                                   1
                                                           mg, 800 mcg
NOVOLIN 70/30 VIAL            E
                                                           K-TAB                         E
NOVOLIN N FLEXPEN             E
                                                           LOKELMA                       3
NOVOLIN N FLEXPEN
                              E                            multivitamin/fluoride
RELION
                                                           oral tablet chewable          1
NOVOLIN N RELION              E                            0.25 mg, 0.5 mg, 1 mg
NOVOLIN N VIAL                E                            NASCOBAL                      3
NOVOLIN R FLEXPEN             E                            potassium chloride crys
                                                                                         1
NOVOLIN R FLEXPEN                                          er
                              E
RELION                                                     potassium chloride er         1
NOVOLIN R RELION              E                            potassium citrate er          1
NOVOLIN R VIAL                E                            PREGENNA                      E
NOVOLOG FLEXPEN               E                            PRENATE                       E
NOVOLOG MIX 70/30                                          PRENATE DHA                   E
                              E
FLEXPEN
                                                           PRENATE ELITE                 E
NOVOLOG MIX 70/30
                              E                            PRENATE ENHANCE               E
VIAL
NOVOLOG PENFILL               E                            PRENATE ESSENTIAL             E
NOVOLOG U-100 VIAL            E                            PRENATE MINI                  E
NOVOTWIST PEN                                              PRENATE PIXIE                 E
                              2
NEEDLE                                                     PRENATE RESTORE               E
TOUJEO MAX                                                 sodium fluoride oral
                              2                                                          1
SOLOSTAR                                                   tablet chewable

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      24
Drug Name                 Drug Tier Notes                  Drug Name                 Drug Tier Notes
TRINAZ                        E                            PROTONIX ORAL
VELTASSA                      3                            TABLET DELAYED               E
                                                           RELEASE
vitamin d
(ergocalciferol) oral                                      RABEPRAZOLE
                              1                            SODIUM ORAL                  E      M
capsule 1.25 mg
(50000 ut)                                                 CAPSULE SPRINKLE
ZALVIT                        E                            rabeprazole sodium
                                                           oral tablet delayed          1      QL
Gastrointestinal                                           release
Agents - Drugs for
Acid Reflux and Ulcer                                      ranitidine hcl oral          1
ACIPHEX                       E                            sucralfate oral tablet       1
CARAFATE ORAL                                              ZEGERID                      E
                              E                            Gastrointestinal
TABLET
DEXILANT                      2       QL                   Agents - Drugs for
                                                           Bowel, Intestine and
esomeprazole                                               Stomach Conditions
magnesium oral
                              E                            AMITIZA                      E
capsule delayed
release                                                    CLENPIQ                      3
famotidine oral tablet        1                            dicyclomine hcl oral
                                                                                        1
gnp lansoprazole              1       QL                   capsule
lansoprazole oral                                          dicyclomine hcl oral
                                                                                        1
capsule delayed               1       QL                   tablet
release                                                    diphenoxylate-atropine
                                                                                        1
misoprostol oral              1                            oral tablet
NEXIUM ORAL                                                gavilyte-g                   1
CAPSULE DELAYED               E                            glycopyrrolate oral
                                                                                        1
RELEASE                                                    tablet 1 mg, 2 mg
omeprazole oral                                            GLYCOPYRROLATE
                                                                                        3
capsule delayed               1       QL                   ORAL TABLET 1.5 MG
release                                                    GOLYTELY                     E
omeprazole-sodium                                          lactulose oral solution      1
                              E
bicarbonate
                                                           LINZESS                      2      ST; QL
pantoprazole sodium
                              1       QL                   MOTEGRITY                    3      ST; QL
oral
PREVACID                      E                            MOTOFEN                      E
PREVACID SOLUTAB                                           MOVANTIK                     E
ORAL TABLET                                                MOVIPREP                     E
                              E
DELAYED RELEASE                                            NULYTELY WITH
DISPERSIBLE 15 MG                                                                       E
                                                           FLAVOR PACKS

