Your 2021 Select Standard Formulary - Effective July 1, 2021
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Your 2021 Select Standard Formulary
Effective July 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 or log on to the OptumRx app to:
• Find a participating retail pharmacy by ZIP code
• Look up possible lower-cost medication alternatives
• Compare medication pricing and optionsUnderstanding your formulary
What is a formulary?
About this formulary
A formulary is a list of prescribed medications or other
When differences between this formulary and your
pharmacy care products, services or supplies chosen for
benefit plan exist, the benefit plan documents rule. This
their safety, cost, and effectiveness. Medications are
formulary may not be a complete list of medications that
listed by categories or classes and are placed into cost
are covered by your plan. Please review your benefit plan
levels known as tiers. It includes both brand and generic
for full details.
prescription medications.
To create the list, OptumRx® is guided by the Pharmacy and When does the formulary change?
Therapeutics Committee. This group of doctors, nurses, and
pharmacists reviews which medications will be covered, how • Medications may move to a lower tier at any time.
well the drugs work, and overall value. They also make sure • Medications may move to a higher tier when a generic
there are safe and covered options. equal becomes available.
• Medications may move to a higher tier or be excluded from
How do I use my formulary? coverage on January 1 or July 1 of each year.
You and your doctor can use the formulary to help you If a medication changes tiers, you may have to pay a different
choose the most cost-effective prescription medications. amount for that medication.
This guide tells you if a medication is generic or brand, and
if special rules apply. If your medication is not listed here, Why are some medications excluded
please visit your plan’s website or call the number on your from coverage?
member ID card. A medication may be excluded from coverage under your
pharmacy benefit when it works the same as or is similar to
What are tiers? another prescription or over-the-counter (OTC) medication.
Tiers are the different cost levels you pay for a medication.
Each tier is assigned a cost, set by your employer or What if I don’t agree with a decision about an
plan sponsor. excluded medication?
You, your authorized representative, or your doctor can
ask for a coverage request by calling the number on your
member ID card.
Medication tips
What is the difference between brand-name and generic medications?
Generic medications contain the same active ingredients (offer the same effect) as brand-name medications, but they
often cost less. In some situations, brand-name medications could be lower in cost.
What if my doctor writes a brand-name prescription?
If your doctor gives you a prescription for a brand-name medication, ask if a Over-the-counter
lower-cost option could be right for you. medications (OTC)
What if I am taking a specialty medication? Talk to your doctor about OTC
options. Even though OTC
Specialty medications are used to treat complex conditions and are generally higher
medications may not be covered
in cost. Please note, not all specialty medications are listed in the formulary. Our
by your pharmacy benefit,
specialty pharmacy can provide most of your specialty medications along with
they may cost less than a
helpful programs and services. Call 1-855-427-4682 and ask how you can have
prescription medication.
your prescriptions delivered right to your home or doctor’s office.
2Reading 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 lower your 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 Use Tier 1 drugs for the lowest out-of-pocket costs.
generics and
some brand name
Tier 2 Mid-range cost
$$ Use Tier 2 drugs instead of Tier 3 to help reduce your
preferred brand out-of-pocket costs.
name
Tier 3 Higher-cost
$$$ Many Tier 3 drugs have lower-cost options in Tier 1 or 2.
brand name and Ask your doctor if they could work for you.
some generics
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.
PA Prior Authorization – Your doctor is required to give OptumRx more information to determine coverage.
QL Quantity Limit – Medication may be limited to a certain quantity.
SP Specialty Medication – Medication is designated as specialty.
ST Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered.
