Your 2021 Premium Standard Formulary
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Your 2021 Premium Standard Formulary
Effective January 1, 2021
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.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 this
for their safety, cost, and effectiveness. Medications are formulary and your benefit plan
listed by categories or classes and are placed into cost exist, the benefit plan documents
levels known as tiers. It includes both brand and generic rule. This may not be a complete
prescription medications. list of medications that are covered
by your plan. Please review your
To create the list, OptumRx® is guided by the Pharmacy and
benefit plan for full details.
Therapeutics Committee. This group of doctors, nurses, and
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 member 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.
• Medications may move to a higher tier when a generic equal 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.
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.
2Medication tips
What is the difference between brand-name and generic
medications? Over-the-counter medications
Generic medications contain the same active ingredients An over-the-counter (OTC)
(offer the same benefits) as brand-name medications, but they medication may be the right
often cost less. Once the patent for a brand-name medication treatment for some conditions.
ends, the FDA can approve a generic version with the same Talk to your doctor about
active ingredients. available OTC options. Even
though OTC medications may
What if my doctor writes a brand-name prescription? not be covered by your pharmacy
If your doctor gives you a prescription for a brand-name benefit, they may cost less than
medication, ask if a generic or lower-cost option could be right a prescription medication.
for you. Generic medications are usually your lowest-cost option.
What if I am taking a specialty medication?
Specialty medications are high-cost oral or injectable medications used to treat complex chronic
conditions. 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.
3Reading 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
SP Specialty Medication – Medication is designated as specialty.
3P Tier 3 preferred
Required prior authorizations*
Therapeutic class Non-preferred medications Preferred medications
Hepatitis C All other brands non-preferred with Epclusa, Harvoni,
prior authorization Mavyret, Vosevi
Multiple sclerosis All other brands non-preferred with Avonex, Bafiertam, Betaseron,
prior authorization Copaxone/Glatopa/glatiramer,
Tecfidera, Vumerity
Immunomodulators All other brands non-preferred with Cimzia, Humira, Inflectra, Otezla,
prior authorization Renf lexis, Rinvoq, Simponi,
Simponi Aria, Skyrizi, Stelara, Tremfya,
Xeljanz, Xeljanz XR
*All of the products listed above are currently subject to prior authorization. Preferred medications
are required prior to new requests for non-preferred medication(s). Existing utilizers of non-
preferred medication(s) within the therapeutic categories of hepatitis C, immunomodulators and
multiple sclerosis will be eligible to remain on current therapy if compliance and efficacy of therapy
are demonstrated. Exceptions will be granted for specific indications where the preferred agents
do not have FDA-approval for use.
4Table of Contents
Analgesics - Drugs for Pain.................................................................................................................................7
Analgesics - Drugs for Pain and Inflammation.................................................................................................... 7
Anesthetics..........................................................................................................................................................8
Anti-Addiction / Substance Abuse Treatment Agents......................................................................................... 8
Antibacterials.......................................................................................................................................................8
Anticoagulants.....................................................................................................................................................9
Anticonvulsants - Drugs for Seizures.................................................................................................................. 9
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.............................................................. 10
Antidepressants.................................................................................................................................................10
Antiemetics - Drugs for Nausea and Vomiting.................................................................................................. 11
Antifungals.........................................................................................................................................................11
Antigout Agents................................................................................................................................................. 11
Antimigraine Agents.......................................................................................................................................... 12
Antineoplastics - Drugs for Cancer....................................................................................................................12
Antiparasitics..................................................................................................................................................... 13
Antiparkinson Agents........................................................................................................................................ 13
Antiplatelets.......................................................................................................................................................13
Antipsychotics - Drugs for Mood Disorders....................................................................................................... 13
Antivirals............................................................................................................................................................13
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........................................................................ 17
Central Nervous System Agents - Miscellaneous............................................................................................. 18
Dental and Oral Agents - Drugs for Mouth and Throat Conditions....................................................................18
Dermatological Agents - Drugs for Skin Conditions.......................................................................................... 18
Diabetes - Antidiabetic Agents.......................................................................................................................... 20
Diabetes - Glucose Monitoring.......................................................................................................................... 21
Diabetes - Glycemic Agents.............................................................................................................................. 22
Diabetes - Insulins.............................................................................................................................................22
Electrolytes / Minerals / Metals / Vitamins.........................................................................................................23
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer................................................................................24
Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions.................................................24
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment............................................. 25
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.......................................................25
Genitourinary Agents - Drugs for Prostate Conditions...................................................................................... 25
Hormonal Agents - Adrenal............................................................................................................................... 25
Hormonal Agents - Men's Health.......................................................................................................................26
Hormonal Agents - Osteoporosis...................................................................................................................... 26
Hormonal Agents - Pituitary.............................................................................................................................. 26
Hormonal Agents - Sex Hormones and Birth Control........................................................................................27
Hormonal Agents - Thyroid............................................................................................................................... 28
Immunological Agents - Drugs for Immune System Stimulation or Suppression.............................................. 29
Inflammatory Bowel Disease Agents.................................................................................................................30
Metabolic Bone Disease Agents - Drugs for Osteoporosis............................................................................... 30
Metabolic Bone Disease Agents - Other........................................................................................................... 30
Miscellaneous Therapeutic Agents................................................................................................................... 30
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...........................................................31
Ophthalmic Agents - Drugs for Glaucoma.........................................................................................................31
5Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions......................................................................... 32
Otic Agents - Drugs for Ear Conditions............................................................................................................. 32
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold........................................................32
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions................................... 33
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis.................................................................... 34
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension.................................................... 34
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm...................................................................... 34
Sleep Disorder Agents...................................................................................................................................... 35
6Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Analgesics - Drugs hydrocodone-
for Pain acetaminophen oral 1
acetaminophen- tablet
1
codeine #2 hydromorphone hcl oral
1
acetaminophen- tablet
1
codeine #3 HYSINGLA ER 2
acetaminophen- KADIAN E
1
codeine #4 LAZANDA E
acetaminophen- morphine sulfate er oral
codeine oral tablet 300- 1 1
tablet extended release
15 mg, 300-60 mg
MS CONTIN E
APADAZ E
NORCO E
apap-caff-
dihydrocodeine oral 1 NUCYNTA E
capsule NUCYNTA ER E
ARYMO ER E OXYCODONE HCL ER E M
BELBUCA 2 oxycodone hcl oral
1
BENZHYDROCODON tablet
E
E-ACETAMINOPHEN oxycodone-
1
butalbital-apap-caffeine 1 acetaminophen
BUTRANS OXYCONTIN 2
TRANSDERMAL PERCOCET E
PATCH WEEKLY 10 ROXICODONE E
E
MCG/HR, 15 MCG/HR,
20 MCG/HR, 5 SUBSYS E
MCG/HR TRAMADOL HCL ER
CONZIP E ORAL CAPSULE
EXTENDED RELEASE E M
DILAUDID ORAL E 24 HOUR 100 MG, 200
DURAGESIC-100 E MG, 300 MG
DURAGESIC-12 E tramadol hcl oral tablet
1
DURAGESIC-25 E 50 mg
DURAGESIC-50 E TREZIX 3
DURAGESIC-75 E ULTRACET E
fentanyl 1 ULTRAM E
FENTANYL CITRATE XTAMPZA ER 2
E M
BUCCAL TABLET ZOHYDRO ER E
FENTORA E Analgesics - Drugs
FIORICET E for Pain and
Inflammation
FIORICET/CODEINE E
ARTHROTEC E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
7Drug Name Drug Tier Notes Drug Name Drug Tier Notes
CAMBIA E Anti-Addiction /
CELEBREX E Substance Abuse
Treatment Agents
celecoxib oral 1
BUNAVAIL 3
diclofenac sodium oral 1
buprenorphine hcl
diclofenac sodium 1
1 sublingual
transdermal gel 1 %
buprenorphine hcl-
DUEXIS E 1
naloxone hcl
etodolac oral tablet 1 CHANTIX 3
FLECTOR E CHANTIX
ibuprofen oral tablet 1 CONTINUING MONTH 3
INDOMETHACIN PAK
ORAL CAPSULE 20 3 CHANTIX STARTING
3
MG MONTH PAK
indomethacin oral EVZIO E
1
capsule 25 mg, 50 mg NALOXONE HCL
ketorolac tromethamine INJECTION
1 E
oral SOLUTION AUTO-
meloxicam oral 1 INJECTOR
MOBIC E naltrexone hcl oral 1
nabumetone oral 1 NARCAN 2
NALFON E SUBOXONE E
NAPRELAN 3 ZUBSOLV 2
Antibacterials
naproxen oral tablet 1
PENNSAID E ACTICLATE E
QMIIZ ODT E amoxicillin oral capsule 1
RELAFEN DS E amoxicillin oral
suspension 1
SPRIX E reconstituted
VIMOVO E amoxicillin oral tablet 1
VOLTAREN E amoxicillin-potassium
ZIPSOR E clavulanate oral
1
ZORVOLEX E suspension
reconstituted
Anesthetics
amoxicillin-potassium
lidocaine external patch 1 1
clavulanate oral tablet
lidocaine-prilocaine azithromycin oral
1
external cream suspension 1
LIDODERM E reconstituted
ZTLIDO E azithromycin 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.
