Your 2021 Formulary Effective January 1, 2021 - Columbia University
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Your 2021 Formulary
Effective January 1, 2021
Please read: This document contains information about the drugs
covered under your pharmacy benefit plan.
For a complete list of covered drugs or if you have questions:
Call the toll-free member phone number
on your ID card.
Visit your plan’s member website listed on your ID card.
• Locate a participating retail pharmacy by zip code.
• Look up possible lower-cost medication alternatives.
• Compare medication pricing and options.
OptumRx Columbia University PremiumYour Formulary
This Formulary outlines the most commonly prescribed medications from your plan’s
complete pharmacy benefit coverage list, also known as a Prescription Drug List (PDL).
A formulary identifies the drugs available for certain conditions and organizes them
into cost levels, also known as tiers. An important part of the Formulary is giving you
choices so you and your doctor can choose the best course of treatment for you.
Go to your plan’s member website for complete and up-to-date
drug information
Since the Formulary may change, we encourage you to visit our website, your plan’s
member website, which should be listed on your ID card. This website is the best source
for up-to-date information about all of the medications your pharmacy benefit covers,
possible lower-cost options and cost comparisons.
2Table of Contents
Informational Section...........................................................................................................................................5
Analgesics - Drugs for Pain.................................................................................................................................9
Analgesics - Drugs for Pain and Inflammation.................................................................................................. 10
Anesthetics........................................................................................................................................................11
Anti-Addiction / Substance Abuse Treatment Agents....................................................................................... 11
Antibacterials.....................................................................................................................................................11
Anticoagulants...................................................................................................................................................13
Anticonvulsants - Drugs for Seizures................................................................................................................ 13
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.............................................................. 14
Antidepressants.................................................................................................................................................14
Antiemetics - Drugs for Nausea and Vomiting.................................................................................................. 15
Antifungals.........................................................................................................................................................16
Antigout Agents................................................................................................................................................. 16
Antimigraine Agents.......................................................................................................................................... 16
Antineoplastics - Drugs for Cancer....................................................................................................................17
Antiparasitics..................................................................................................................................................... 18
Antiparkinson Agents........................................................................................................................................ 18
Antiplatelets.......................................................................................................................................................18
Antipsychotics - Drugs for Mood Disorders....................................................................................................... 18
Antivirals............................................................................................................................................................19
Anxiolytics - Drugs for Anxiety...........................................................................................................................20
Bipolar Agents - Drugs for Mood Disorders.......................................................................................................20
Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders..............................................20
Cardiovascular Agents - Drugs for Heart and Circulation Conditions............................................................... 21
Central Nervous System Agents - Drugs for Attention Deficit Disorder........................................................... 25
Central Nervous System Agents - Drugs for Multiple Sclerosis........................................................................ 26
Central Nervous System Agents - Miscellaneous............................................................................................. 27
Dental and Oral Agents - Drugs for Mouth and Throat Conditions....................................................................27
Dermatological Agents - Drugs for Skin Conditions.......................................................................................... 27
Diabetes - Antidiabetic Agents.......................................................................................................................... 30
Diabetes - Glucose Monitoring.......................................................................................................................... 31
Diabetes - Glycemic Agents.............................................................................................................................. 32
Diabetes - Insulins.............................................................................................................................................32
Electrolytes / Minerals / Metals / Vitamins.........................................................................................................33
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer................................................................................34
Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions.................................................35
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment............................................. 36
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.......................................................36
Genitourinary Agents - Drugs for Prostate Conditions...................................................................................... 37
Hormonal Agents - Adrenal............................................................................................................................... 37
Hormonal Agents - Men's Health.......................................................................................................................37
Hormonal Agents - Osteoporosis...................................................................................................................... 38
Hormonal Agents - Pituitary.............................................................................................................................. 38
Hormonal Agents - Sex Hormones and Birth Control........................................................................................39
Hormonal Agents - Thyroid............................................................................................................................... 41
Immunological Agents - Drugs for Immune System Stimulation or Suppression.............................................. 42
Inflammatory Bowel Disease Agents.................................................................................................................43
Metabolic Bone Disease Agents - Drugs for Osteoporosis............................................................................... 43
Metabolic Bone Disease Agents - Other........................................................................................................... 44
Miscellaneous Therapeutic Agents................................................................................................................... 44
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...........................................................45
TOC-3Ophthalmic Agents - Drugs for Glaucoma.........................................................................................................45
Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions......................................................................... 46
Otic Agents - Drugs for Ear Conditions............................................................................................................. 46
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold........................................................46
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions................................... 47
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis.................................................................... 49
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension.................................................... 49
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm...................................................................... 49
Sleep Disorder Agents...................................................................................................................................... 50
TOC-4At OptumRx, we want to help you better understand
your medication options.
Your pharmacy benefit offers flexibility and choice in determining the right medication
for you. To help you get the most out of your pharmacy benefit, we’ve included some
of the most commonly asked questions about the Formulary.
What is a Formulary?
This document is a list of commonly prescribed medications preferred by your plan
sponsor for their safety, cost and effectiveness. Drugs are listed by common categories or
class. They are placed into cost levels known as tiers. It includes both brand and generic
prescription medications approved by the U.S. Food and Drug Administration (FDA).
Please note: Where differences are noted between this Formulary and your benefit
plan documents, the benefit plan documents will rule. It is not intended to be a
complete list of medications, and not all medications listed may be covered under your
plan. Please look at your benefit plan documents provided by your employer or plan
sponsor to see what medications are covered under your plan. You may also log on
to your plan’s member website or call the toll-free member phone number on your
ID card for more information.
How do I use my Formulary?
When choosing a medication, you and your doctor should consult the Formulary. It
will help you and your doctor choose the most cost-effective prescription drugs. 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. It is organized by common medical conditions.
Medications are then listed alphabetically.
If your medication is not listed in this document, please visit your plan’s member
website or call the toll-free member phone number on your ID card.
When does the Formulary change?
• Medications may move to a lower tier at any time.
• Medications may move to a higher tier when its generic becomes available.
• Medications 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.
For the most up-to-date list, call customer service at the toll-free member
phone number on your ID card.
5What are tiers?
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost,
which is determined by your employer or plan sponsor. This is how much you will pay
when you fill a prescription. Tier 1 medications are your lowest-cost options. If your
medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available.
Discuss these options with your doctor.
Check your benefit plan documents to find out your specific pharmacy plan costs.
$ Drug Tier Includes Helpful Tips
Tier 1 Generic drugs. Use Tier 1 drugs for
Lowest Cost the lowest out-of-
$
pocket costs.
Tier 2 Single-source Use Tier 2 drugs, instead
Mid-range brand drugs. of Tier 3, to help reduce
$$
Cost your out-of-pocket costs.
Tier 3 Multi-source Many Tier 3 drugs have
Highest Cost brand drugs. lower-cost options in Tier
$$$
1 or 2. Ask your doctor if
they could work for you.
Please note: Some plans may have two or four tiers, while others may not have
any. If you have a high deductible plan, the tier cost levels will apply once you hit
your deductible. Refer to your enrollment and plan materials on your plan’s member
website, or call the toll-free member phone number on your ID card for more
information about your benefit plan.
Why are some medications excluded from coverage?
Medications may be excluded from coverage under your pharmacy benefit when it
works the same as or similar to another prescription medication or an over-the-counter
(OTC) medication. There may be other medication options available.
What if I don’t agree with a decision about an excluded medication?
You (or your authorized representative) and your doctor can ask for an initial coverage
decision by calling the toll-free member phone number on the back of your ID card.
Should I talk to my doctor about OTC medications?