3P Tier 3 preferred
3Table of Contents
Analgesics - Drugs for Pain.................................................................................................................................6
Analgesics - Drugs for Pain and Inflammation.................................................................................................... 6
Anesthetics..........................................................................................................................................................6
Anti-Addiction / Substance Abuse Treatment Agents......................................................................................... 7
Antibacterials.......................................................................................................................................................7
Anticoagulants.....................................................................................................................................................8
Anticonvulsants - Drugs for Seizures.................................................................................................................. 8
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia................................................................ 8
Antidepressants...................................................................................................................................................8
Antiemetics - Drugs for Nausea and Vomiting.................................................................................................... 9
Antifungals...........................................................................................................................................................9
Antigout Agents................................................................................................................................................... 9
Antimigraine Agents............................................................................................................................................ 9
Antineoplastics - Drugs for Cancer......................................................................................................................9
Antiparasitics..................................................................................................................................................... 10
Antiparkinson Agents........................................................................................................................................ 10
Antiplatelets.......................................................................................................................................................10
Antipsychotics - Drugs for Mood Disorders....................................................................................................... 10
Antivirals............................................................................................................................................................11
Anxiolytics - Drugs for Anxiety...........................................................................................................................11
Bipolar Agents - Drugs for Mood Disorders.......................................................................................................11
Blood Products and Modifiers - Drugs for Blood Disorders...............................................................................11
Cardiovascular Agents - Drugs for Heart and Circulation Conditions............................................................... 12
Central Nervous System Agents - Drugs for Attention Deficit Disorder............................................................ 13
Central Nervous System Agents - Drugs for Multiple Sclerosis........................................................................ 14
Central Nervous System Agents - Miscellaneous............................................................................................. 14
Dental and Oral Agents - Drugs for Mouth and Throat Conditions....................................................................14
Dermatological Agents - Drugs for Skin Conditions.......................................................................................... 15
Diabetes - Antidiabetic Agents.......................................................................................................................... 16
Diabetes - Glucose Monitoring.......................................................................................................................... 16
Diabetes - Glycemic Agents.............................................................................................................................. 17
Diabetes - Insulins.............................................................................................................................................17
Electrolytes / Minerals / Metals / Vitamins.........................................................................................................18
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer................................................................................18
Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions.................................................19
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment............................................. 19
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.......................................................19
Genitourinary Agents - Drugs for Prostate Conditions...................................................................................... 20
Hormonal Agents - Adrenal............................................................................................................................... 20
Hormonal Agents - Men's Health.......................................................................................................................20
Hormonal Agents - Osteoporosis...................................................................................................................... 20
Hormonal Agents - Pituitary.............................................................................................................................. 20