8Drug Name Drug Tier Notes Drug Name Drug Tier Notes
cefdinir 1 NUZYRA ORAL 3
cefuroxime axetil 1 penicillin v potassium
1
cephalexin oral capsule 1 oral tablet
cephalexin oral SEYSARA 3
suspension 1 SILVADENE E
reconstituted SOLODYN E
ciprofloxacin hcl oral SOLOSEC 3
1
tablet 250 mg, 500 mg
sulfamethoxazole-
clarithromycin oral 1
1 trimethoprim oral tablet
tablet
TARGADOX E
clindamycin hcl oral 1
XENLETA 3
CLINDESSE 3
XEPI 3
DIFICID 3
XIMINO 3
DORYX MPC E
Anticoagulants
DORYX ORAL
TABLET DELAYED ELIQUIS 2
E
RELEASE 200 MG, 50 ELIQUIS DVT/PE
2
MG STARTER PACK
doxycycline hyclate oral enoxaparin sodium 1 SP
1
capsule PRADAXA 2
doxycycline hyclate oral warfarin sodium oral 1
1
tablet
XARELTO 2
doxycycline
monohydrate oral 1 XARELTO STARTER
2
capsule PACK
doxycycline Anticonvulsants -
1 Drugs for Seizures
monohydrate oral tablet
levofloxacin oral tablet 1 BRIVIACT 3
metronidazole oral carbamazepine oral
1 1
tablet tablet
metronidazole vaginal 1 CARBATROL E
minocycline hcl oral DEPAKOTE E
1
capsule DEPAKOTE ER E
MINOLIRA E DEPAKOTE
E
mupirocin external 1 SPRINKLES
nitrofurantoin DILANTIN INFATABS E
1
macrocrystal oral DILANTIN ORAL
E
nitrofurantoin CAPSULE 100 MG
monohydrate 1 DILANTIN ORAL
E
macrocrystals SUSPENSION
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 Drug Name Drug Tier Notes
divalproex sodium er 1 VALTOCO 15 MG
3
divalproex sodium oral DOSE
1
tablet delayed release VALTOCO 20 MG
3
EPIDIOLEX 3 SP DOSE
FYCOMPA 3 VALTOCO 5 MG
3
DOSE
gabapentin oral
1 VIMPAT 3
capsule
gabapentin oral tablet 1 XCOPRI 3
KEPPRA ORAL E XCOPRI (250 MG
3
DAILY DOSE)
KEPPRA XR E
XCOPRI (350 MG
LAMICTAL E 3
DAILY DOSE)
LAMICTAL ODT E ZONEGRAN E
LAMICTAL STARTER E zonisamide oral 1
LAMICTAL XR ORAL Antidementia Agents
TABLET EXTENDED E - Drugs for
RELEASE 24 HOUR Alzheimer's Disease
lamotrigine er 1 and Dementia
lamotrigine oral tablet 1 donepezil hcl oral tablet
1
levetiracetam oral 10 mg, 23 mg
1
tablet memantine hcl oral
1
NAYZILAM 3 tablet 10 mg, 5 mg
NEURONTIN E NAMZARIC 2
Antidepressants
ONFI E
oxcarbazepine oral amitriptyline hcl oral 1
1
tablet BRISDELLE E
OXTELLAR XR E bupropion hcl er (sr) 1
QUDEXY XR E bupropion hcl er (xl)
SABRIL E SP oral tablet extended
1
release 24 hour 150
SYMPAZAN 3 mg, 300 mg
TEGRETOL E BUPROPION HCL ER
TEGRETOL-XR E (XL) ORAL TABLET
E M
TOPAMAX E EXTENDED RELEASE
24 HOUR 450 MG
TOPAMAX SPRINKLE E
bupropion hcl oral 1
topiramate oral tablet 1
CELEXA E
TRILEPTAL E
citalopram
TROKENDI XR 3 hydrobromide oral 1
VALTOCO 10 MG tablet
3
DOSE
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 Drug Name Drug Tier Notes
CYMBALTA E metoclopramide hcl
1
desvenlafaxine oral tablet 10 mg
1
succinate er ondansetron hcl oral
1
doxepin hcl oral tablet 4 mg, 8 mg
1
capsule ondansetron odt 1
duloxetine hcl oral 1 prochlorperazine
1
EFFEXOR XR E maleate oral
escitalopram oxalate SANCUSO E
1
oral tablet scopolamine 1
fluoxetine hcl oral VARUBI (180 MG
1 3
capsule DOSE)
fluoxetine hcl oral tablet 1 Antifungals
fluvoxamine maleate 1 ciclopirox external
1
FORFIVO XL E solution
LEXAPRO E clotrimazole external
1
cream
mirtazapine oral tablet 1
clotrimazole-
nortriptyline hcl oral betamethasone 1
1
capsule external cream
paroxetine hcl 1 CRESEMBA ORAL 3
PAXIL CR E fluconazole oral tablet 1
PAXIL ORAL TABLET E GYNAZOLE-1 3
PRISTIQ E JUBLIA E
PROZAC E KERYDIN 3
sertraline hcl oral tablet 1 ketoconazole external
1
trazodone hcl oral 1 cream
TRINTELLIX 3 ketoconazole external
1
venlafaxine hcl 1 shampoo
venlafaxine hcl er 1 nystatin external cream 1
VIIBRYD 3 nystatin mouth/throat 1
VIIBRYD STARTER terbinafine hcl oral 1
3
PACK terconazole vaginal
1
WELLBUTRIN SR E cream
WELLBUTRIN XL E TOLSURA E
Antigout Agents
ZOLOFT E
Antiemetics - Drugs allopurinol oral 1
for Nausea and COLCHICINE ORAL
E
Vomiting CAPSULE
meclizine hcl oral tablet 1 colchicine 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 Drug Name Drug Tier Notes
COLCRYS E ARIMIDEX E
febuxostat 1 BELRAPZO E SP
GLOPERBA E BENDAMUSTINE HCL E SP
MITIGARE E CABOMETYX 2 SP
Antimigraine Agents capecitabine 1 SP
AIMOVIG 2 ERLEADA E SP
AJOVY E GLEEVEC E SP
eletriptan hydrobromide 1 IBRANCE ORAL
3 SP
EMGALITY 2 CAPSULE
EMGALITY (300 MG IDHIFA 3 SP
2
DOSE) imatinib mesylate 1 SP
IMITREX E IMBRUVICA ORAL
3 SP
IMITREX STATDOSE TABLET
E
REFILL KANJINTI 2 SP
IMITREX STATDOSE letrozole oral 1
E
SYSTEM LYNPARZA 2 SP
MAXALT E MVASI 2 SP
MAXALT-MLT E NUBEQA 3 SP
NURTEC 2 OGIVRI E SP
ONZETRA XSAIL E REVLIMID 2 SP
RELPAX E RUBRACA 2 SP
REYVOW E RUXIENCE 2 SP
rizatriptan benzoate 1 SPRYCEL 2 SP
sumatriptan succinate tamoxifen citrate oral 1
1
oral
TARGRETIN
TOSYMRA E 3 SP
EXTERNAL
TREXIMET E TARGRETIN ORAL E SP
UBRELVY 2 TAZVERIK E SP
ZEMBRACE temozolomide 1 SP
E
SYMTOUCH
TRAZIMERA 2 SP
ZOMIG ORAL E
TREANDA E SP
ZOMIG ZMT E
TRUXIMA E SP
Antineoplastics -
Drugs for Cancer XTANDI 3 SP
AFINITOR ORAL YONSA E SP
TABLET 2.5 MG, 5 E SP ZEJULA 2 SP
MG, 7.5 MG ZIRABEV 2 SP
anastrozole oral 1 ZYTIGA E SP
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 Drug Name Drug Tier Notes
Antiparasitics LATUDA 3
ARAKODA 3 olanzapine oral tablet 1
EMVERM 2 PERSERIS 3
hydroxychloroquine quetiapine fumarate 1
1
sulfate oral quetiapine fumarate er 1
NATROBA E REXULTI 3
PLAQUENIL E RISPERDAL E
Antiparkinson Agents risperidone oral tablet 1
benztropine mesylate SAPHRIS 2
1
oral
SECUADO E
carbidopa-levodopa
1 SEROQUEL E
oral tablet
GOCOVRI E SEROQUEL XR E
INBRIJA 3 SP VRAYLAR 3
NOURIANZ 3 ziprasidone hcl 1
OSMOLEX ER E ZYPREXA E