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      25
Drug Name                 Drug Tier Notes                  Drug Name                   Drug Tier Notes
OMECLAMOX-PAK                 2                            oxybutynin chloride er         1
peg 3350-kcl-na bicarb-                                    oxybutynin chloride oral
                              1                                                           1
nacl                                                       tablet
PLENVU                        3                            phenazopyridine hcl
PREPOPIK                      3                            oral tablet 100 mg, 200        1
                                                           mg
PYLERA                        2
                                                           RENAGEL                        E
RELISTOR                      E
                                                           sildenafil citrate oral
SUPREP BOWEL                                               tablet 100 mg, 25 mg,          1     QL
                              3
PREP KIT                                                   50 mg
SYMPROIC                      2       ST; QL               solifenacin succinate          1
TRULANCE                      E                            STAXYN                         E
VIBERZI                       3       PA; QL               STENDRA                        E
ZELNORM                       3       PA; QL               tadalafil oral                 1     QL
Genetic or Enzyme                                          tolterodine tartrate er        1
Disorder - Drugs for
Replacement,                                               TOVIAZ                         3
Modification,                                              VELPHORO                       3
Treatment                                                  VESICARE                       E
CERDELGA                      3       PA; SP               VIAGRA                         E
CREON                         2                            Genitourinary Agents
NITYR                         3       PA; SP               - Drugs for Prostate
PANCREAZE                     E                            Conditions

PERTZYE                       E                            alfuzosin hcl er               1
STRENSIQ                      2       PA; SP               AVODART                        E
VIOKACE                       E                            dutasteride oral               1
ZENPEP                        2                            finasteride oral tablet 5
                                                                                          1
                                                           mg
Genitourinary Agents
- Drugs for Bladder,                                       FLOMAX                         E
Genital and Kidney                                         tamsulosin hcl                 1
Conditions
                                                           terazosin hcl oral
AURYXIA                       3                            capsule 1 mg, 10 mg, 5         1
CIALIS                        E                            mg
DEPEN TITRATABS               2       SP                   Hormonal Agents -
                                                           Adrenal
INTRAROSA                     3
                                                           CORTEF                         E
LEVITRA                       E
                                                           dexamethasone oral
MYRBETRIQ                     2                                                           1
                                                           tablet

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      26
Drug Name                 Drug Tier Notes                  Drug Name               Drug Tier Notes
hydrocortisone oral           1                            VOGELXO PUMP                E
KENALOG INJECTION                                          XYOSTED                     3       PA
SUSPENSION 40                 E                            Hormonal Agents -
MG/ML                                                      Osteoporosis
methylprednisolone                                         OSPHENA                     3
                              1
oral
                                                           raloxifene hcl              1
prednisolone oral
                              1                            Hormonal Agents -
solution
                                                           Pituitary
prednisolone sodium
                              1                            ACTHAR                      2       PA; SP
phosphate oral solution
prednisone oral tablet        1                            cabergoline                 1
prednisone oral tablet                                     CETROTIDE                   E       SP
                              1
therapy pack                                               FOLLISTIM AQ                2       PA; SP
RAYOS                         E                                                                PA; Made by
TAPERDEX 12-DAY               3                            ganirelix acetate           1       Organon/Merc
                                                                                               k; SP
TAPERDEX 6-DAY                3
                                                           GENOTROPIN                  E       SP
TAPERDEX 7-DAY                3
                                                           GENOTROPIN
Hormonal Agents -                                                                      E       SP
                                                           MINIQUICK
Men's Health
                                                           GONAL-F                     E       SP
ANDRODERM                     2       PA
                                                           GONAL-F RFF                 E       SP
ANDROGEL                      E
                                                           GONAL-F RFF
ANDROGEL PUMP                 E                                                        E       SP
                                                           REDIJECT
DEPO-                                                      HUMATROPE                   E       SP
                              E
TESTOSTERONE
                                                           LUPRON DEPOT (1-
FORTESTA                      E                            MONTH)
                                                                                       2       PA; SP
TESTIM                        E                            INTRAMUSCULAR KIT
testosterone cypionate                                     7.5 MG
                              1       PA
intramuscular                                              LUPRON DEPOT (3-
testosterone                                               MONTH)
                                                                                       2       PA; SP
transdermal gel 1.62 %,                                    INTRAMUSCULAR KIT
10 mg/act (2%), 20.25                                      22.5 MG
mg/1.25gm (1.62%),                                         LUPRON DEPOT (4-
20.25 mg/act (1.62%),         1       PA                   MONTH)
                                                                                       2       PA; SP
25 mg/2.5gm (1%),                                          INTRAMUSCULAR KIT
40.5 mg/2.5gm                                              30MG
(1.62%), 50 mg/5gm                                         LUPRON DEPOT (6-
(1%)                                                       MONTH)
                                                                                       2       PA; SP
VOGELXO                       E                            INTRAMUSCULAR KIT
                                                           45MG