6An OTC medication may be the right treatment option for some conditions. Talk to
your doctor about available OTC options. Even though these medications may not
be covered under your pharmacy benefit, they may cost less than your out-of-pocket
expense for prescription medications.
What is the difference between brand-name and generic medications?
Generic medications contain the same active ingredients (what makes the medication
work) as brand-name medications, but they often cost less. Once the patent of a
brand-name medication ends, the FDA can approve a generic version with the same
active ingredients. These types of medications are known as generic medications.
Sometimes the same company that makes a brand-name medication also makes the
generic version.
Is it a generic or brand-name drug?
The drug list shows brand-name drugs in bold type (for example, Clobex)
and generic drugs in plain type (for example, clobetasol).
What if my doctor writes a brand-name prescription?
The next time your doctor gives you a prescription for a brand-name medication,
ask if a generic equivalent or lower-cost option is available and if it might be right
for you. Generic medications are usually your lowest-cost option, but not always.
Visit your plan’s member website to make sure.
Are you taking a specialty medication?
Specialty medications treat rare or complex conditions and are typically higher cost
medications. Please note, not all specialty medications are listed in the Formulary.
BriovaRx, the OptumRx specialty pharmacy, can provide most of your specialty
medications along with helpful programs and services. Call BriovaRx and have your
prescriptions delivered right to your home or office.
How do I get updated information about my pharmacy benefit?
Since the Formulary may change during your plan year, we encourage you to visit your
plan’s member website or call the toll-free member phone number on your ID card for
more current information.
7When you register at on our website and open an account, you can use the website’s
helpful tools and features to:
• Look up the price of drugs covered by your plan
• Find lower-cost options
• Refill and renew home delivery prescriptions
• View your order status and claims history
• View your benefits in real time
Programs and Limits
Some medications are noted with letters or symbols next to them. The letters and
symbols refer to our pharmacy benefit programs and are provided to help you check
which medications may have a program or limit. Your benefit plan determines how
these medications may be covered for you.
AR Age Restrictions – Some restrictions may apply based on patient age.
rior Authorization – Your doctor is required to provide additional
P
PA
information to determine coverage.
tep Therapy – Trial of lower cost medication(s) is required before
S
ST
a higher-cost medication is covered.
uantity Limits – Amount of medication covered per copayment
Q
QL
or in a specific time period.
Specialty Medication – Medication is designated as a specialty
SP
pharmacy drug.
Excluded – May be excluded from coverage or subject to prior
E
authorization. Lower-cost options are available and covered.
To learn more about a pharmacy program or to find out if it applies to you, please
visit your plan’s member website or call the toll-free member phone number on your
ID card.
8Drug Name Drug Tier Notes
Analgesics - Drugs for Pain
acetaminophen-codeine #2 1 QL
acetaminophen-codeine #3 1 QL
acetaminophen-codeine #4 1 QL
acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg 1 QL
APADAZ (benzhydrocodone-acetaminophen) E
apap-caff-dihydrocodeine oral capsule 1 QL
ARYMO ER (morphine sulfate) E
BELBUCA (buprenorphine hcl) 2 PA; QL
BENZHYDROCODONE-ACETAMINOPHEN E
butalbital-apap-caffeine 1
BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15
E
MCG/HR, 20 MCG/HR, 5 MCG/HR (buprenorphine)
CONZIP (tramadol hcl) E
DILAUDID ORAL (hydromorphone hcl) E
DURAGESIC-100 (fentanyl) E
DURAGESIC-12 (fentanyl) E
DURAGESIC-25 (fentanyl) E
DURAGESIC-50 (fentanyl) E
DURAGESIC-75 (fentanyl) E
fentanyl 1 PA; QL
FENTANYL CITRATE BUCCAL TABLET E
FENTORA (fentanyl citrate) E
FIORICET (butalbital-apap-caffeine) E
FIORICET/CODEINE (butalbital-apap-caff-cod) E
hydrocodone-acetaminophen oral tablet 1 QL
hydromorphone hcl oral tablet 1 QL
HYSINGLA ER (hydrocodone bitartrate) 2 PA; QL
KADIAN (morphine sulfate) E
LAZANDA (fentanyl citrate) E
morphine sulfate er oral tablet extended release 1 PA; QL
MS CONTIN (morphine sulfate) E
NORCO (hydrocodone-acetaminophen) E
NUCYNTA (tapentadol hcl) E
NUCYNTA ER (tapentadol hcl) E
OXAYDO ORAL TABLET ABUSE-DETERRENT 5 MG, 7.5 MG
E
(oxycodone hcl)
OXYCODONE HCL ER E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
9Drug Name Drug Tier Notes
oxycodone hcl oral tablet 1 QL
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg,
1 QL
5-325 mg, 7.5-325 mg
OXYCONTIN (oxycodone hcl) 2 PA; QL
PERCOCET (oxycodone-acetaminophen) E
ROXICODONE (oxycodone hcl) E
SUBSYS (fentanyl) E
TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE
E
24 HOUR 100 MG, 200 MG, 300 MG
tramadol hcl oral tablet 50 mg 1 QL
TREZIX (apap-caff-dihydrocodeine) 3 QL
ULTRACET (tramadol-acetaminophen) E
ULTRAM (tramadol hcl) E
XTAMPZA ER (oxycodone) 2 PA; QL
ZOHYDRO ER ORAL CAPSULE ER 12 HOUR ABUSE-
DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG E
(hydrocodone bitartrate)
Analgesics - Drugs for Pain and Inflammation
ARTHROTEC (diclofenac-misoprostol) E
CAMBIA (diclofenac potassium(migraine)) E
CELEBREX (celecoxib) E
celecoxib oral 1
DICLOFENAC E
diclofenac sodium oral 1
diclofenac sodium transdermal gel 1 % 1
DUEXIS (ibuprofen-famotidine) E
etodolac oral tablet 1
FLECTOR (diclofenac epolamine) E
ibuprofen oral tablet 200 mg E
ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1
indomethacin oral capsule 25 mg, 50 mg 1
KETOROLAC TROMETHAMINE NASAL E
ketorolac tromethamine oral 1
meloxicam oral 1
MOBIC (meloxicam) E
nabumetone oral 1
NALFON (fenoprofen calcium) E
NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR
3
375 MG, 500 MG (naproxen sodium)
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
10Drug Name Drug Tier Notes
naproxen oral tablet 1
PENNSAID (diclofenac sodium) E
QMIIZ ODT (meloxicam) E
nabumetone (Relafen) E
RELAFEN DS (nabumetone) E
SPRIX (ketorolac tromethamine) E
VIMOVO (naproxen-esomeprazole) E
VOLTAREN (diclofenac sodium) E
ZIPSOR (diclofenac potassium) E
ZORVOLEX (diclofenac) E
Anesthetics
lidocaine external patch 5 % 1
lidocaine-prilocaine external cream 1
LIDODERM (lidocaine) E
ZTLIDO (lidocaine) E
Anti-Addiction / Substance Abuse Treatment Agents
BUNAVAIL (buprenorphine hcl-naloxone hcl) 2 QL
buprenorphine hcl sublingual 1 QL
buprenorphine hcl-naloxone hcl 1 QL
CHANTIX (varenicline tartrate) 2 ST
CHANTIX CONTINUING MONTH PAK (varenicline tartrate) 2 ST
CHANTIX STARTING MONTH PAK (varenicline tartrate) 2 ST
NALOXONE HCL INJECTION SOLUTION AUTO-INJECTOR E
naltrexone hcl oral 1
NARCAN (naloxone hcl) 2
SUBOXONE (buprenorphine hcl-naloxone hcl) E
ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG (buprenorphine
2
hcl-naloxone hcl)
ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG, 11.4-2.9 MG,
2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG (buprenorphine hcl- 2 QL
naloxone hcl)
Antibacterials
ACTICLATE (doxycycline hyclate) E
amoxicillin oral capsule 1
amoxicillin oral suspension reconstituted 1
amoxicillin oral tablet 1
amoxicillin-potassium clavulanate oral suspension reconstituted 1
amoxicillin-potassium clavulanate 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.