pramipexole Antivirals
1
dihydrochloride acyclovir oral capsule 1
ropinirole hcl 1 acyclovir oral tablet 1
RYTARY 3 ATRIPLA E
Antiplatelets BARACLUDE ORAL
E SP
ASPIRIN- TABLET
E M
OMEPRAZOLE BIKTARVY 3
BRILINTA 2 CIMDUO 2
clopidogrel bisulfate DESCOVY E
1
oral DOVATO 2
PLAVIX E entecavir 1 SP
prasugrel hcl 1 EPCLUSA 2 SP
YOSPRALA E GENVOYA 3
Antipsychotics -
HARVONI 2 SP
Drugs for Mood
Disorders JULUCA 2
ABILIFY E LEDIPASVIR-
E M; SP
SOFOSBUVIR
aripiprazole oral tablet 1
MAVYRET 2 SP
ARISTADA 3
ODEFSEY 3
ARISTADA INITIO 3
oseltamivir phosphate
INVEGA SUSTENNA 3 1
oral
INVEGA TRINZA 3 PREZCOBIX 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 Drug Name Drug Tier Notes
SOFOSBUVIR- Bipolar Agents -
E M; SP Drugs for Mood
VELPATASVIR
SYMFI 2 Disorders
SYMFI LO 2 lithium carbonate er 1
TAMIFLU E lithium carbonate oral
1
capsule
TEMIXYS E
Blood Products /
TIVICAY 2 Modifiers / Volume
TRIUMEQ 2 Expanders - Drugs for
Bleeding Disorders
TRUVADA E
valacyclovir hcl oral 1 ADYNOVATE 3 SP
VALTREX E AFSTYLA
INTRAVENOUS KIT
VEMLIDY 3 SP 1000 UNIT, 2000 UNIT, 3 SP
VOSEVI 2 SP 250 UNIT, 3000 UNIT,
XOFLUZA (40 MG 500 UNIT
3
DOSE) ARANESP (ALBUMIN
2 SP
XOFLUZA (80 MG FREE)
3
DOSE) ELOCTATE 3 SP
ZOVIRAX EXTERNAL E EPOGEN E SP
ZOVIRAX ORAL ESPEROCT E SP
E
SUSPENSION FULPHILA E SP
Anxiolytics - Drugs GRANIX E SP
for Anxiety
JIVI 3 SP
alprazolam oral tablet 1
MULPLETA 2 SP
ATIVAN ORAL E
NEULASTA 3 SP
buspirone hcl oral 1
NEULASTA ONPRO 3 SP
clonazepam oral tablet 1
NEUPOGEN E SP
diazepam oral tablet 1
NIVESTYM 2 SP
hydroxyzine hcl oral
1 NOVOEIGHT 3 SP
tablet
hydroxyzine pamoate NUWIQ 3 SP
1
oral PROCRIT E SP
KLONOPIN E RETACRIT 2 SP
lorazepam oral tablet 1 UDENYCA E SP
triazolam 1 ULTOMIRIS 3 SP
VALIUM E ZARXIO 2 SP
XANAX E ZIEXTENZO 3 SP
XANAX XR E
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 Drug Name Drug Tier Notes
Cardiovascular chlorthalidone 1
Agents - Drugs for clonidine hcl oral 1
Heart and Circulation
Conditions COLESTID E
ALTACE E COLESTID
E
FLAVORED
amiodarone hcl oral 1
CONSENSI E
amlodipine besylate
1 COREG E
oral
amlodipine besylate- COREG CR E
1
benazepril hcl CORLANOR 3
amlodipine besylate- COZAAR E
1
valsartan CRESTOR E
amlodipine-olmesartan 1 digoxin oral tablet 1
ATACAND E diltiazem hcl er coated
atenolol oral 1 beads oral capsule
1
atenolol-chlorthalidone 1 extended release 24
hour
atorvastatin calcium
1 dilt-xr 1
oral
AVAPRO E DIOVAN E
AZOR E DIOVAN HCT E
benazepril hcl oral 1 doxazosin mesylate
1
oral
BENICAR E
DYAZIDE E
BENICAR HCT E
EDARBI 3
bisoprolol fumarate 1
EDARBYCLOR 3
bisoprolol-
1 enalapril maleate oral 1
hydrochlorothiazide
bumetanide oral 1 ENTRESTO 2
BYSTOLIC 2 EXFORGE E
candesartan cilexetil 1 EXFORGE HCT E
CARDIZEM LA ORAL ezetimibe 1
TABLET EXTENDED ezetimibe-simvastatin 1
RELEASE 24 HOUR E fenofibrate micronized
180 MG, 240 MG, 300 oral capsule 134 mg, 1
MG, 360 MG, 420 MG 200 mg, 67 mg
cartia xt 1 fenofibrate oral tablet 1
carvedilol 1 fenofibric acid oral
CATAPRES-TTS-1 E capsule delayed 1
CATAPRES-TTS-2 E release
CATAPRES-TTS-3 E flecainide acetate 1
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 Drug Name Drug Tier Notes
furosemide oral tablet 1 nadolol oral 1
gemfibrozil oral 1 NEXLETOL 2
guanfacine hcl 1 NEXLIZET 2
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
INNOPRAN XL E olmesartan medoxomil
1
irbesartan 1 oral
irbesartan- olmesartan medoxomil-
1 1
hydrochlorothiazide hctz
isosorbide mononitrate olmesartan-amlodipine-
1 1
er hctz
KAPSPARGO omega-3-acid ethyl
E 1
SPRINKLE esters
KATERZIA E PRALUENT 2
labetalol hcl oral 1 PRAVACHOL E
LASIX E pravastatin sodium 1
LESCOL XL E prazosin hcl oral 1
LIPITOR E PRINIVIL E
lisinopril oral 1 propranolol hcl er 1
lisinopril- propranolol hcl oral
1 1
hydrochlorothiazide tablet
LIVALO E QUESTRAN E
losartan potassium oral 1 QUESTRAN LIGHT E
losartan potassium-hctz 1 ramipril 1
LOTREL E RANEXA E
lovastatin 1 ranolazine er 1
LOVAZA E REPATHA 2
metoprolol succinate er 1 REPATHA
PUSHTRONEX 2
metoprolol tartrate oral 1 SYSTEM
MICARDIS E REPATHA
2
MICARDIS HCT E SURECLICK
MULTAQ 3 rosuvastatin calcium 1
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 Drug Name Drug Tier Notes
simvastatin oral 1 ADHANSIA XR E
sotalol hcl oral 1 amphetamine-
1
spironolactone oral 1 dextroamphetamine
TEKTURNA 2 amphetamine-
1
dextroamphetamine er
TEKTURNA HCT 2
atomoxetine hcl 1
telmisartan 1
CONCERTA E
telmisartan-hctz 1
dexmethylphenidate hcl
TENORMIN E 1
er
TIKOSYN E dexmethylphenidate hcl
1
TOPROL XL E oral tablet 10 mg, 5 mg
torsemide 1 EVEKEO E
triamterene-hctz 1 EVEKEO ODT 3
TRIBENZOR E FOCALIN E
TRICOR E FOCALIN XR E
valsartan 1 guanfacine hcl er 1
valsartan- INTUNIV E
1
hydrochlorothiazide JORNAY PM 3
VASCEPA 2 methylphenidate hcl er
verapamil hcl er oral (la) oral capsule
capsule extended extended release 24 1
release 24 hour 120 1 hour 10 mg, 20 mg, 30
mg, 180 mg, 240 mg, mg, 40 mg
360 mg METHYLPHENIDATE
3
verapamil hcl er oral HCL ER (XR)
1
tablet extended release methylphenidate hcl er
VYTORIN E oral tablet extended 1
WELCHOL E release
ZESTRIL E methylphenidate hcl
1
oral tablet
ZETIA E
RITALIN E
ZOCOR ORAL
TABLET 10 MG, 20 E RITALIN LA E
MG, 40 MG, 80 MG STRATTERA E
ZYPITAMAG E VYVANSE 2
Central Nervous Central Nervous
System Agents - System Agents -
Drugs for Attention Drugs for Multiple
Deficit Disorder Sclerosis
ADDERALL E AMPYRA 3 SP
ADDERALL XR E AUBAGIO 3 SP
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 Drug Name Drug Tier Notes