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      27
Drug Name                 Drug Tier Notes                  Drug Name               Drug Tier Notes
MENOPUR                       3       PA; SP               drospirenone-ethinyl
                                                                                       1
NOCDURNA                      3                            estradiol
NOCTIVA                       E                            DUAVEE                      2
NORDITROPIN                                                ELESTRIN                    3
                              2       PA; SP
FLEXPRO                                                    ENDOMETRIN                  2
NUTROPIN AQ                                                enskyce                     1
                              2       PA; SP
NUSPIN 10                                                  errin                       1
NUTROPIN AQ                                                estarylla                   1
                              2       PA; SP
NUSPIN 20
                                                           ESTRACE                     E
NUTROPIN AQ
                              2       PA; SP               estradiol oral              1
NUSPIN 5
OMNITROPE                     E       SP                   estradiol transdermal       1
ORILISSA                      2       PA; QL               estradiol vaginal           1
OVIDREL                       3       PA; SP               EVAMIST                     3
SAIZEN                        E       SP                   femynor                     1
SAIZENPREP                    E       SP                   GENERESS FE                 E
SANDOSTATIN                   E       SP                   gianvi                      1
ZOMACTON                      E       SP                   IMVEXXY
                                                                                       3
                                                           MAINTENANCE PACK
Hormonal Agents -
Sex Hormones and                                           IMVEXXY STARTER
                                                                                       3
Birth Control                                              PACK
ANNOVERA                      E                            isibloom                    1
apri                          1                            junel 1.5/30                1
aviane                        1                            junel 1/20                  1
BEYAZ                         E                            junel fe 1.5/30             1
BIJUVA                        3                            junel fe 1/20               1
blisovi 24 fe                 1                            junel fe 24                 1
blisovi fe 1.5/30             1                            kariva                      1
blisovi fe 1/20               1                            kurvelo                     1
CLIMARA                       E                            larin fe 1/20               1
CLIMARA PRO                   2                            larissia                    1
cryselle-28                   1                            lessina                     1
DELESTROGEN                                                levonorgest-eth est &
                                                                                       1       QL
INTRAMUSCULAR OIL             E                            eth est
20 MG/ML, 40 MG/ML
DIVIGEL                       3

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      28
Drug Name                   Drug Tier Notes                Drug Name               Drug Tier Notes
levonorgest-eth estrad                                     ORTHO TRI-CYCLEN
                                                                                       E
91-day oral tablet 0.15-                                   LO
                               1      QL
0.03 &0.01 mg, 0.15-                                       ORTHO-NOVUM 1/35
0.03 mg                                                                                E
                                                           (28)
levonorgestrel-ethinyl                                     ORTHO-NOVUM 7/7/7
estrad oral tablet 0.1-20                                                              E
                               1                           (28)
mg-mcg, 0.15-30 mg-
mcg                                                        PREMARIN ORAL               2
LO LOESTRIN FE                 E                           PREMARIN VAGINAL            2
LOESTRIN 1.5/30 (21)           E                           PREMPHASE                   2
LOESTRIN 1/20 (21)             E                           PREMPRO                     2
LOESTRIN FE 1.5/30             E                           progesterone
                                                                                       1
                                                           micronized oral
LOESTRIN FE 1/20               E
                                                           PROMETRIUM                  E
low-ogestrel                   1
                                                           SAFYRAL                     E
MAKENA                         2      PA; SP
                                                           SEASONIQUE                  E
medroxyprogesterone
                               1      QL                   SLYND                       E
acetate intramuscular
medroxyprogesterone                                        sprintec 28                 1
                               1
acetate oral                                               syeda                       1
MINASTRIN 24 FE                E                           TAYTULLA                    3
MINIVELLE                      3                           tri femynor                 1
MIRENA (52 MG)                 3                           tri-linyah                  1
mono-linyah                    1                           tri-lo-marzia               1
NATAZIA                        2                           tri-lo-sprintec             1
nikki                          1                           tri-sprintec                1
norethindrone acetate                                      VAGIFEM                     E
                               1
oral                                                       vienva                      1
norethindrone acet-                                        viorele                     1
                               1
ethinyl est
                                                           VIVELLE-DOT                 E
norethindrone oral             1
                                                           xulane                      1
norgestimate-ethinyl
                               1                           YASMIN 28                   E
estradiol triphasic
nortrel 1/35 (21)              1                           YAZ                         E
nortrel 1/35 (28)              1                           Hormonal Agents -
                                                           Thyroid
NUVARING                       3
                                                           ARMOUR THYROID              3       ST
ORTHO MICRONOR                 E
                                                           CYTOMEL                     E