11Drug Name Drug Tier Notes
azithromycin oral suspension reconstituted 1
azithromycin oral tablet 1
cefdinir 1
cefuroxime axetil 1
cephalexin oral capsule 1
cephalexin oral suspension reconstituted 1
ciprofloxacin hcl oral tablet 250 mg, 500 mg 1
clarithromycin oral tablet 1
clindamycin hcl oral 1
CLINDESSE (clindamycin phosphate (1 dose)) 2
DIFICID (fidaxomicin) 2
DORYX (doxycycline hyclate) E
DORYX MPC (doxycycline hyclate) E
doxycycline hyclate oral capsule 1
doxycycline hyclate oral tablet 100 mg, 150 mg, 50 mg, 75 mg 1
doxycycline hyclate oral tablet 20 mg E
DOXYCYCLINE HYCLATE ORAL TABLET DELAYED
E
RELEASE 80 MG
doxycycline monohydrate oral capsule 1
doxycycline monohydrate oral tablet 1
levofloxacin oral tablet 1
metronidazole oral tablet 1
metronidazole vaginal 1
minocycline hcl oral capsule 1
MINOLIRA (minocycline hcl) E
mupirocin external 1
nitrofurantoin macrocrystal oral 1
nitrofurantoin monohydrate macrocrystals 1
NUZYRA ORAL (omadacycline tosylate) 2
penicillin v potassium oral tablet 1
SEYSARA (sarecycline hcl) 2
SILVADENE (silver sulfadiazine) E
SOLODYN (minocycline hcl) E
SOLOSEC (secnidazole) 2
sulfamethoxazole-trimethoprim oral tablet 1
TARGADOX (doxycycline hyclate) E
XENLETA (lefamulin acetate) 2
XEPI (ozenoxacin) 2
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
12Drug Name Drug Tier Notes
XIMINO (minocycline hcl) 2
Anticoagulants
ELIQUIS (apixaban) 2
ELIQUIS DVT/PE STARTER PACK ORAL TABLET 5 MG
2
(apixaban)
enoxaparin sodium 1 SP
PRADAXA (dabigatran etexilate mesylate) 2
warfarin sodium oral 1
XARELTO (rivaroxaban) 2
XARELTO STARTER PACK (rivaroxaban) 2
Anticonvulsants - Drugs for Seizures
BRIVIACT (brivaracetam) 2
carbamazepine oral tablet 1
CARBATROL (carbamazepine) E
DEPAKOTE (divalproex sodium) E
DEPAKOTE ER (divalproex sodium) E
DEPAKOTE SPRINKLES (divalproex sodium) E
DILANTIN INFATABS (phenytoin) E
DILANTIN ORAL CAPSULE 100 MG (phenytoin sodium
E
extended)
DILANTIN ORAL SUSPENSION (phenytoin) E
divalproex sodium er 1
divalproex sodium oral tablet delayed release 1
EPIDIOLEX (cannabidiol) 2 PA; SP
FYCOMPA (perampanel) 2
gabapentin oral capsule 1
gabapentin oral tablet 1
KEPPRA ORAL (levetiracetam) E
KEPPRA XR (levetiracetam) E
LAMICTAL (lamotrigine) E
LAMICTAL ODT (lamotrigine) E
LAMICTAL STARTER (lamotrigine) E
LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24
E
HOUR (lamotrigine)
lamotrigine er 1
lamotrigine oral tablet 1
levetiracetam oral tablet 1
NAYZILAM (midazolam (anticonvulsant)) 2
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
13Drug Name Drug Tier Notes
NEURONTIN (gabapentin) E
ONFI (clobazam) E
oxcarbazepine oral tablet 1
OXTELLAR XR (oxcarbazepine) E
QUDEXY XR (topiramate) E
SABRIL (vigabatrin) E SP
SYMPAZAN (clobazam) 2 PA
TEGRETOL (carbamazepine) E
TEGRETOL-XR (carbamazepine) E
TOPAMAX (topiramate) E
TOPAMAX SPRINKLE (topiramate) E
topiramate oral tablet 1
TRILEPTAL (oxcarbazepine) E
TROKENDI XR (topiramate) 2
VALTOCO 10 MG DOSE (diazepam) 2
VALTOCO 15 MG DOSE (diazepam) 2
VALTOCO 20 MG DOSE (diazepam) 2
VALTOCO 5 MG DOSE (diazepam) 2
VIMPAT (lacosamide) 2
XCOPRI (cenobamate) 2
XCOPRI (250 MG DAILY DOSE) (cenobamate) 2
XCOPRI (350 MG DAILY DOSE) (cenobamate) 2
ZONEGRAN (zonisamide) E
zonisamide oral 1
Antidementia Agents - Drugs for Alzheimer's Disease and
Dementia
donepezil hcl oral tablet 10 mg, 23 mg 1
memantine hcl oral tablet 10 mg, 5 mg 1
NAMZARIC (memantine hcl-donepezil hcl) 2
Antidepressants
amitriptyline hcl oral 1
BRISDELLE (paroxetine mesylate) E
bupropion hcl er (sr) 1
bupropion hcl er (xl) oral tablet extended release 24 hour 150
1
mg, 300 mg
BUPROPION HCL ER (XL) ORAL TABLET EXTENDED
E
RELEASE 24 HOUR 450 MG
bupropion hcl oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
14Drug Name Drug Tier Notes
CELEXA (citalopram hydrobromide) E
citalopram hydrobromide oral tablet 1
CYMBALTA (duloxetine hcl) E
desvenlafaxine succinate er 1
doxepin hcl oral capsule 1
duloxetine hcl oral 1
EFFEXOR XR (venlafaxine hcl) E
escitalopram oxalate oral tablet 1
fluoxetine hcl oral capsule 1
fluoxetine hcl oral tablet 1
fluvoxamine maleate 1
FORFIVO XL (bupropion hcl) E
LEXAPRO (escitalopram oxalate) E
mirtazapine oral tablet 1
nortriptyline hcl oral capsule 1
paroxetine hcl 1
PAXIL CR (paroxetine hcl) E
PAXIL ORAL TABLET (paroxetine hcl) E
PRISTIQ (desvenlafaxine succinate) E
PROZAC (fluoxetine hcl) E
sertraline hcl oral tablet 1
trazodone hcl oral 1
TRINTELLIX (vortioxetine hbr) 2
venlafaxine hcl 1
venlafaxine hcl er 1
VIIBRYD (vilazodone hcl) 2
VIIBRYD STARTER PACK (vilazodone hcl) 2
WELLBUTRIN SR (bupropion hcl) E
WELLBUTRIN XL (bupropion hcl) E
ZOLOFT (sertraline hcl) E
Antiemetics - Drugs for Nausea and Vomiting
meclizine hcl oral tablet 1
metoclopramide hcl oral tablet 10 mg 1
ondansetron hcl oral tablet 4 mg, 8 mg 1
ondansetron odt 1
prochlorperazine maleate oral 1
SANCUSO (granisetron) E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
15Drug Name Drug Tier Notes
scopolamine 1
VARUBI (180 MG DOSE) (rolapitant hcl) 2 QL
Antifungals
ciclopirox external solution 1
clotrimazole external cream 1
clotrimazole-betamethasone external cream 1
fluconazole oral tablet 1
GYNAZOLE-1 (butoconazole nitrate (1 dose)) 2
JUBLIA (efinaconazole) E
KERYDIN (tavaborole) 2 PA
ketoconazole external cream 1
ketoconazole external shampoo 1
nystatin external cream 1
nystatin mouth/throat 1
terbinafine hcl oral 1
terconazole vaginal cream 1