AVONEX PEN 2 SP Central Nervous
AVONEX PREFILLED 2 SP System Agents -
Miscellaneous
BAFIERTAM 2 SP
ADDYI 3
BETASERON 2 SP
ADIPEX-P E
COPAXONE 2 SP
AUSTEDO 3 SP
EXTAVIA E SP
CONTRAVE E
GILENYA 3 3P; SP
GRALISE 3
glatiramer acetate 1 SP
HORIZANT 3
MAVENCLAD (10
3 3P; SP LYRICA E
TABS)
MAVENCLAD (4 phentermine hcl oral
3 3P; SP 1
TABS) tablet
MAVENCLAD (5 pregabalin oral capsule 1
3 3P; SP
TABS) QSYMIA 3
MAVENCLAD (6 SAXENDA 3
3 3P; SP
TABS) TEGSEDI 3 SP
MAVENCLAD (7 TIGLUTIK 3 SP
3 3P; SP
TABS)
VYLEESI 3
MAVENCLAD (8
3 3P; SP Dental and Oral
TABS)
Agents - Drugs for
MAVENCLAD (9 Mouth and Throat
3 3P; SP
TABS) Conditions
MAYZENT 3 3P; SP chlorhexidine gluconate
1
PLEGRIDY E SP mouth/throat
PLEGRIDY STARTER lidocaine viscous hcl 1
E SP
PACK Dermatological
REBIF E SP Agents - Drugs for
REBIF REBIDOSE E SP Skin Conditions
REBIF REBIDOSE ABSORICA 3
E SP
TITRATION PACK ABSORICA LD 3
REBIF TITRATION ACANYA E
E SP
PACK ACZONE EXTERNAL
E
TECFIDERA 2 SP GEL 5 %
VUMERITY 2 SP ACZONE EXTERNAL
2
VUMERITY GEL 7.5 %
2 SP
(STARTER) AKLIEF E
ALA SCALP E
AMZEEQ 3
APEXICON E 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 Drug Name Drug Tier Notes
AVITA E DIFFERIN EXTERNAL
E
BENZACLIN E CREAM
BENZACLIN WITH DIFFERIN EXTERNAL
E E
PUMP GEL 0.3 %
BENZAMYCIN E DIFFERIN EXTERNAL
E
LOTION
betamethasone
dipropionate external 1 DUOBRII E
cream DUPIXENT
BRYHALI 3 SUBCUTANEOUS
2 SP
SOLUTION
CALCIPOTRIENE PREFILLED SYRINGE
E M
EXTERNAL FOAM
ELIDEL E
CAPEX E
ENSTILAR 3
claravis 1
EPIDUO E
CLINDAGEL E
EPIDUO FORTE 3
clindamycin phosphate-
benzoyl peroxide 1 EUCRISA 2
external gel 1-5 % FINACEA 3
clindamycin phosphate fluocinonide external
1 1
external lotion cream
clindamycin phosphate FLUOROPLEX 3
1
external solution HALOBETASOL
clindamycin phosphate PROPIONATE E M
1
external swab EXTERNAL FOAM
CLINDAMYCIN HALOG EXTERNAL
E
PHOSPHATE GEL 1 % E M CREAM
EXTERNAL HALOG EXTERNAL
E
clindamycin phosphate OINTMENT
1
gel 1 % external hydrocortisone external
1
clobetasol propionate cream
1
external cream hydrocortisone external
1
clobetasol propionate ointment
1
external ointment IMIQUIMOD PUMP
clobetasol propionate CREAM 3.75 % E
1
external solution EXTERNAL
CLOBEX E IMIQUIMOD PUMP
CLOBEX SPRAY E CREAM 3.75 % E M
EXTERNAL
CLODERM E
IMPOYZ E
CORDRAN
E KENALOG EXTERNAL E
EXTERNAL TAPE
DESONATE E LEXETTE E
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 Drug Name Drug Tier Notes
METROGEL E tretinoin external cream 1
metronidazole external triamcinolone acetonide
1 1
cream external cream
metronidazole external triamcinolone acetonide
1 1
gel external ointment
MIRVASO 3 TRIANEX E
mometasone furoate ULTRAVATE E
1
external cream VECTICAL E
NORITATE E VELTIN E
ONEXTON 3 VERDESO E
ORACEA E ZIANA E
PANDEL E ZYCLARA E
PROPECIA E ZYCLARA PUMP E
PSORCON E Diabetes -
QBREXZA 3 Antidiabetic Agents
RETIN-A E ADLYXIN E
RETIN-A MICRO GEL ADLYXIN STARTER
E E
0.04 %, 0.1 % PACK
RETIN-A MICRO ALOGLIPTIN
E M
PUMP EXTERNAL E BENZOATE
GEL 0.04 %, 0.1 % ALOGLIPTIN-
E M
RETIN-A MICRO METFORMIN HCL
PUMP EXTERNAL 2 ALOGLIPTIN-
GEL 0.06 %, 0.08 % E M
PIOGLITAZONE
RHOFADE 3 BYDUREON 2
SERNIVO 3 BYDUREON BCISE
2
SOOLANTRA 3 AUTOINJECTOR
SORILUX E BYETTA 10 MCG PEN 2
TACLONEX BYETTA 5 MCG PEN 2
EXTERNAL E FARXIGA 2
OINTMENT
FORTAMET E
TACLONEX
EXTERNAL 3 glimepiride 1
SUSPENSION glipizide er 1
tacrolimus external glipizide ir 1
1
ointment GLUMETZA E
TAZORAC EXTERNAL glyburide oral 1
E
CREAM 0.1 %
GLYXAMBI 2
TOPICORT SPRAY E
INVOKAMET E
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 Drug Name Drug Tier Notes
INVOKAMET XR E Diabetes - Glucose
INVOKANA E Monitoring
JANUMET 2 ACCU-CHEK
FASTCLIX LANCET 2
JANUMET XR 2 KIT
JANUVIA 2 ACCU-CHEK GUIDE
E
JARDIANCE 2 TEST STRIPS
JENTADUETO 2 ACCU-CHEK GUIDE
E
JENTADUETO XR 2 KIT W/DEVICE
KAZANO E ACCU-CHEK
SOFTCLIX LANCET 2
KOMBIGLYZE XR E DEVICE KIT
metformin hcl er 1 CONTOUR MONITOR 2
metformin hcl er (mod) E CONTOUR CONTROL 2
metformin hcl er (osm) E CONTOUR NEXT
2
metformin hcl oral CONTROL
1
tablet CONTOUR NEXT
2
NESINA E MONITOR
ONGLYZA E CONTOUR NEXT
2
OSENI E TEST
OZEMPIC 2 CONTOUR TEST 2
pioglitazone hcl 1 DEXCOM G4 / G5 / G6
RECEIVER,
QTERN E TRANSMITTER,
RYBELSUS 2 SENSOR (INCLUDING 2
SEGLUROMET E PLATINUM,
PLATINUM
SOLIQUA 2 PEDIATRIC)
STEGLATRO E DEXCOM G4 / G5 / G6
STEGLUJAN E RECEIVER,
SYMLINPEN 120 3 TRANSMITTER,
SENSOR (INCLUDING 2
SYMLINPEN 60 3 PLATINUM,
SYNJARDY 2 PLATINUM
SYNJARDY XR 2 PEDIATRIC) DEVICE
TRADJENTA 2 FREESTYLE LIBRE 14
E
DAY READER
TRIJARDY XR 2
FREESTYLE LIBRE 14
TRULICITY 2 E
DAY SENSOR
VICTOZA 2 FREESTYLE LIBRE 2
E
XIGDUO XR 2 READER SYSTM
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 Drug Name Drug Tier Notes
FREESTYLE LIBRE 2 HUMALOG KWIKPEN 2
E
SENSOR SYSTM HUMALOG MIX 50/50
2
FREESTYLE LIBRE KWIKPEN
E
READER HUMALOG MIX 50/50
2
FREESTYLE LIBRE VIAL
E
SENSOR SYSTEM HUMALOG MIX 75/25
2
ONETOUCH ULTRA E KWIKPEN
ONETOUCH VERIO HUMALOG MIX 75/25
E 2
TEST STRIPS VIAL
V-GO 20 2 HUMALOG U-100
2
V-GO 30 2 JUNIOR KWIKPEN
V-GO 40 2 HUMALOG VIAL 2
Diabetes - Glycemic HUMULIN 70/30
2
Agents 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
2
GLUCAGON Made by KWIKPEN
2
EMERGENCY KIT Fresenius HUMULIN R U-500
2
GVOKE PFS 2 VIAL
Diabetes - Insulins HUMULIN R VIAL 2
ADMELOG E INSULIN ASP PROT &
E M
ASP FLEXPEN
ADMELOG
E INSULIN ASPART E M
SOLOSTAR
APIDRA SOLOSTAR E INSULIN ASPART
E M
FLEXPEN
APIDRA VIAL E
INSULIN ASPART
BASAGLAR KWIKPEN E E M
PENFILL
BD AUTOSHIELD DUO INSULIN ASPART
2 E M
PEN NEEDLES PROT & ASPART