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      29
Drug Name                   Drug Tier Notes                Drug Name               Drug Tier Notes
euthyrox                       1                           COSENTYX
                                                                                       E       SP
levothyroxine sodium                                       SENSOREADY PEN
                               1
oral                                                       CUTAQUIG                    E       SP
liothyronine sodium oral       1                           cyclosporine modified
                                                                                       1       SP
methimazole oral               1                           oral capsule
NATURE-THROID                                              ENBREL MINI                 3       PA; SP
ORAL TABLET 113.75                                         ENBREL
MG, 130 MG, 146.25                                         SUBCUTANEOUS
                                                                                       3       PA; SP
MG, 16.25 MG, 195                                          SOLUTION
                               3      ST
MG, 260 MG, 32.5 MG,                                       PREFILLED SYRINGE
325 MG, 48.75 MG, 65                                       ENBREL SURECLICK            3       PA; SP
MG, 81.25 MG, 97.5
MG                                                         FIRAZYR                     3       PA; SP
np thyroid oral tablet 60                                  HAEGARDA                    3       PA; SP
                               1
mg                                                         HUMIRA                      2       PA; SP
SYNTHROID                      E                           HUMIRA PEDIATRIC
                                                                                       2       PA; SP
TIROSINT                       E                           CROHNS START
TIROSINT-SOL                   E                           HUMIRA PEN                  2       PA; SP
Immunological                                              HUMIRA PEN-
                                                                                       2       PA; SP
Agents - Drugs for                                         CD/UC/HS STARTER
Immune System                                              HUMIRA PEN-
Stimulation or                                             PS/UV/ADOL HS               2       PA; SP
Suppression                                                START
ACTEMRA ACTPEN                 3      PA; 3P; SP           INFLECTRA                   2       PA; SP
ACTEMRA                                                    leflunomide oral            1
                               3      PA; 3P; SP
SUBCUTANEOUS                                               methotrexate oral           1
azathioprine oral              1                           methotrexate sodium
                                                                                       1
CIMZIA                         2      PA; SP               oral
CIMZIA PREFILLED                                           mycophenolate mofetil
                               2      PA; SP                                           1       SP
KIT                                                        oral capsule
CIMZIA STARTER KIT             2      PA; SP               mycophenolate mofetil
                                                                                       1       SP
COSENTYX (300 MG                                           oral tablet
                               E      SP
DOSE)                                                      mycophenolate sodium        1       SP
COSENTYX 150                                               OLUMIANT                    E       SP
                               E      SP
MG/ML                                                      ORENCIA                     3       PA; 3P; SP
COSENTYX                                                   ORENCIA CLICKJECT           3       PA; 3P; SP
SENSOREADY (300                E      SP
MG)                                                        OTEZLA                      2       PA; SP
                                                           PANZYGA                     E       SP

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      30
Drug Name                   Drug Tier Notes                Drug Name                 Drug Tier Notes
PROGRAF ORAL                                               Metabolic Bone
                               3      SP                   Disease Agents -
CAPSULE
RASUVO                         2      PA; QL               Drugs for
                                                           Osteoporosis
REMICADE                       E      SP
                                                           alendronate sodium
RENFLEXIS                      2      PA; SP                                            1
                                                           oral tablet 10 mg, 5 mg
RINVOQ                         2      PA; SP               alendronate sodium
RUCONEST                       3      PA; SP               oral tablet 35 mg, 70        1      QL
SIMPONI                        2      PA; SP               mg

SIMPONI ARIA                   2      PA; SP               BINOSTO                      3      QL

sirolimus oral tablet          1      SP                   FORTEO
                                                           SUBCUTANEOUS
SKYRIZI (150 MG                                                                         2      PA; SP
                               2      PA; SP               SOLUTION 600
DOSE)                                                      MCG/2.4ML
STELARA                        2      PA; SP               ibandronate sodium
                                                                                        1      QL
tacrolimus oral                1      SP                   oral
TAKHZYRO                       3      PA; SP               PROLIA                       2      PA; SP; QL
TALTZ                          3      PA; 3P; SP           RAYALDEE                     3
TREMFYA                        2      PA; SP               TYMLOS                       2      PA; SP
XELJANZ                        2      PA; SP               Metabolic Bone
                                                           Disease Agents -
XELJANZ XR                     2      PA; SP
                                                           Other
Inflammatory Bowel
Disease Agents                                             calcitriol oral capsule      1