TOLSURA E
Antigout Agents
allopurinol oral 1
COLCHICINE ORAL CAPSULE E
colchicine oral tablet 1
COLCRYS (colchicine) E
febuxostat 1
GLOPERBA (colchicine) E
MITIGARE (colchicine) E
Antimigraine Agents
AIMOVIG (erenumab-aooe) 2 PA; QL
AJOVY (fremanezumab-vfrm) E
eletriptan hydrobromide 1 QL
EMGALITY (galcanezumab-gnlm) 2 PA; QL
EMGALITY (300 MG DOSE) (galcanezumab-gnlm) 2 PA; QL
IMITREX (sumatriptan succinate) E
IMITREX STATDOSE REFILL (sumatriptan succinate) E
IMITREX STATDOSE SYSTEM (sumatriptan succinate) E
MAXALT (rizatriptan benzoate) E
MAXALT-MLT (rizatriptan benzoate) E
NURTEC (rimegepant sulfate) 2 PA; QL
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
16Drug Name Drug Tier Notes
ONZETRA XSAIL (sumatriptan succinate) E
RELPAX (eletriptan hydrobromide) E
REYVOW (lasmiditan succinate) E
rizatriptan benzoate 1 QL
sumatriptan succinate oral 1 QL
TOSYMRA (sumatriptan) E
TREXIMET (sumatriptan-naproxen sodium) E
UBRELVY (ubrogepant) 2 PA; QL
ZEMBRACE SYMTOUCH (sumatriptan succinate) E
ZOMIG ORAL (zolmitriptan) E
ZOMIG ZMT (zolmitriptan) E
Antineoplastics - Drugs for Cancer
AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG (everolimus) E SP
anastrozole oral 1
ARIMIDEX (anastrozole) E
BELRAPZO (bendamustine hcl) E SP
BENDAMUSTINE HCL E SP
CABOMETYX (cabozantinib s-malate) 2 PA; SP
capecitabine 1 PA; SP
ERLEADA (apalutamide) E SP
GLEEVEC (imatinib mesylate) E SP
HERZUMA (trastuzumab-pkrb) E SP
IBRANCE ORAL CAPSULE (palbociclib) 2 PA; SP
IDHIFA (enasidenib mesylate) 2 PA; SP; QL
imatinib mesylate 1 PA; SP
IMBRUVICA ORAL TABLET (ibrutinib) 2 PA; SP
KANJINTI (trastuzumab-anns) 2 PA; SP
letrozole oral 1
LYNPARZA (olaparib) 2 PA; SP
MVASI (bevacizumab-awwb) 2 PA; SP
NUBEQA (darolutamide) 2 PA; SP
OGIVRI (trastuzumab-dkst) E SP
REVLIMID (lenalidomide) 2 PA; SP
RUBRACA (rucaparib camsylate) 2 PA; SP
RUXIENCE (rituximab-pvvr) 2 PA; SP
SPRYCEL (dasatinib) 2 PA; SP
tamoxifen citrate oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
17Drug Name Drug Tier Notes
TARGRETIN EXTERNAL (bexarotene) 2 PA; SP
TARGRETIN ORAL (bexarotene) E SP
TAZVERIK (tazemetostat hbr) E SP
temozolomide 1 PA; SP
TRAZIMERA (trastuzumab-qyyp) 2 PA; SP
TREANDA (bendamustine hcl) E SP
TRUXIMA (rituximab-abbs) E SP
XTANDI (enzalutamide) 2 PA; SP
YONSA (abiraterone acetate) E SP
ZEJULA (niraparib tosylate) 2 PA; SP
ZIRABEV (bevacizumab-bvzr) 2 PA; SP
ZYTIGA (abiraterone acetate) E SP
Antiparasitics
ARAKODA (tafenoquine succinate) 2
EMVERM (mebendazole) 2
hydroxychloroquine sulfate oral 1
NATROBA (spinosad) E
PLAQUENIL (hydroxychloroquine sulfate) E
Antiparkinson Agents
benztropine mesylate oral 1
carbidopa-levodopa oral tablet 1
GOCOVRI (amantadine hcl) E
INBRIJA (levodopa) 2 PA; SP
NOURIANZ (istradefylline) 2 PA
OSMOLEX ER (amantadine hcl) E
pramipexole dihydrochloride 1
ropinirole hcl 1
RYTARY (carbidopa-levodopa) 2
Antiplatelets
ASPIRIN-OMEPRAZOLE E
BRILINTA (ticagrelor) 2
clopidogrel bisulfate oral 1
PLAVIX (clopidogrel bisulfate) E
prasugrel hcl 1
YOSPRALA (aspirin-omeprazole) E
Antipsychotics - Drugs for Mood Disorders
ABILIFY (aripiprazole) E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
18Drug Name Drug Tier Notes
aripiprazole oral tablet 1
ARISTADA (aripiprazole lauroxil) 2
ARISTADA INITIO (aripiprazole lauroxil) 2
INVEGA SUSTENNA (paliperidone palmitate) 2
INVEGA TRINZA (paliperidone palmitate) 2
LATUDA (lurasidone hcl) 2
olanzapine oral tablet 1
PERSERIS (risperidone) 2
quetiapine fumarate 1
quetiapine fumarate er 1
REXULTI (brexpiprazole) 2
RISPERDAL (risperidone) E
risperidone oral tablet 1
SAPHRIS (asenapine maleate) 2
SECUADO (asenapine) E
SEROQUEL (quetiapine fumarate) E
SEROQUEL XR (quetiapine fumarate) E
VRAYLAR (cariprazine hcl) 2
ziprasidone hcl 1
ZYPREXA (olanzapine) E
Antivirals
acyclovir oral capsule 1
acyclovir oral tablet 1
ATRIPLA (efavirenz-emtricitab-tenofovir) E
BARACLUDE ORAL TABLET (entecavir) E SP
BIKTARVY (bictegravir-emtricitab-tenofov) 2
CIMDUO (lamivudine-tenofovir) 2
DESCOVY (emtricitabine-tenofovir af) E
DOVATO (dolutegravir-lamivudine) 2
entecavir 1 SP
EPCLUSA (sofosbuvir-velpatasvir) 2 PA; SP; QL
GENVOYA (elviteg-cobic-emtricit-tenofaf) 2
HARVONI (ledipasvir-sofosbuvir) 2 PA; SP; QL
JULUCA (dolutegravir-rilpivirine) 2
LEDIPASVIR-SOFOSBUVIR E SP
MAVYRET (glecaprevir-pibrentasvir) 2 PA; SP; QL
ODEFSEY (emtricitab-rilpivir-tenofov af) 2
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
19Drug Name Drug Tier Notes
oseltamivir phosphate oral 1 QL
PREZCOBIX (darunavir-cobicistat) 2
SOFOSBUVIR-VELPATASVIR E SP
SYMFI (efavirenz-lamivudine-tenofovir) 3
SYMFI LO (efavirenz-lamivudine-tenofovir) 3
TAMIFLU (oseltamivir phosphate) E
TEMIXYS (lamivudine-tenofovir) E
TIVICAY (dolutegravir sodium) 2
TRIUMEQ (abacavir-dolutegravir-lamivud) 2
TRUVADA (emtricitabine-tenofovir df) E
valacyclovir hcl oral 1
VALTREX (valacyclovir hcl) E
VEMLIDY (tenofovir alafenamide fumarate) 2 SP
VOSEVI (sofosbuv-velpatasv-voxilaprev) 2 PA; SP; QL
XOFLUZA (40 MG DOSE) (baloxavir marboxil) 2 QL
XOFLUZA (80 MG DOSE) (baloxavir marboxil) 2 QL
ZOVIRAX EXTERNAL (acyclovir) E
ZOVIRAX ORAL SUSPENSION (acyclovir) E
Anxiolytics - Drugs for Anxiety
alprazolam oral tablet 1
ATIVAN ORAL (lorazepam) E
buspirone hcl oral 1
clonazepam oral tablet 1
diazepam oral tablet 1
hydroxyzine hcl oral tablet 1
hydroxyzine pamoate oral 1
KLONOPIN (clonazepam) E
lorazepam oral tablet 1
triazolam 1
VALIUM (diazepam) E