BD ULTRA-FINE INSULIN LISPRO E M
2
INSULIN SYRINGES
INSULIN LISPRO (1
BD ULTRA-FINE PEN E M
2 UNIT DIAL)
NEEDLES
INSULIN LISPRO
BD VEO INSULIN SYR E M
2 JUNIOR KWIKPEN
U/F 1/2UNIT
INSULIN LISPRO
FIASP E E M
PROT & LISPRO
FIASP FLEXTOUCH E LANTUS SOLOSTAR 2
FIASP PENFILL E 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.
22Drug Name Drug Tier Notes Drug Name Drug Tier Notes
LEVEMIR U-100 TRESIBA E
E
FLEXTOUCH TRESIBA
E
LEVEMIR U-100 VIAL E FLEXTOUCH
NOVOFINE Electrolytes / Minerals
AUTOCOVER PEN 2 / Metals / Vitamins
NEEDLE AZESCO E
NOVOFINE PEN CARNITOR ORAL E
2
NEEDLE
CARNITOR SF E
NOVOFINE PLUS PEN
2 cyanocobalamin
NEEDLE
injection solution 1000 1
NOVOLIN 70/30 mcg/ml
E
FLEXPEN
ergocalciferol oral
NOVOLIN 70/30 1
E capsule
FLEXPEN RELION
folic acid oral tablet 1
NOVOLIN 70/30
E klor-con m20 1
RELION
NOVOLIN 70/30 VIAL E K-TAB E
NOVOLIN N FLEXPEN E LOKELMA 3
NOVOLIN N FLEXPEN multivitamin/fluoride
E oral tablet chewable 1
RELION
0.25 mg, 0.5 mg, 1 mg
NOVOLIN N RELION E
NASCOBAL 3
NOVOLIN N VIAL E
potassium chloride crys
NOVOLIN R FLEXPEN E 1
er
NOVOLIN R FLEXPEN potassium chloride er 1
E
RELION
potassium citrate er 1
NOVOLIN R RELION E
PREGENNA E
NOVOLIN R VIAL E
PRENATE DHA E
NOVOLOG FLEXPEN E
PRENATE ELITE E
NOVOLOG MIX 70/30
E PRENATE ENHANCE E
FLEXPEN
NOVOLOG MIX 70/30 PRENATE ESSENTIAL E
E
VIAL PRENATE MINI E
NOVOLOG PENFILL E PRENATE PIXIE E
NOVOLOG U-100 VIAL E PRENATE RESTORE E
NOVOTWIST PEN sodium fluoride oral
2 1
NEEDLE tablet chewable
TOUJEO MAX TRINAZ E
2
SOLOSTAR VELTASSA 3
TOUJEO SOLOSTAR 2 VITAFOL FE+ 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 Drug Name Drug Tier Notes
VITAFOL-OB+DHA E rabeprazole sodium
vitamin d oral tablet delayed 1
(ergocalciferol) oral release
1
capsule 1.25 mg sucralfate oral tablet 1
(50000 ut) ZEGERID E
VITATHELY WITH Gastrointestinal
E
GINGER Agents - Drugs for
ZALVIT E Bowel, Intestine and
Gastrointestinal Stomach Conditions
Agents - Drugs for AMITIZA E
Acid Reflux and Ulcer CLENPIQ 3
ACIPHEX E dicyclomine hcl oral
1
CARAFATE ORAL capsule
E
TABLET dicyclomine hcl oral
1
DEXILANT 2 tablet
esomeprazole diphenoxylate-atropine
1
magnesium oral oral tablet
1
capsule delayed gavilyte-g 1
release
glycopyrrolate oral
famotidine oral tablet 1 1
tablet 1 mg, 2 mg
lansoprazole oral GLYCOPYRROLATE
capsule delayed 1 3
ORAL TABLET 1.5 MG
release
GOLYTELY E
NEXIUM ORAL
CAPSULE DELAYED E hyoscyamine sulfate sl 1
RELEASE hyoscyamine sulfate
1
omeprazole oral sublingual
capsule delayed 1 lactulose oral solution 1
release LINZESS 2
omeprazole-sodium MOTEGRITY 3
E
bicarbonate
MOTOFEN E
pantoprazole sodium
oral tablet delayed 1 MOVANTIK E
release MOVIPREP E
PREVACID E NULYTELY WITH
E
PREVACID SOLUTAB E FLAVOR PACKS
PROTONIX ORAL OMECLAMOX-PAK 2
TABLET DELAYED E OSMOPREP E
RELEASE PLENVU E
RABEPRAZOLE PYLERA 2
SODIUM ORAL E M
CAPSULE SPRINKLE RELISTOR E
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 Drug Name Drug Tier Notes
SUPREP BOWEL RENAGEL E
3
PREP KIT sildenafil citrate oral
SYMPROIC 2 tablet 100 mg, 25 mg, 1
TRULANCE E 50 mg
VIBERZI 3 solifenacin succinate 1
ZELNORM 3 STAXYN E
Genetic or Enzyme STENDRA E
Disorder - Drugs for tadalafil oral 1
Replacement, tolterodine tartrate er 1
Modification,
Treatment TOVIAZ 3
CERDELGA 3 SP VELPHORO 3
CREON 2 VESICARE E
EXONDYS 51 E SP VIAGRA E
NITYR 3 SP Genitourinary Agents
- Drugs for Prostate
PANCREAZE E Conditions
PERTZYE E alfuzosin hcl er 1
STRENSIQ AVODART E
SUBCUTANEOUS
SOLUTION 28 2 SP dutasteride oral 1
MG/0.7ML, 40 MG/ML, finasteride oral tablet 5
1
80 MG/0.8ML mg
VIOKACE E FLOMAX E
VYONDYS 53 E SP tamsulosin hcl 1
ZENPEP 2 terazosin hcl oral
Genitourinary Agents capsule 1 mg, 10 mg, 5 1
- Drugs for Bladder, mg
Genital and Kidney Hormonal Agents -
Conditions Adrenal
AURYXIA 3 CORTEF E
CIALIS E dexamethasone oral
1
DEPEN TITRATABS 2 SP tablet
LEVITRA E hydrocortisone oral 1
MYRBETRIQ 2 KENALOG INJECTION
SUSPENSION 40 E
oxybutynin chloride er 1 MG/ML
oxybutynin chloride oral methylprednisolone
1 1
tablet oral
phenazopyridine hcl prednisolone oral
oral tablet 100 mg, 200 1 1
solution
mg
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 Drug Name Drug Tier Notes
prednisolone sodium Hormonal Agents -
1 Pituitary
phosphate oral solution
prednisone oral tablet 1 ACTHAR 2 SP
prednisone oral tablet cabergoline 1
1
therapy pack CETROTIDE E SP
RAYOS E FOLLISTIM AQ 2 SP
TAPERDEX 12-DAY 3 ganirelix acetate
TAPERDEX 6-DAY 3 solution prefilled
1 SP
TAPERDEX 7-DAY 3 syringe 250 mcg/0.5ml
subcutaneous
Hormonal Agents -
Men's Health ganirelix acetate
Made by
solution prefilled
ANDRODERM 2 1 Organon/Merc
syringe 250 mcg/0.5ml
k; SP
ANDROGEL E subcutaneous
ANDROGEL PUMP E GENOTROPIN E SP
AVEED E GENOTROPIN
E SP
DEPO- MINIQUICK
E
TESTOSTERONE GONAL-F E SP
FORTESTA E GONAL-F RFF E SP
JATENZO E GONAL-F RFF
E SP
NATESTO E REDIJECT
TESTIM E HUMATROPE E SP
TESTOPEL E LUPRON DEPOT (1-
MONTH)
testosterone cypionate 2 SP
1 INTRAMUSCULAR KIT
intramuscular 7.5 MG
testosterone LUPRON DEPOT (3-
transdermal gel 1.62 %, MONTH)
10 mg/act (2%), 20.25 2 SP
INTRAMUSCULAR KIT
mg/1.25gm (1.62%), 22.5 MG
20.25 mg/act (1.62%), 1
25 mg/2.5gm (1%), LUPRON DEPOT (4-
40.5 mg/2.5gm MONTH)
2 SP
(1.62%), 50 mg/5gm INTRAMUSCULAR KIT
(1%) 30MG
VOGELXO E LUPRON DEPOT (6-
MONTH)
VOGELXO PUMP E 2 SP
INTRAMUSCULAR KIT
XYOSTED 3 45MG
Hormonal Agents - NOCDURNA 3
Osteoporosis NORDITROPIN
2 SP
OSPHENA 3 FLEXPRO
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 Drug Name Drug Tier Notes