APRISO                         2                           SENSIPAR                     E
                                                           Miscellaneous
ASACOL HD                      E
                                                           Therapeutic Agents
CANASA                         E
                                                                                               PA; Non-
DELZICOL                       E                           BOTOX                        2
                                                                                               Cosmetic; SP
DIPENTUM                       E                           DUROLANE                     2      PA; SP
LIALDA                         E                           EUFLEXXA                     2      PA; SP
mesalamine oral tablet                                     FIRDAPSE                     E      SP
                               1
delayed release
                                                           GEL-ONE                      E      SP
PENTASA                        3
                                                           GELSYN-3                     2      PA; SP
PROCTOFOAM HC
                               2                           GENVISC 850                  E      SP
RECTAL FOAM 1-1 %
sulfasalazine oral tablet      1                           HYALGAN                      E      SP

UCERIS ORAL                    E                           HYMOVIS                      E      SP

UCERIS RECTAL                  3                           MONOVISC                     E      SP
                                                           ORTHOVISC                    E      SP

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      31
Drug Name                 Drug Tier Notes                  Drug Name                 Drug Tier Notes
SODIUM                                                     ofloxacin ophthalmic         1
HYALURONATE                   E       SP                   olopatadine hcl
INTRA-ARTICULAR                                                                         1
                                                           ophthalmic
SUPARTZ FX                    E       SP                   PATADAY
SYNVISC                       E       SP                   OPHTHALMIC                   E
SYNVISC ONE                   E       SP                   SOLUTION 0.2 %
TRIVISC                       E       SP                   PATANOL
                                                           OPHTHALMIC                   E
VISCO-3                       E       SP                   SOLUTION 0.1 %
Ophthalmic Agents -                                        PAZEO                        E
Drugs for Eye Allergy,
Infection and                                              PRED FORTE                   E
Inflammation                                               prednisolone acetate
                                                                                        1
AZASITE                       3                            ophthalmic
BESIVANCE                     3                            PROLENSA                     2      QL
BROMSITE                      E                            VIGAMOX                      E
ciprofloxacin hcl                                          Ophthalmic Agents -
                              1                            Drugs for Glaucoma
ophthalmic
erythromycin                                               ALPHAGAN P
                              1                            OPHTHALMIC                   2
ophthalmic
                                                           SOLUTION 0.1 %
gentamicin sulfate
                              1                            ALPHAGAN P
ophthalmic
                                                           OPHTHALMIC                   E
ILEVRO                        E                            SOLUTION 0.15 %
INVELTYS                      3                            AZOPT                        2
ketorolac tromethamine                                     BETIMOL                      3
                              1
ophthalmic
                                                           brimonidine tartrate
LOTEMAX                                                                                 1
                              3       QL                   ophthalmic
OPHTHALMIC GEL
                                                           COMBIGAN                     2
LOTEMAX
OPHTHALMIC                    3       QL                   COSOPT                       E
OINTMENT                                                   dorzolamide hcl-timolol
                                                                                        1
LOTEMAX                                                    mal
OPHTHALMIC                    E                            dorzolamide hcl-timolol
                                                                                        1
SUSPENSION                                                 mal pf
LOTEMAX SM                    3                            latanoprost ophthalmic       1
MOXEZA                        2                            LUMIGAN                      2      QL
moxifloxacin hcl                                           RHOPRESSA                    2
                              1
ophthalmic                                                 ROCKLATAN                    2      QL
NEVANAC                       E                            SIMBRINZA                    2