XANAX (alprazolam) E
XANAX XR (alprazolam) E
Bipolar Agents - Drugs for Mood Disorders
lithium carbonate er 1
lithium carbonate oral capsule 1
Blood Products / Modifiers / Volume Expanders - Drugs for
Bleeding Disorders
ADYNOVATE 2 SP
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
20Drug Name Drug Tier Notes
AFSTYLA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250
2 SP
UNIT, 3000 UNIT, 500 UNIT (antihemophil fact single chain)
ARANESP (ALBUMIN FREE) (darbepoetin alfa) 2 PA; SP
ELOCTATE (antihem fact (bdd-rfviiifc)) 2 SP
EPOGEN (epoetin alfa) E SP
ESPEROCT (antihemoph fact rcmb gpeg-exei) E SP
FULPHILA (pegfilgrastim-jmdb) E SP
GRANIX (tbo-filgrastim) E SP
JIVI (ahf (bdd-rfviii peg-aucl)) 2 SP
MULPLETA (lusutrombopag) 2 PA; SP
NEULASTA (pegfilgrastim) 2 PA; SP
NEULASTA ONPRO (pegfilgrastim) 2 PA; SP
NEUPOGEN (filgrastim) E SP
NIVESTYM (filgrastim-aafi) 2 PA; SP
NOVOEIGHT (antihemophil fact bd truncated) 2 SP
NUWIQ (antihem fact (bdd-rfviii,sim)) 2 SP
PROCRIT (epoetin alfa) E SP
RETACRIT (epoetin alfa-epbx) 2 PA; SP
UDENYCA (pegfilgrastim-cbqv) E SP
ULTOMIRIS (ravulizumab-cwvz) 2 PA; SP
ZARXIO (filgrastim-sndz) 2 PA; SP
ZIEXTENZO (pegfilgrastim-bmez) 2 PA; SP
Cardiovascular Agents - Drugs for Heart and Circulation
Conditions
ALTACE (ramipril) E
amiodarone hcl oral 1
amlodipine besylate oral 1
amlodipine besylate-benazepril hcl 1
amlodipine besylate-valsartan 1
amlodipine-olmesartan 1
ATACAND (candesartan cilexetil) E
atenolol oral 1
atenolol-chlorthalidone 1
atorvastatin calcium oral 1
AVAPRO (irbesartan) E
AZOR (amlodipine-olmesartan) E
benazepril hcl oral 1
BENICAR (olmesartan medoxomil) E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
21Drug Name Drug Tier Notes
BENICAR HCT (olmesartan medoxomil-hctz) E
bisoprolol fumarate 1
bisoprolol-hydrochlorothiazide 1
bumetanide oral 1
BYSTOLIC (nebivolol hcl) 2
candesartan cilexetil 1
CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24
HOUR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG (diltiazem E
hcl coated beads)
diltiazem hcl coated beads (Cartia Xt) 1
carvedilol 1
CATAPRES-TTS-1 (clonidine) E
CATAPRES-TTS-2 (clonidine) E
CATAPRES-TTS-3 (clonidine) E
chlorthalidone 1
clonidine hcl oral 1
COLESTID (colestipol hcl) E
COLESTID FLAVORED (colestipol hcl) E
CONSENSI (amlodipine besylate-celecoxib) E
COREG (carvedilol) E
COREG CR (carvedilol phosphate) E
CORLANOR (ivabradine hcl) 2 PA; QL
COZAAR (losartan potassium) E
CRESTOR (rosuvastatin calcium) E
digoxin oral tablet 1
diltiazem hcl er coated beads oral capsule extended release 24
1
hour
dilt-xr 1
DIOVAN (valsartan) E
DIOVAN HCT (valsartan-hydrochlorothiazide) E
doxazosin mesylate oral 1
DYAZIDE (triamterene-hctz) E
EDARBI (azilsartan medoxomil) 2
EDARBYCLOR (azilsartan-chlorthalidone) 2
enalapril maleate oral 1
ENTRESTO (sacubitril-valsartan) 2
EXFORGE (amlodipine besylate-valsartan) E
EXFORGE HCT (amlodipine-valsartan-hctz) E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
22Drug Name Drug Tier Notes
ezetimibe 1
ezetimibe-simvastatin 1
fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg 1
fenofibrate oral tablet 1
fenofibric acid oral capsule delayed release 1
flecainide acetate 1
furosemide oral tablet 1
gemfibrozil oral 1
guanfacine hcl 1
HEMANGEOL (propranolol hcl) 2
hydralazine hcl oral 1
hydrochlorothiazide oral 1
HYZAAR (losartan potassium-hctz) E
INDERAL LA (propranolol hcl) E
INDERAL XL (propranolol hcl sr beads) E
INNOPRAN XL (propranolol hcl sr beads) E
irbesartan 1
irbesartan-hydrochlorothiazide 1
isosorbide mononitrate er 1
KAPSPARGO SPRINKLE (metoprolol succinate) E
KATERZIA (amlodipine benzoate) E
labetalol hcl oral 1
LASIX (furosemide) E
LESCOL XL (fluvastatin sodium) E
LIPITOR (atorvastatin calcium) E
lisinopril oral 1
lisinopril-hydrochlorothiazide 1
LIVALO (pitavastatin calcium) E
losartan potassium oral 1
losartan potassium-hctz 1
LOTREL (amlodipine besy-benazepril hcl) E
lovastatin 1
LOVAZA (omega-3-acid ethyl esters) E
metoprolol succinate er 1
metoprolol tartrate oral 1
MICARDIS (telmisartan) E
MICARDIS HCT (telmisartan-hctz) E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
23Drug Name Drug Tier Notes
MULTAQ (dronedarone hcl) 2
nadolol oral 1
NEXLETOL (bempedoic acid) 2 PA; QL
NEXLIZET (bempedoic acid-ezetimibe) 2 PA; QL
NIASPAN (niacin (antihyperlipidemic)) E
nifedipine er 1
nifedipine er osmotic release 1
nitroglycerin sublingual 1
NITROSTAT (nitroglycerin) E
NORVASC (amlodipine besylate) E
olmesartan medoxomil oral 1
olmesartan medoxomil-hctz 1
olmesartan-amlodipine-hctz 1
omega-3-acid ethyl esters 1 PA
PRALUENT (alirocumab) 2 PA; QL
PRAVACHOL (pravastatin sodium) E
pravastatin sodium 1
prazosin hcl oral 1
PRINIVIL (lisinopril) E
propranolol hcl er 1
propranolol hcl oral tablet 1
QUESTRAN (cholestyramine) E
QUESTRAN LIGHT (cholestyramine light) E
ramipril 1
RANEXA (ranolazine) E
ranolazine er 1
REPATHA (evolocumab) 2 PA; QL
REPATHA PUSHTRONEX SYSTEM (evolocumab) 2 PA; QL
REPATHA SURECLICK (evolocumab) 2 PA; QL
rosuvastatin calcium 1
simvastatin oral 1
sotalol hcl oral 1
spironolactone oral 1
TEKTURNA (aliskiren fumarate) 3
TEKTURNA HCT (aliskiren-hydrochlorothiazide) 2
telmisartan 1
telmisartan-hctz 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
24Drug Name Drug Tier Notes
TENORMIN (atenolol) E
TIKOSYN (dofetilide) E
TOPROL XL (metoprolol succinate) E
torsemide 1
triamterene-hctz 1
TRIBENZOR (olmesartan-amlodipine-hctz) E