NUTROPIN AQ ENDOMETRIN 2
2 SP
NUSPIN 10 enskyce 1
NUTROPIN AQ estarylla 1
2 SP
NUSPIN 20
ESTRACE E
NUTROPIN AQ
2 SP estradiol oral 1
NUSPIN 5
OMNITROPE E SP estradiol transdermal 1
ORILISSA 2 estradiol vaginal 1
SAIZEN E SP ESTROGEL 3
SAIZENPREP E SP etonogestrel-ethinyl
1
estradiol
SANDOSTATIN E SP
EVAMIST 3
ZOMACTON E SP
femynor 1
ZOMACTON (FOR
E SP GENERESS FE E
ZOMA-JET 10)
Hormonal Agents - gianvi 1
Sex Hormones and IMVEXXY
Birth Control 3
MAINTENANCE PACK
ANNOVERA E IMVEXXY STARTER
3
apri 1 PACK
aviane 1 isibloom 1
BEYAZ E junel 1.5/30 1
BIJUVA 3 junel 1/20 1
blisovi 24 fe 1 junel fe 1.5/30 1
blisovi fe 1.5/30 1 junel fe 1/20 1
blisovi fe 1/20 1 junel fe 24 1
CLIMARA E kariva 1
CLIMARA PRO 2 kurvelo 1
cryselle-28 1 larin fe 1/20 1
DELESTROGEN larissia 1
INTRAMUSCULAR OIL E lessina 1
20 MG/ML, 40 MG/ML levonorgest-eth est &
1
DIVIGEL 3 eth est
dotti 1 levonorgest-eth estrad
drospirenone-ethinyl 91-day oral tablet 0.15-
1 1
estradiol 0.03 &0.01 mg, 0.15-
0.03 mg
DUAVEE 2
ELESTRIN 3
eluryng 1
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 Drug Name Drug Tier Notes
levonorgestrel-ethinyl PROMETRIUM E
estrad oral tablet 0.1-20 SAFYRAL E
1
mg-mcg, 0.15-30 mg-
mcg SEASONIQUE E
LO LOESTRIN FE E SLYND E
LOESTRIN 1.5/30 (21) E sprintec 28 1
LOESTRIN 1/20 (21) E sronyx 1
LOESTRIN FE 1.5/30 E syeda 1
LOESTRIN FE 1/20 E TAYTULLA 3
low-ogestrel 1 tri femynor 1
MAKENA 2 SP tri-lo-marzia 1
medroxyprogesterone tri-lo-sprintec 1
1
acetate intramuscular tri-previfem 1
medroxyprogesterone tri-sprintec 1
1
acetate oral VAGIFEM E
microgestin fe 1/20 1 vienva 1
MINASTRIN 24 FE E viorele 1
MIRENA (52 MG) 3 VIVELLE-DOT E
mono-linyah 1 xulane 1
NATAZIA 2 YASMIN 28 E
nikki 1 YAZ E
norethindrone acetate Hormonal Agents -
1
oral Thyroid
norethindrone acet- ARMOUR THYROID 3
1
ethinyl est
CYTOMEL E
norethindrone oral 1
euthyrox 1
norgestimate-ethinyl
1 levothyroxine sodium
estradiol triphasic 1
oral
nortrel 1/35 (21) 1
levoxyl 1
nortrel 1/35 (28) 1
liothyronine sodium oral 1
NUVARING 3
methimazole oral 1
ORTHO MICRONOR E
NATURE-THROID
PREMARIN ORAL 2 ORAL TABLET 113.75
PREMARIN VAGINAL 2 MG, 130 MG, 146.25
PREMPHASE 2 MG, 16.25 MG, 195
3
MG, 260 MG, 32.5 MG,
PREMPRO 2 325 MG, 48.75 MG, 65
progesterone MG, 81.25 MG, 97.5
1
micronized oral MG
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 Drug Name Drug Tier Notes
np thyroid oral tablet 60 HUMIRA PEDIATRIC
1 2 SP
mg CROHNS START
SYNTHROID E HUMIRA PEN 2 SP
TIROSINT E HUMIRA PEN-
2 SP
TIROSINT-SOL E CD/UC/HS STARTER
Immunological HUMIRA PEN-
Agents - Drugs for PS/UV/ADOL HS 2 SP
Immune System START
Stimulation or INFLECTRA 2 SP
Suppression
leflunomide oral 1
ACTEMRA ACTPEN 3 3P; SP methotrexate oral 1
ACTEMRA methotrexate sodium
3 3P; SP 1
SUBCUTANEOUS oral
ASCENIV E SP mycophenolate mofetil
1 SP
azathioprine oral 1 oral capsule
CIMZIA 2 SP mycophenolate mofetil
1 SP
CIMZIA PREFILLED oral tablet
2 SP
KIT mycophenolate sodium 1 SP
CIMZIA STARTER KIT 2 SP OLUMIANT E SP
COSENTYX (300 MG ORENCIA CLICKJECT 3 3P; SP
E SP
DOSE) ORENCIA
COSENTYX 150 SUBCUTANEOUS
E SP
MG/ML SOLUTION 3 3P; SP
COSENTYX PREFILLED SYRINGE
SENSOREADY (300 E SP 125 MG/ML
MG) OTEZLA 2 SP
COSENTYX PANZYGA E SP
E SP
SENSOREADY PEN PROGRAF ORAL
3 SP
CUTAQUIG E SP CAPSULE
cyclosporine modified RASUVO 2
1 SP
oral capsule REMICADE E SP
ENBREL MINI 3 SP RENFLEXIS 2 SP
ENBREL RINVOQ 2 SP
SUBCUTANEOUS
3 SP RUCONEST 3 SP
SOLUTION
PREFILLED SYRINGE SIMPONI 2 SP
ENBREL SURECLICK 3 SP SIMPONI ARIA 2 SP
FIRAZYR 3 SP sirolimus oral tablet 1 SP
HAEGARDA 3 SP SKYRIZI (150 MG
2 SP
HUMIRA 2 SP DOSE)
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 Drug Name Drug Tier Notes
STELARA 2 SP Metabolic Bone
tacrolimus oral 1 SP Disease Agents -
Other
TAKHZYRO 3 SP
calcitriol oral capsule 1
TALTZ 3 3P; SP
SENSIPAR E
TREMFYA 2 SP
Miscellaneous
XELJANZ 2 SP Therapeutic Agents
XELJANZ XR 2 SP Non-Cosmetic;
BOTOX 2
XEMBIFY 3 SP SP
Inflammatory Bowel DUROLANE 2 SP
Disease Agents ENDARI 3
APRISO 2 EUFLEXXA 2 SP
ASACOL HD E FIRDAPSE E SP
CANASA E GEL-ONE E SP
DELZICOL E GELSYN-3 2 SP
DIPENTUM E GENVISC 850 E SP
LIALDA E HYALGAN E SP
mesalamine oral tablet HYMOVIS E SP
1
delayed release
MONOVISC E SP
PENTASA 3
ORTHOVISC E SP
PROCTOFOAM HC 2
OXBRYTA E SP
sulfasalazine oral tablet 1
PALFORZIA (12 MG
UCERIS ORAL E E SP
DAILY DOSE)
UCERIS RECTAL 3 PALFORZIA (120 MG
E SP
Metabolic Bone DAILY DOSE)
Disease Agents - PALFORZIA (160 MG
Drugs for E SP
DAILY DOSE)
Osteoporosis
PALFORZIA (20 MG
alendronate sodium E SP
1 DAILY DOSE)
oral tablet
PALFORZIA (200 MG
BINOSTO 3 E SP
DAILY DOSE)
FORTEO 2 SP PALFORZIA (240 MG
E SP
ibandronate sodium DAILY DOSE)
1
oral PALFORZIA (3 MG
E SP
PROLIA 2 SP DAILY DOSE)
RAYALDEE 3 PALFORZIA (300 MG
E SP
TYMLOS 2 SP MAINTENANCE)
PALFORZIA (300 MG
E SP
TITRATION)
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 Drug Name Drug Tier Notes
PALFORZIA (40 MG LOTEMAX SM 3
E SP
DAILY DOSE) MOXEZA 2
PALFORZIA (6 MG MOXIFLOXACIN HCL
E SP
DAILY DOSE) INTRAOCULAR 3
PALFORZIA (80 MG SOLUTION
E SP
DAILY DOSE) moxifloxacin hcl
1
PALFORZIA INITIAL ophthalmic
E SP
ESCALATION NEVANAC E
SODIUM ofloxacin ophthalmic 1
HYALURONATE E SP
INTRA-ARTICULAR olopatadine hcl
1
ophthalmic
SUPARTZ FX E SP
PATADAY
SYNVISC E SP OPHTHALMIC 3
SYNVISC ONE E SP SOLUTION 0.2 %
TRILURON E SP PAZEO E
TRIVISC E SP PRED FORTE E
VISCO-3 E SP prednisolone acetate
1
Ophthalmic Agents - ophthalmic
Drugs for Eye Allergy, PROLENSA 2
Infection and VIGAMOX E
Inflammation