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      32
Drug Name                 Drug Tier Notes                  Drug Name                 Drug Tier Notes
timolol maleate                                            Respiratory Tract /
                              1                            Pulmonary Agents -
ophthalmic solution
TIMOPTIC                      E                            Drugs for Allergies,
                                                           Cough, Cold
TIMOPTIC OCUDOSE              E
                                                           azelastine hcl nasal         1      QL
TIMOPTIC-XE                   E
                                                           benzonatate                  1
TRAVATAN Z                    3       QL
                                                           cetirizine hcl oral
VYZULTA                       E                                                         1
                                                           solution
XALATAN                       E                            CLARINEX                     E
ZIOPTAN                       E                            CLARINEX-D 12
                                                                                        E
Ophthalmic Agents -                                        HOUR
Drugs for                                                  cyproheptadine hcl oral
Miscellaneous Eye                                                                       1
                                                           tablet
Conditions
                                                           desloratadine oral
LATISSE                       E                                                         1
                                                           tablet
neomycin-polymyxin-                                        DYMISTA                      2      QL
dexameth ophthalmic
                              1                            FASENRA                      2      PA; SP
suspension 3.5-10000-
0.1                                                        FASENRA PEN                  2      PA; SP
polymyxin b-                                               fluticasone propionate
                              1                                                         1
trimethoprim                                               nasal
RESTASIS                      2       PA                   ipratropium bromide
                                                                                        1
RESTASIS                                                   nasal
                              2       PA
MULTIDOSE                                                  levocetirizine
TOBRADEX                                                   dihydrochloride oral         1
OPHTHALMIC                    E                            tablet
SUSPENSION                                                 mometasone furoate
                                                                                        1      QL
tobramycin-                                                nasal
                              1
dexamethasone                                              NASONEX                      E
XIIDRA                        2       PA                   NUCALA                       2      PA; SP; QL
Otic Agents - Drugs                                        OMNARIS                      3      QL
for Ear Conditions                                         promethazine hcl oral
                                                                                        1
CIPRODEX                      2                            tablet
neomycin-polymyxin-hc                                      promethazine-codeine         1      PA; QL
                              1
otic suspension                                            promethazine-dm              1
ofloxacin otic                1                            pseudoephedrine-
                                                                                        1
OTOVEL                        3                            bromphen-dm
                                                           QNASL                        3      QL
                                                           QNASL CHILDRENS              3      QL

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      33
Drug Name                 Drug Tier Notes                  Drug Name                Drug Tier Notes
XHANCE                        E                            ARNUITY ELLIPTA             2       QL
XOLAIR                        2       PA; SP               ASMANEX (120
                                                                                       E
ZETONNA                       3       QL                   METERED DOSES)
Respiratory Tract /                                        ASMANEX (14
                                                                                       E
Pulmonary Agents -                                         METERED DOSES)
Drugs for Asthma and                                       ASMANEX (30
                                                                                       E
Other Lung                                                 METERED DOSES)
Conditions                                                 ASMANEX (60
                                                                                       E
ADVAIR DISKUS                 2       QL                   METERED DOSES)
ADVAIR HFA                    2       QL                   ASMANEX (7
                                                                                       E
AIRDUO RESPICLICK                                          METERED DOSES)
                              E
113/14                                                     ASMANEX HFA                 E
AIRDUO RESPICLICK                                          ATROVENT HFA                3       QL
                              E
232/14                                                     AUVI-Q INJECTION
AIRDUO RESPICLICK                                          SOLUTION AUTO-
                              E
55/14                                                      INJECTOR 0.15               E
albuterol sulfate hfa                                      MG/0.15ML, 0.3
aerosol solution 108                  Made by              MG/0.3ML
                              1
(90 base) mcg/act                     Perrigo; QL          BEVESPI
                                                                                       E
inhalation                                                 AEROSPHERE
albuterol sulfate hfa                                      BREO ELLIPTA                2       QL
aerosol solution 108                  Made by Teva;        budesonide inhalation       1       QL
                              1
(90 base) mcg/act                     QL
inhalation                                                 BUDESONIDE-
                                                           FORMOTEROL                  E       M
ALBUTEROL                                                  FUMARATE
SULFATE HFA
AEROSOL SOLUTION                      Made by Par;         COMBIVENT
                              E                                                        2       QL
108 (90 BASE)                         M                    RESPIMAT
MCG/ACT                                                    DULERA                      E
INHALATION                                                 epinephrine injection
                                                                                       1
ALBUTEROL                                                  solution auto-injector
SULFATE HFA                                                EPIPEN 2-PAK                3       ST
AEROSOL SOLUTION                      Made by
                              E                            EPIPEN JR 2-PAK             E
108 (90 BASE)                         Prasco; M
MCG/ACT                                                    FLOVENT DISKUS              2       QL
INHALATION                                                 FLOVENT HFA                 2       QL
albuterol sulfate
                              1       QL
inhalation
ALVESCO                       E
ANORO ELLIPTA                 2       QL