TRICOR (fenofibrate) E
valsartan 1
valsartan-hydrochlorothiazide 1
VASCEPA (icosapent ethyl) 2 PA
verapamil hcl er oral capsule extended release 24 hour 120 mg,
1
180 mg, 240 mg, 360 mg
verapamil hcl er oral tablet extended release 1
VYTORIN (ezetimibe-simvastatin) E
WELCHOL (colesevelam hcl) E
ZESTRIL (lisinopril) E
ZETIA (ezetimibe) E
ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG
E
(simvastatin)
ZYPITAMAG (pitavastatin magnesium) E
Central Nervous System Agents - Drugs for Attention
Deficit Disorder
ADDERALL (amphetamine-dextroamphetamine) E
ADDERALL XR (amphetamine-dextroamphetamine) E
ADHANSIA XR (methylphenidate hcl) E
amphetamine-dextroamphetamine 1 PA; QL
amphetamine-dextroamphetamine er 1 PA; QL
atomoxetine hcl 1
CONCERTA (methylphenidate hcl) E
dexmethylphenidate hcl er 1 PA; QL
dexmethylphenidate hcl oral tablet 10 mg, 5 mg 1 PA; QL
EVEKEO (amphetamine sulfate) E
EVEKEO ODT (amphetamine sulfate) 2 PA; QL
FOCALIN (dexmethylphenidate hcl) E
FOCALIN XR (dexmethylphenidate hcl) E
guanfacine hcl er 1
INTUNIV (guanfacine hcl) E
JORNAY PM (methylphenidate hcl) 2 PA; QL
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
25Drug Name Drug Tier Notes
methylphenidate hcl er (la) oral capsule extended release 24
1 PA; QL
hour 10 mg, 20 mg, 30 mg, 40 mg
METHYLPHENIDATE HCL ER (XR) 2 PA; QL
methylphenidate hcl er oral tablet extended release 1 PA; QL
methylphenidate hcl oral tablet 1 PA; QL
RITALIN (methylphenidate hcl) E
RITALIN LA (methylphenidate hcl) E
STRATTERA (atomoxetine hcl) E
VYVANSE (lisdexamfetamine dimesylate) 2 PA; QL
Central Nervous System Agents - Drugs for Multiple
Sclerosis
AMPYRA (dalfampridine) 3 PA; SP; QL
AUBAGIO (teriflunomide) 2 PA; SP; QL
AVONEX PEN (interferon beta-1a) 2 PA; SP; QL
AVONEX PREFILLED (interferon beta-1a) 2 PA; SP; QL
BAFIERTAM (monomethyl fumarate) 2 PA; SP; QL
BETASERON (interferon beta-1b) 2 PA; SP; QL
COPAXONE (glatiramer acetate) 3 PA; SP; QL
EXTAVIA (interferon beta-1b) E SP
GILENYA (fingolimod hcl) 2 PA; SP; QL
glatiramer acetate 1 PA; SP; QL
MAVENCLAD (10 TABS) (cladribine) 2 PA; SP
MAVENCLAD (4 TABS) (cladribine) 2 PA; SP
MAVENCLAD (5 TABS) (cladribine) 2 PA; SP
MAVENCLAD (6 TABS) (cladribine) 2 PA; SP
MAVENCLAD (7 TABS) (cladribine) 2 PA; SP
MAVENCLAD (8 TABS) (cladribine) 2 PA; SP
MAVENCLAD (9 TABS) (cladribine) 2 PA; SP
MAYZENT (siponimod fumarate) 2 PA; SP; QL
PLEGRIDY (peginterferon beta-1a) E SP
PLEGRIDY STARTER PACK (peginterferon beta-1a) E SP
REBIF (interferon beta-1a) E SP
REBIF REBIDOSE (interferon beta-1a) E SP
REBIF REBIDOSE TITRATION PACK (interferon beta-1a) E SP
REBIF TITRATION PACK (interferon beta-1a) E SP
TECFIDERA STARTER PACK (dimethyl fumarate) 2 PA; SP; QL
TECFIDERA ORAL CAPSULE DELAYED RELEASE (dimethyl
3 PA; SP; QL
fumarate)
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
26Drug Name Drug Tier Notes
VUMERITY (diroximel fumarate) 2 PA; SP; QL
VUMERITY (STARTER) (diroximel fumarate) 2 PA; SP; QL
Central Nervous System Agents - Miscellaneous
ADDYI (flibanserin) 2 PA; QL
ADIPEX-P (phentermine hcl) E
AUSTEDO (deutetrabenazine) 2 PA; SP; QL
CONTRAVE (naltrexone-bupropion hcl) E
GRALISE (gabapentin (once-daily)) 2
HORIZANT (gabapentin enacarbil) 2 PA; QL
LYRICA (pregabalin) E
phentermine hcl oral tablet 1 PA
pregabalin oral capsule 1
QSYMIA (phentermine-topiramate) 2 PA
SAXENDA (liraglutide -weight management) 2 PA
TEGSEDI (inotersen sodium) 2 PA; SP
TIGLUTIK (riluzole) 2 PA; SP; QL
VYLEESI (bremelanotide acetate) 2 PA; QL
Dental and Oral Agents - Drugs for Mouth and Throat
Conditions
chlorhexidine gluconate mouth/throat 1
lidocaine viscous hcl 1
Dermatological Agents - Drugs for Skin Conditions
ABSORICA LD (isotretinoin micronized) 2 PA
ACANYA (clindamycin phos-benzoyl perox) E
ACZONE EXTERNAL GEL 5 % (dapsone) E
ACZONE EXTERNAL GEL 7.5 % (dapsone) 2
AKLIEF (trifarotene) E
ALA SCALP (hydrocortisone) E
AMZEEQ (minocycline hcl micronized) 2
APEXICON E (diflorasone diacet emoll base) E
BENZACLIN (clindamycin phos-benzoyl perox) E
BENZACLIN WITH PUMP (clindamycin phos-benzoyl perox) E
BENZAMYCIN (benzoyl peroxide-erythromycin) E
betamethasone dipropionate external cream 1
CALCIPOTRIENE EXTERNAL FOAM E
CAPEX (fluocinolone acetonide) E
isotretinoin (Claravis) 1 PA
CLINDAGEL (clindamycin phosphate) E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
27Drug Name Drug Tier Notes
clindamycin phosphate-benzoyl peroxide external gel 1-5 % 1
clindamycin phosphate external lotion 1
clindamycin phosphate external solution 1
clindamycin phosphate external swab 1
CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL E
clindamycin phosphate gel 1 % external 1
clobetasol propionate external cream 1
clobetasol propionate external ointment 1
clobetasol propionate external solution 1
CLOBEX (clobetasol propionate) E
CLOBEX SPRAY (clobetasol propionate) E
CLODERM (clocortolone pivalate) E
CORDRAN EXTERNAL TAPE (flurandrenolide) E
DAPSONE EXTERNAL GEL 7.5 % E
DESONATE (desonide) E
DIFFERIN EXTERNAL CREAM (adapalene) E
DIFFERIN EXTERNAL GEL 0.3 % (adapalene) E
DIFFERIN EXTERNAL LOTION (adapalene) E
DUOBRII (halobetasol prop-tazarotene) E
DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED
2 PA; SP; QL
SYRINGE (dupilumab)
ELIDEL (pimecrolimus) E
EPIDUO (adapalene-benzoyl peroxide) E
EPIDUO FORTE (adapalene-benzoyl peroxide) 2
EUCRISA (crisaborole) 2
FINACEA EXTERNAL FOAM (azelaic acid) 2
FINACEA EXTERNAL GEL (azelaic acid) 3