Ophthalmic Agents -
AZASITE 3 Drugs for Glaucoma
BESIVANCE 3 ALPHAGAN P
BROMSITE E OPHTHALMIC 2
ciprofloxacin hcl SOLUTION 0.1 %
1
ophthalmic ALPHAGAN P
erythromycin OPHTHALMIC E
1 SOLUTION 0.15 %
ophthalmic
ILEVRO E AZOPT 2
INVELTYS 3 BETIMOL 3
ketorolac tromethamine brimonidine tartrate
1 1
ophthalmic ophthalmic
LOTEMAX COMBIGAN 2
3
OPHTHALMIC GEL COSOPT E
LOTEMAX COSOPT PF E
OPHTHALMIC 3 dorzolamide hcl-timolol
OINTMENT 1
mal
LOTEMAX latanoprost ophthalmic 1
OPHTHALMIC E
SUSPENSION LUMIGAN 2
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 Drug Name Drug Tier Notes
RHOPRESSA 3 Respiratory Tract /
ROCKLATAN 3 Pulmonary Agents -
Drugs for Allergies,
SIMBRINZA 2 Cough, Cold
timolol maleate azelastine hcl nasal 1
1
ophthalmic solution
benzonatate 1
TIMOPTIC E
cetirizine hcl oral
TIMOPTIC OCUDOSE E 1
solution
TIMOPTIC-XE E CLARINEX E
VYZULTA E CLARINEX-D 12
E
XALATAN E HOUR
ZIOPTAN E cyproheptadine hcl oral
1
Ophthalmic Agents - tablet
Drugs for DYMISTA 2
Miscellaneous Eye FASENRA 2 SP
Conditions
FASENRA PEN 2 SP
BEOVU E SP
fluticasone propionate
CEQUA E 1
nasal
LATISSE E hydrocodone polst-
1
polymyxin b- chlorphen polst er susp
1
trimethoprim ipratropium bromide
1
RESTASIS 2 nasal
RESTASIS levocetirizine
2
MULTIDOSE dihydrochloride oral 1
TOBRADEX tablet
OPHTHALMIC E mometasone furoate
1
SUSPENSION nasal
tobramycin- NASONEX E
1
dexamethasone NUCALA 2 SP
XIIDRA 2 OMNARIS 3
Otic Agents - Drugs promethazine hcl oral
for Ear Conditions 1
tablet
CIPRODEX 2 promethazine-codeine 1
neomycin-polymyxin-hc promethazine-dm 1
1
otic suspension
pseudoephedrine-
ofloxacin otic 1 bromphen-dm oral 1
OTOVEL 3 syrup
QNASL 3
QNASL CHILDRENS 3
XHANCE 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 Drug Name Drug Tier Notes
XOLAIR 2 SP ATROVENT HFA 3
ZETONNA 3 AUVI-Q INJECTION
Respiratory Tract / SOLUTION AUTO-
Pulmonary Agents - INJECTOR 0.15 E
Drugs for Asthma and MG/0.15ML, 0.3
Other Lung MG/0.3ML
Conditions BEVESPI
E
ADVAIR DISKUS 2 AEROSPHERE
ADVAIR HFA 2 BREO ELLIPTA 2
AIRDUO RESPICLICK budesonide inhalation 1
E
113/14 BUDESONIDE-
AIRDUO RESPICLICK FORMOTEROL E M
E FUMARATE
232/14
AIRDUO RESPICLICK COMBIVENT
E 2
55/14 RESPIMAT
albuterol sulfate hfa DUAKLIR PRESSAIR E
aerosol solution 108 DULERA E
1
(90 base) mcg/act epinephrine injection
inhalation 1
solution auto-injector
ALBUTEROL EPIPEN 2-PAK 3
SULFATE HFA
AEROSOL SOLUTION EPIPEN JR 2-PAK E
E M
108 (90 BASE) FLOVENT DISKUS 2
MCG/ACT FLOVENT HFA 2
INHALATION
fluticasone-salmeterol
albuterol sulfate inhalation aerosol
1
inhalation powder breath
ALVESCO E activated 100-50 1
ANORO ELLIPTA 2 mcg/dose, 250-50
mcg/dose, 500-50
ARNUITY ELLIPTA 2 mcg/dose
ASMANEX (120 INCRUSE ELLIPTA E
E
METERED DOSES)
ipratropium-albuterol 1
ASMANEX (14
E LEVALBUTEROL HFA
METERED DOSES)
INHALATION
ASMANEX (30 E M
E AEROSOL 45
METERED DOSES) MCG/ACT
ASMANEX (60 LONHALA MAGNAIR
E 3
METERED DOSES) REFILL KIT
ASMANEX (7 LONHALA MAGNAIR
E 3
METERED DOSES) STARTER KIT
ASMANEX HFA 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 Drug Name Drug Tier Notes
montelukast sodium PULMOZYME 2 SP
1
oral tablet TOBI NEBULIZER E SP
montelukast sodium TOBI PODHALER 3 SP
1
oral tablet chewable
tobramycin nebulization
PERFOROMIST 3 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 TRIKAFTA 3 SP
2
FLEXHALER
Respiratory Tract /
PULMICORT Pulmonary Agents -
E
SUSPENSION Drugs for Pulmonary
QVAR REDIHALER E Hypertension
SEEBRI NEOHALER E ADCIRCA E SP
SEREVENT DISKUS 2 ADEMPAS 2 SP
SINGULAIR E LETAIRIS E SP
SPIRIVA OPSUMIT 2 SP
2
HANDIHALER ORENITRAM 3 SP
SPIRIVA RESPIMAT 2 REMODULIN E SP
STIOLTO RESPIMAT 2 sildenafil citrate oral
1 SP
STRIVERDI tablet 20 mg
2
RESPIMAT TRACLEER 62.5 MG,
E SP
SYMBICORT 2 125 MG
SYMJEPI 3 Skeletal Muscle
Relaxants - Drugs for
TRELEGY ELLIPTA 2
Muscle Pain and
TUDORZA PRESSAIR E Spasm
UTIBRON NEOHALER E AMRIX E
VENTOLIN HFA E baclofen oral 1
wixela inhub 1 carisoprodol oral 1
XOPENEX HFA E cyclobenzaprine hcl
1
YUPELRI 3 oral
Respiratory Tract / LORZONE 3
Pulmonary Agents - metaxalone 1
Drugs for Cystic
Fibrosis methocarbamol oral 1
BETHKIS 2 SP NORGESIC FORTE E
KITABIS PAK E SP ORPHENGESIC
E
FORTE
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
OZOBAX E
SKELAXIN E
SOMA E
tizanidine hcl oral tablet 1
VANADOM E
ZANAFLEX E
Sleep Disorder
Agents
AMBIEN E
AMBIEN CR E
armodafinil 1
eszopiclone 1
LUNESTA E
modafinil 1
NUVIGIL E
PROVIGIL E
RESTORIL E
SILENOR 3
SUNOSI 2
temazepam 1
WAKIX 3 SP
XYREM 3 SP
zolpidem tartrate er 1
zolpidem tartrate oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
35Index of Drugs
ABILIFY.....................................13 ALOGLIPTIN-PIOGLITAZONE. 20 ASMANEX (14 METERED
ABSORICA............................... 18 ALPHAGAN P........................... 31 DOSES).................................... 33
ABSORICA LD..........................18 alprazolam................................ 14 ASMANEX (30 METERED
ACANYA................................... 18 ALTACE.................................... 15 DOSES).................................... 33
ACCU-CHEK FASTCLIX ALVESCO................................. 33 ASMANEX (60 METERED
LANCET KIT............................. 21 AMBIEN.................................... 35 DOSES).................................... 33
ACCU-CHEK GUIDE KIT AMBIEN CR.............................. 35 ASMANEX (7 METERED
W/DEVICE................................ 21 amiodarone hcl......................... 15 DOSES).................................... 33