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      34
Drug Name                 Drug Tier Notes                  Drug Name                 Drug Tier Notes
fluticasone-salmeterol                                     SYMBICORT                    2      QL
inhalation aerosol                                         SYMJEPI                      3
powder breath
activated 100-50              1       QL                   TRELEGY ELLIPTA              2      QL
mcg/dose, 250-50                                           TUDORZA PRESSAIR             E
mcg/dose, 500-50                                           UTIBRON NEOHALER             E
mcg/dose
                                                           VENTOLIN HFA                 2      QL
INCRUSE ELLIPTA               2       QL
                                                           wixela inhub                 1      QL
ipratropium-albuterol         1       QL
                                                           XOPENEX HFA                  E
LEVALBUTEROL HFA
INHALATION                                                 YUPELRI                      E
                              E       M
AEROSOL 45                                                 Respiratory Tract /
MCG/ACT                                                    Pulmonary Agents -
LONHALA MAGNAIR                                            Drugs for Cystic
                              3       QL                   Fibrosis
REFILL KIT
LONHALA MAGNAIR                                            BETHKIS                      2      SP
                              3       QL
STARTER KIT                                                KITABIS PAK                  E      SP
montelukast sodium                                         PULMOZYME                    2      PA; SP
                              1
oral tablet                                                TOBI NEBULIZER               E      SP
montelukast sodium                                         TOBI PODHALER                E      SP
                              1
oral tablet chewable
                                                           tobramycin nebulization
PERFOROMIST                   3       QL                   solution 300 mg/5ml          1      SP
PROAIR DIGIHALER              E                            inhalation
PROAIR HFA                    E                            TOBRAMYCIN
PROAIR RESPICLICK             E                            NEBULIZATION
                                                                                        E      M; SP
                                                           SOLUTION 300
PROVENTIL HFA                 E                            MG/5ML INHALATION
PULMICORT                                                  Respiratory Tract /
                              2       QL
FLEXHALER                                                  Pulmonary Agents -
PULMICORT                                                  Drugs for Pulmonary
                              E
SUSPENSION                                                 Hypertension
QVAR REDIHALER                E                            ADCIRCA                      E      SP
SEEBRI NEOHALER               E                            ADEMPAS                      2      PA; SP; QL
SEREVENT DISKUS               2       QL                   LETAIRIS                     E      SP
SINGULAIR                     E                            OPSUMIT                      2      PA; SP; QL
SPIRIVA                                                    ORENITRAM                    3      PA; SP
                              2       QL
HANDIHALER                                                 REMODULIN                    E      SP
SPIRIVA RESPIMAT              2       QL                   sildenafil citrate oral
                                                                                        1      PA; SP; QL
STIOLTO RESPIMAT              2       QL                   tablet 20 mg

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      35
Drug Name                 Drug Tier Notes                  Drug Name                Drug Tier Notes
TRACLEER 62.5 MG,                                          XYREM                       3       PA; SP; QL
                              E       SP
125 MG                                                     zolpidem tartrate er        1       QL
Skeletal Muscle                                            zolpidem tartrate oral      1       QL
Relaxants - Drugs for
Muscle Pain and
Spasm
AMRIX                         E
baclofen oral                 1
carisoprodol oral             1
cyclobenzaprine hcl
                              1
oral
LORZONE                       3
metaxalone                    1
methocarbamol oral            1
NORGESIC FORTE                E
ORPHENGESIC
                              E       M
FORTE
SKELAXIN                      E
SOMA                          E
tizanidine hcl oral           1
ZANAFLEX                      E
Sleep Disorder
Agents
AMBIEN                        E
AMBIEN CR                     E
armodafinil                   1       PA; QL
eszopiclone                   1       QL
LUNESTA                       E
modafinil                     1       PA; QL
NUVIGIL                       E
PROVIGIL                      E
RESTORIL                      E
SILENOR                       3       QL
SUNOSI                        2       PA; QL
temazepam                     1       QL
WAKIX                         3       PA; SP; QL

For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.