fluocinonide external cream 1
FLUOROPLEX (fluorouracil) 2
HALOBETASOL PROPIONATE EXTERNAL FOAM E
HALOG EXTERNAL CREAM (halcinonide) E
HALOG EXTERNAL OINTMENT (halcinonide) E
hydrocortisone external cream 0.5 % E
hydrocortisone external cream 1 %, 2.5 % 1
hydrocortisone external ointment 1 %, 2.5 % 1
IMIQUIMOD PUMP E
IMPOYZ (clobetasol propionate) E
KENALOG EXTERNAL (triamcinolone acetonide) E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
28Drug Name Drug Tier Notes
LEXETTE (halobetasol propionate) E
METROGEL (metronidazole) E
metronidazole external cream 1
metronidazole external gel 1
MIRVASO (brimonidine tartrate) 2
mometasone furoate external cream 1
NORITATE (metronidazole) E
ONEXTON (clindamycin phos-benzoyl perox) 2
ORACEA (doxycycline) E
PANDEL (hydrocortisone probutate) E
PROPECIA (finasteride) E
PSORCON E
QBREXZA (glycopyrronium tosylate) 2
RETIN-A (tretinoin) E
RETIN-A MICRO GEL 0.04 %, 0.1 % (tretinoin microsphere) E
RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.1 %
E
(tretinoin microsphere)
RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %, 0.08 %
2 PA
(tretinoin microsphere)
RHOFADE (oxymetazoline hcl) 2
SERNIVO (betamethasone dipropionate) 2
SOOLANTRA (ivermectin) 2
SORILUX (calcipotriene) E
TACLONEX EXTERNAL OINTMENT (calcipotriene-betameth
E
diprop)
TACLONEX EXTERNAL SUSPENSION (calcipotriene-
3
betameth diprop)
tacrolimus external ointment 1
TAZORAC EXTERNAL CREAM 0.1 % (tazarotene) E
TOPICORT SPRAY (desoximetasone) E
tretinoin external cream 1 PA
triamcinolone acetonide external cream 1
triamcinolone acetonide external ointment 1
ULTRAVATE (halobetasol propionate) E
VECTICAL (calcitriol) E
VELTIN (clindamycin-tretinoin) E
VERDESO (desonide) E
ZIANA (clindamycin-tretinoin) E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
29Drug Name Drug Tier Notes
ZYCLARA (imiquimod) E
ZYCLARA PUMP (imiquimod) E
Diabetes - Antidiabetic Agents
ADLYXIN (lixisenatide) E
ADLYXIN STARTER PACK (lixisenatide) E
ALOGLIPTIN BENZOATE E
ALOGLIPTIN-METFORMIN HCL E
ALOGLIPTIN-PIOGLITAZONE E
BYDUREON (exenatide) 2
BYDUREON BCISE AUTOINJECTOR (exenatide) 2
BYETTA 10 MCG PEN (exenatide) 2
BYETTA 5 MCG PEN (exenatide) 2
FARXIGA (dapagliflozin propanediol) 2
FORTAMET (metformin hcl) E
glimepiride 1
glipizide er 1
glipizide ir 1
GLUMETZA (metformin hcl) E
glyburide oral 1
GLYXAMBI (empagliflozin-linagliptin) 2
INVOKAMET (canagliflozin-metformin hcl) E
INVOKAMET XR (canagliflozin-metformin hcl) E
INVOKANA (canagliflozin) E
JANUMET (sitagliptin-metformin hcl) 2
JANUMET XR (sitagliptin-metformin hcl) 2
JANUVIA (sitagliptin phosphate) 2
JARDIANCE (empagliflozin) 2
JENTADUETO (linagliptin-metformin hcl) 2
JENTADUETO XR (linagliptin-metformin hcl) 2
KAZANO (alogliptin-metformin hcl) E
KOMBIGLYZE XR (saxagliptin-metformin) E
metformin hcl er 1
metformin hcl er (mod) E
metformin hcl er (osm) E
metformin hcl oral tablet 1
NESINA (alogliptin benzoate) E
ONGLYZA (saxagliptin hcl) E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
30Drug Name Drug Tier Notes
OSENI (alogliptin-pioglitazone) E
OZEMPIC (semaglutide) 2
pioglitazone hcl 1
QTERN (dapagliflozin-saxagliptin) E
RYBELSUS (semaglutide) 2
SEGLUROMET (ertugliflozin-metformin hcl) E
SOLIQUA (insulin glargine-lixisenatide) 2
STEGLATRO (ertugliflozin l-pyroglutamicac) E
STEGLUJAN (ertugliflozin-sitagliptin) E
SYMLINPEN 120 (pramlintide acetate) 2 PA
SYMLINPEN 60 (pramlintide acetate) 2 PA
SYNJARDY (empagliflozin-metformin hcl) 2
SYNJARDY XR (empagliflozin-metformin hcl) 2
TRADJENTA (linagliptin) 2
TRIJARDY XR (empagliflozin-linaglip-metform) 2
TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR
2
0.75 MG/0.5ML, 1.5 MG/0.5ML (dulaglutide)
VICTOZA (liraglutide) 2
XIGDUO XR (dapagliflozin-metformin hcl) 2
Diabetes - Glucose Monitoring
ACCU-CHEK FASTCLIX LANCET KIT (lancets misc.) 2
ACCU-CHEK GUIDE TEST STRIPS (glucose blood) E
ACCU-CHEK SOFTCLIX LANCET DEVICE KIT (lancets misc.) 2
CONTOUR CONTROL (blood glucose calibration) E
CONTOUR NEXT CONTROL (blood glucose calibration) E
CONTOUR NEXT MONITOR (blood glucose monitoring suppl) 2
CONTOUR NEXT TEST (glucose blood) 2
CONTOUR TEST (glucose blood) 2
DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR
(INCLUDING PLATINUM, PLATINUM PEDIATRIC) (continuous E
blood gluc transmit)
DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR
(INCLUDING PLATINUM, PLATINUM PEDIATRIC) DEVICE E
(continuous blood gluc receiver)
FREESTYLE LIBRE 14 DAY READER (continuous blood gluc
E
receiver)
FREESTYLE LIBRE 14 DAY SENSOR (continuous blood gluc
E
sensor)
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
31Drug Name Drug Tier Notes
FREESTYLE LIBRE 2 READER SYSTM (continuous blood gluc
E
receiver)
FREESTYLE LIBRE 2 SENSOR SYSTM (continuous blood gluc
E
sensor)
FREESTYLE LIBRE READER (continuous blood gluc receiver) E
FREESTYLE LIBRE SENSOR SYSTEM (continuous blood gluc
E
sensor)
ONETOUCH ULTRA (glucose blood) E
ONETOUCH VERIO TEST STRIPS (glucose blood) E
Diabetes - Glycemic Agents
BAQSIMI ONE PACK (glucagon) 2
BAQSIMI TWO PACK (glucagon) 2
GLUCAGON EMERGENCY KIT (glucagon (rdna)) 2
GVOKE PFS (glucagon) 2
Diabetes - Insulins
ADMELOG (insulin lispro) E
ADMELOG SOLOSTAR (insulin lispro) E
APIDRA SOLOSTAR (insulin glulisine) E
APIDRA VIAL (insulin glulisine) E
BASAGLAR KWIKPEN (insulin glargine) E
FIASP (insulin aspart (w/niacinamide)) E
FIASP FLEXTOUCH (insulin aspart (w/niacinamide)) E