ACCU-CHEK SOFTCLIX AMITIZA....................................24 ASMANEX HFA........................ 33
LANCET DEVICE KIT...............21 amitriptyline hcl......................... 10 ASPIRIN-OMEPRAZOLE......... 13
acetaminophen-codeine..............7 amlodipine besylate.................. 15 ATACAND.................................15
acetaminophen-codeine #2.........7 amlodipine besylate-benazepril atenolol..................................... 15
acetaminophen-codeine #3.........7 hcl............................................. 15 atenolol-chlorthalidone..............15
acetaminophen-codeine #4.........7 amlodipine besylate-valsartan.. 15 ATIVAN..................................... 14
ACIPHEX.................................. 24 amlodipine-olmesartan..............15 atomoxetine hcl.........................17
ACTEMRA................................ 29 amoxicillin................................... 8 atorvastatin calcium.................. 15
ACTEMRA ACTPEN.................29 amoxicillin-potassium ATRIPLA................................... 13
ACTHAR................................... 26 clavulanate..................................8 ATROVENT HFA...................... 33
ACTICLATE................................ 8 amphetamine- AUBAGIO..................................17
acyclovir.................................... 13 dextroamphetamine.................. 17 AURYXIA.................................. 25
ACZONE................................... 18 amphetamine- AUSTEDO.................................18
ADCIRCA..................................34 dextroamphetamine er.............. 17 AUVI-Q......................................33
ADDERALL............................... 17 AMPYRA...................................17 AVAPRO................................... 15
ADDERALL XR......................... 17 AMRIX.......................................34 AVEED......................................26
ADDYI....................................... 18 AMZEEQ...................................18 aviane....................................... 27
ADEMPAS................................ 34 anastrozole............................... 12 AVITA........................................19
ADHANSIA XR..........................17 ANDRODERM.......................... 26 AVODART.................................25
ADIPEX-P................................. 18 ANDROGEL..............................26 AVONEX PEN...........................18
ADLYXIN...................................20 ANDROGEL PUMP.................. 26 AVONEX PREFILLED.............. 18
ADLYXIN STARTER PACK...... 20 ANNOVERA..............................27 AZASITE................................... 31
ADMELOG................................ 22 ANORO ELLIPTA..................... 33 azathioprine.............................. 29
ADMELOG SOLOSTAR........... 22 APADAZ......................................7 azelastine hcl............................ 32
ADVAIR DISKUS...................... 33 apap-caff-dihydrocodeine........... 7 AZESCO................................... 23
ADVAIR HFA............................ 33 APEXICON E............................ 18 azithromycin................................8
ADYNOVATE............................14 APIDRA SOLOSTAR................ 22 AZOPT...................................... 31
AFINITOR................................. 12 APIDRA VIAL............................22 AZOR........................................ 15
AFSTYLA.................................. 14 apri............................................ 27 baclofen.................................... 34
AIMOVIG...................................12 APRISO.................................... 30 BAFIERTAM............................. 18
AIRDUO RESPICLICK 113/14..33 ARAKODA................................ 13 BAQSIMI ONE PACK............... 22
AIRDUO RESPICLICK 232/14..33 ARANESP (ALBUMIN FREE)... 14 BAQSIMI TWO PACK...............22
AIRDUO RESPICLICK 55/14....33 ARIMIDEX.................................12 BARACLUDE............................ 13
AJOVY...................................... 12 aripiprazole............................... 13 BASAGLAR KWIKPEN............. 22
AKLIEF......................................18 ARISTADA................................ 13 BD AUTOSHIELD DUO PEN
ALA SCALP.............................. 18 ARISTADA INITIO.................... 13 NEEDLES................................. 22
albuterol sulfate.........................33 armodafinil................................ 35 BD ULTRA-FINE INSULIN
albuterol sulfate hfa...................33 ARMOUR THYROID.................28 SYRINGES............................... 22
ALBUTEROL SULFATE HFA... 33 ARNUITY ELLIPTA...................33 BD ULTRA-FINE PEN
alendronate sodium.................. 30 ARTHROTEC..............................7 NEEDLES................................. 22
alfuzosin hcl er.......................... 25 ARYMO ER.................................7 BD VEO INSULIN SYR U/F
allopurinol..................................11 ASACOL HD............................. 30 1/2UNIT.....................................22
ALOGLIPTIN BENZOATE........ 20 ASCENIV.................................. 29 BELBUCA................................... 7
ALOGLIPTIN-METFORMIN ASMANEX (120 METERED BELRAPZO...............................12
HCL...........................................20 DOSES).................................... 33 benazepril hcl............................15
36You can also read