                                                      36
Index of Drugs
ABILIFY.....................................13     ADMELOG................................ 23            apap-caff-dihydrocodeine........... 7
ABILIFY MAINTENA................. 13               ADMELOG SOLOSTAR........... 23                        APEXICON E............................ 19
ABSORICA............................... 19         ADVAIR DISKUS...................... 34                APIDRA SOLOSTAR................ 23
ABSORICA LD..........................19            ADVAIR HFA............................ 34             APIDRA VIAL............................23
ABSTRAL....................................7       ADYNOVATE............................14               apri............................................ 28
ACANYA................................... 19       AFINITOR................................. 12          APRISO.................................... 31
ACCU-CHEK AVIVA                                    AFSTYLA.................................. 14          ARAKODA................................ 13
CONNECT KIT W/DEVICE.......22                      AIMOVIG...................................12          ARANESP (ALBUMIN FREE)... 15
ACCU-CHEK AVIVA DEVICE...22                        AIRDUO RESPICLICK 113/14..34                          ARIMIDEX.................................12
ACCU-CHEK AVIVA PLUS                               AIRDUO RESPICLICK 232/14..34                          aripiprazole............................... 13
KIT W/DEVICE..........................22           AIRDUO RESPICLICK 55/14....34                         ARISTADA................................ 13
ACCU-CHEK COMPACT                                  AJOVY...................................... 12        ARISTADA INITIO.................... 13
PLUS CARE KIT....................... 22            ALA SCALP.............................. 19            armodafinil................................ 36
ACCU-CHEK COMPACT                                  albuterol sulfate.........................34          ARMOUR THYROID.................29
PLUS CONTROL...................... 22              albuterol sulfate hfa...................34            ARNUITY ELLIPTA...................34
ACCU-CHEK COMPACT                                  ALBUTEROL SULFATE HFA... 34                           ARTHROTEC..............................8
PLUS TEST STRIPS................ 22                alendronate sodium.................. 31               ARYMO ER.................................7
ACCU-CHEK FASTCLIX                                 alfuzosin hcl er.......................... 26         ASACOL HD............................. 31
LANCET KIT............................. 22         allopurinol..................................12       ASMANEX (120 METERED
ACCU-CHEK GUIDE                                    ALOGLIPTIN BENZOATE........ 21                        DOSES).................................... 34
CONTROL................................ 22         ALOGLIPTIN-METFORMIN                                  ASMANEX (14 METERED
ACCU-CHEK GUIDE KIT                                HCL...........................................21      DOSES).................................... 34
W/DEVICE................................ 22        ALOGLIPTIN-PIOGLITAZONE. 21                           ASMANEX (30 METERED
ACCU-CHEK MULTICLIX                                ALPHAGAN P........................... 32              DOSES).................................... 34
LANCET DEVICE KIT...............22                 alprazolam................................ 14         ASMANEX (60 METERED
ACCU-CHEK NANO                                     ALTACE.................................... 15         DOSES).................................... 34
SMARTVIEW KIT W/DEVICE...22                        ALVESCO................................. 34           ASMANEX (7 METERED
ACCU-CHEK SMARTVIEW                                AMBIEN.................................... 36         DOSES).................................... 34
CONTROL................................ 22         AMBIEN CR.............................. 36            ASMANEX HFA........................ 34
ACCU-CHEK SMARTVIEW                                amiodarone hcl......................... 15            ASPIRIN-OMEPRAZOLE......... 13
TEST STRIPS...........................22           AMITIZA....................................25         ATACAND.................................15
ACCU-CHEK SOFTCLIX                                 amitriptyline hcl......................... 10         atenolol..................................... 15
LANCET DEVICE KIT...............22                 amlodipine besylate.................. 15              atenolol-chlorthalidone..............15
acetaminophen-codeine..............7               amlodipine besylate-benazepril                        ATIVAN..................................... 14
acetaminophen-codeine #2.........7                 hcl............................................. 15   atomoxetine hcl.........................18
acetaminophen-codeine #3.........7                 amlodipine besylate-valsartan.. 15                    atorvastatin calcium.................. 15
acetaminophen-codeine #4.........7                 amlodipine-olmesartan..............15                 ATRIPLA................................... 14
ACIPHEX.................................. 25       amoxicillin............................... 8, 9       ATROVENT HFA...................... 34
ACTEMRA................................ 30         amoxicillin-potassium                                 AUBAGIO..................................18
ACTEMRA ACTPEN.................30                  clavulanate..................................9        AURYXIA.................................. 26
ACTHAR................................... 27       amphetamine-                                          AUSTEDO.................................18
ACTICLATE................................ 8        dextroamphetamine.................. 17                AUVI-Q......................................34
acyclovir.................................... 14   amphetamine-                                          AVAPRO................................... 15
ACZONE................................... 19       dextroamphetamine er.............. 17                 aviane....................................... 28
ADCIRCA..................................35        AMPYRA...................................18           AVODART.................................26
ADDERALL............................... 17         AMRIX.......................................36        AVONEX PEN...........................18
ADDERALL XR......................... 17            anastrozole............................... 12         AVONEX PREFILLED.............. 18
ADDYI....................................... 18    ANDRODERM.......................... 27                AZASITE................................... 32
ADEMPAS................................ 35         ANDROGEL..............................27              azathioprine.............................. 30
ADHANSIA XR..........................17            ANDROGEL PUMP.................. 27                    azelastine hcl............................ 33
ADIPEX-P................................. 18       ANNOVERA..............................28              AZESCO................................... 24
ADLYXIN...................................21       ANORO ELLIPTA..................... 34                 azithromycin................................9
ADLYXIN STARTER PACK...... 21                      APADAZ......................................7         AZOPT...................................... 32
                                                                           37
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