FIASP PENFILL (insulin aspart (w/niacinamide)) E
HUMALOG KWIKPEN (insulin lispro) 2
HUMALOG MIX 50/50 KWIKPEN (insulin lispro prot & lispro) 2
HUMALOG MIX 50/50 VIAL (insulin lispro prot & lispro) 2
HUMALOG MIX 75/25 KWIKPEN (insulin lispro prot & lispro) 2
HUMALOG MIX 75/25 VIAL (insulin lispro prot & lispro) 2
HUMALOG U-100 JUNIOR KWIKPEN (insulin lispro) 2
HUMALOG VIAL (insulin lispro) 2
HUMULIN 70/30 KWIKPEN (insulin nph isophane & regular) 2
HUMULIN 70/30 VIAL (insulin nph isophane & regular) 2
HUMULIN N KWIKPEN (insulin nph human (isophane)) 2
HUMULIN N VIAL (insulin nph human (isophane)) 2
HUMULIN R U-500 KWIKPEN (insulin regular human) 2
HUMULIN R U-500 VIAL (insulin regular human) 2
HUMULIN R VIAL (insulin regular human) 2
INSULIN ASP PROT & ASP FLEXPEN E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
32Drug Name Drug Tier Notes
INSULIN ASPART E
INSULIN ASPART FLEXPEN E
INSULIN ASPART PENFILL E
INSULIN ASPART PROT & ASPART E
INSULIN LISPRO E
INSULIN LISPRO (1 UNIT DIAL) E
INSULIN LISPRO JUNIOR KWIKPEN E
INSULIN LISPRO PROT & LISPRO E
LANTUS SOLOSTAR (insulin glargine) 2
LANTUS U-100 VIAL (insulin glargine) 2
LEVEMIR U-100 FLEXTOUCH (insulin detemir) E
LEVEMIR U-100 VIAL (insulin detemir) E
NOVOFINE AUTOCOVER PEN NEEDLE (insulin pen needle) 2
NOVOFINE PEN NEEDLE (insulin pen needle) 2
NOVOFINE PLUS PEN NEEDLE (insulin pen needle) 2
NOVOLIN 70/30 FLEXPEN (insulin nph isophane & regular) E
NOVOLIN 70/30 VIAL (insulin nph isophane & regular) E
NOVOLIN N FLEXPEN (insulin nph human (isophane)) E
NOVOLIN N VIAL (insulin nph human (isophane)) E
NOVOLIN R FLEXPEN (insulin regular human) E
NOVOLIN R VIAL (insulin regular human) E
NOVOLOG FLEXPEN (insulin aspart) E
NOVOLOG MIX 70/30 FLEXPEN (insulin aspart prot & aspart) E
NOVOLOG MIX 70/30 VIAL (insulin aspart prot & aspart) E
NOVOLOG PENFILL (insulin aspart) E
NOVOLOG U-100 VIAL (insulin aspart) E
NOVOTWIST PEN NEEDLE (insulin pen needle) 2
TOUJEO MAX SOLOSTAR (insulin glargine) 2
TOUJEO SOLOSTAR (insulin glargine) 2
TRESIBA (insulin degludec) E
TRESIBA FLEXTOUCH (insulin degludec) E
Electrolytes / Minerals / Metals / Vitamins
AZESCHEW PRENATAL/POSTNATAL E
AZESCO E
CARNITOR ORAL (levocarnitine) E
CARNITOR SF (levocarnitine) E
CITRANATAL BLOOM (prenatal-dss-fecb-fegl-fa) E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
33Drug Name Drug Tier Notes
cyanocobalamin injection solution 1000 mcg/ml 1
CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML 2
ENBRACE HR (prenat vit-fe gly cys-fa-omega) E
ergocalciferol oral capsule 1
folic acid oral tablet 1 mg, 800 mcg 1
potassium chloride crys er (Klor-Con M20) 1
K-TAB (potassium chloride) E
LOKELMA (sodium zirconium cyclosilicate) 2
multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg 1
NASCOBAL (cyanocobalamin) 2
NESTABS ONE (prenat-fe-methylfol-dha w/o a) E
potassium chloride crys er 1
potassium chloride er 1
potassium citrate er 1
PREGENNA E
PRENARA E
PRENATE (prenat mv-min-methylfolate-fa) E
PRENATE DHA (prenat-feasp-meth-fa-dha w/o a) E
PRENATE ELITE (prenatal-feaspgly-methylfol-fa) E
PRENATE ENHANCE (prenat w/o a-fe-methfol-fa-dha) E
PRENATE ESSENTIAL (prenat-feasp-meth-fa-dha w/o a) E
PRENATE MINI (prenat-fecbn-feasp-meth-fa-dha) E
PRENATE PIXIE (prenat-feasp-meth-fa-dha w/o a) E
PRENATE RESTORE (prenat w/o a-fe-methfol-fa-dha) E
PRENATVITE COMPLETE E
PRIMACARE (pren-fe-meth-fa-omeg w/o a) E
sodium fluoride oral tablet chewable 1
TRINAZ E
TRISTART ONE (prenat w/o a-fecbn-meth-fa-dha) E
VELTASSA (patiromer sorbitex calcium) 2
VITAFOL FE+ (prenat-fe poly-methfol-fa-dha) E
VITAFOL-OB+DHA (prenatal mv-min-fe fum-fa-dha) E
vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) 1
VITATHELY WITH GINGER (prenatal vit-fe fumarate-fa) E
ZALVIT E
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer
ACIPHEX (rabeprazole sodium) E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
34Drug Name Drug Tier Notes
CARAFATE ORAL TABLET (sucralfate) E
NEXIUM ORAL CAPSULE DELAYED RELEASE
E
(esomeprazole magnesium)
omeprazole oral capsule delayed release 1
omeprazole-sodium bicarbonate E
pantoprazole sodium oral tablet delayed release 1
PREVACID (lansoprazole) E
PREVACID SOLUTAB (lansoprazole) E
PROTONIX ORAL TABLET DELAYED RELEASE
E
(pantoprazole sodium)
RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE E
sucralfate oral tablet 1
ZEGERID (omeprazole-sodium bicarbonate) E
Gastrointestinal Agents - Drugs for Bowel, Intestine and
Stomach Conditions
AMITIZA (lubiprostone) E
CLENPIQ (sod picosulfate-mag ox-cit acd) 2
dicyclomine hcl oral capsule 1
dicyclomine hcl oral tablet 1
diphenoxylate-atropine oral tablet 1
peg 3350-kcl-nabcb-nacl-nasulf (Gavilyte-G) 1
glycopyrrolate oral tablet 1 mg, 2 mg 1
GOLYTELY (peg 3350-kcl-nabcb-nacl-nasulf) E
hyoscyamine sulfate sl 1
hyoscyamine sulfate sublingual 1
lactulose oral solution 1
LINZESS (linaclotide) 2
MOTEGRITY (prucalopride succinate) 2
MOTOFEN (difenoxin-atropine) E
MOVANTIK (naloxegol oxalate) E
MOVIPREP (peg-kcl-nacl-nasulf-na asc-c) E
NULYTELY LEMON-LIME (peg 3350-kcl-na bicarb-nacl) E
NULYTELY WITH FLAVOR PACKS (peg 3350-kcl-na bicarb-
E
nacl)
OMECLAMOX-PAK (amoxicill-clarithro-omeprazole) 2
OSMOPREP (sod phos mono-sod phos dibasic) E
PLENVU (peg-kcl-nacl-nasulf-na asc-c) E
PYLERA (bis subcit-metronid-tetracyc) 2
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
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