Hormonal Agents - Sex Hormones and Birth Control........................................................................................21
Hormonal Agents - Thyroid............................................................................................................................... 22
Immunological Agents - Drugs for Immune System Stimulation or Suppression.............................................. 22
Inflammatory Bowel Disease Agents.................................................................................................................23
Metabolic Bone Disease Agents - Drugs for Osteoporosis............................................................................... 24
Metabolic Bone Disease Agents - Other........................................................................................................... 24
Miscellaneous Therapeutic Agents................................................................................................................... 24
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...........................................................24
Ophthalmic Agents - Drugs for Glaucoma.........................................................................................................24
4Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions......................................................................... 25
Otic Agents - Drugs for Ear Conditions............................................................................................................. 25
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold........................................................25
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions................................... 26
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis.................................................................... 27
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension.................................................... 27
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm...................................................................... 27
Sleep Disorder Agents...................................................................................................................................... 27
5Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Analgesics - Drugs oxycodone-
for Pain acetaminophen oral
acetaminophen- tablet 10-325 mg, 2.5- 1 QL
1 QL 325 mg, 5-325 mg, 7.5-
codeine #2
325 mg
acetaminophen-
1 QL OXYCONTIN 2 PA; QL
codeine #3
acetaminophen- tramadol hcl oral tablet
1 QL 1 QL
codeine #4 50 mg
acetaminophen- TREZIX 3 QL
codeine oral tablet 300- 1 QL XTAMPZA ER 2 PA; QL
15 mg, 300-60 mg Analgesics - Drugs
apap-caff- for Pain and
dihydrocodeine oral 1 QL Inflammation
capsule celecoxib oral 1 QL
BELBUCA 2 PA; QL diclofenac sodium
1 QL
butalbital-apap-caffeine 1 external gel 1 %
fentanyl 1 PA; QL diclofenac sodium oral 1
hydrocodone- etodolac oral tablet 1
acetaminophen oral 1 QL ibuprofen oral tablet 1
tablet
INDOMETHACIN
hydromorphone hcl oral ORAL CAPSULE 20 3 ST
1 QL
tablet MG
HYSINGLA ER 2 PA; QL indomethacin oral
1
morphine sulfate capsule 25 mg, 50 mg
(concentrate) oral ketorolac tromethamine
1 QL 1 QL
solution 100 mg/5ml, oral
20 mg/ml
meloxicam oral tablet 1
morphine sulfate er oral
1 PA; QL nabumetone oral 1
tablet extended release
morphine sulfate oral NAPRELAN 3
1 QL
solution naproxen oral tablet 1
NUCYNTA 3 QL naproxen sodium oral
1
oxycodone hcl oral tablet
1 QL
tablet Anesthetics
OXYCODONE- lidocaine external patch 1
ACETAMINOPHEN lidocaine-prilocaine
ORAL TABLET 10-300 3 QL 1
external cream
MG, 2.5-300 MG, 5-300
MG
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
6Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Anti-Addiction / clarithromycin oral
Substance Abuse 1
tablet
Treatment Agents clindamycin hcl oral 1
BUNAVAIL 3 QL CLINDESSE 3
buprenorphine hcl DIFICID ORAL
1 QL 3
sublingual TABLET
buprenorphine hcl- doxycycline hyclate oral
1 QL 1
naloxone hcl capsule
CHANTIX STARTING doxycycline hyclate oral
3 QL 1
MONTH PAK tablet
naltrexone hcl oral 1 doxycycline
NARCAN 2 monohydrate oral 1
ZUBSOLV 2 QL capsule
Antibacterials doxycycline
1
monohydrate oral tablet
amoxicillin oral capsule 1
levofloxacin oral tablet 1
amoxicillin oral
suspension 1 metronidazole oral
1
reconstituted tablet
amoxicillin oral tablet 1 metronidazole vaginal 1
amoxicillin-potassium minocycline hcl oral
1
clavulanate oral capsule
1
suspension mupirocin external 1
reconstituted nitrofurantoin
1
amoxicillin-potassium macrocrystal
1
clavulanate oral tablet nitrofurantoin
azithromycin oral monohydrate 1
suspension 1 macrocrystals
reconstituted NUZYRA ORAL 3
azithromycin oral tablet 1 penicillin v potassium
1
cefdinir 1 oral tablet
cefuroxime axetil 1 SEYSARA 3 ST
cephalexin oral capsule 1 SOLOSEC 3
cephalexin oral sulfamethoxazole-
1
suspension 1 trimethoprim oral tablet
reconstituted XENLETA 3
ciprofloxacin hcl oral XEPI 3
1
tablet 250 mg, 500 mg
XIMINO 3
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
Anticoagulants VIMPAT 3
ELIQUIS 2 QL XCOPRI 3 ST
ELIQUIS DVT/PE zonisamide oral 1
2 QL
STARTER PACK Antidementia Agents
enoxaparin sodium 1 SP; QL - Drugs for
PRADAXA 2 QL Alzheimer's Disease
and Dementia
warfarin sodium oral 1
donepezil hcl oral tablet
XARELTO 2 QL 1
10 mg, 23 mg
XARELTO STARTER memantine hcl oral
2 QL 1
PACK tablet 10 mg, 5 mg
Anticonvulsants - NAMZARIC 2 QL
Drugs for Seizures
Antidepressants
BRIVIACT
3 amitriptyline hcl oral 1
INTRAVENOUS
BRIVIACT ORAL 3 ST bupropion hcl er (sr) 1 QL
carbamazepine oral bupropion hcl er (xl)
1 oral tablet extended
tablet 1 QL
release 24 hour 150
divalproex sodium er 1 mg, 300 mg
divalproex sodium oral BUPROPION HCL ER
1
tablet delayed release (XL) ORAL TABLET
3 ST; QL
EPIDIOLEX 3 PA; SP EXTENDED RELEASE
FYCOMPA 3 24 HOUR 450 MG
gabapentin oral bupropion hcl oral 1
1
capsule citalopram
gabapentin oral tablet 1 hydrobromide oral 1
tablet
lamotrigine er 1
desvenlafaxine
lamotrigine oral tablet 1 1 QL
succinate er
levetiracetam oral doxepin hcl oral
1
tablet capsule 10 mg, 100
1
NAYZILAM 3 QL mg, 25 mg, 50 mg, 75
oxcarbazepine oral mg
1
tablet duloxetine hcl oral 1 QL
SYMPAZAN 3 PA escitalopram oxalate
1
topiramate oral tablet 1 oral tablet
TROKENDI XR 3 ST fluoxetine hcl oral
1
capsule
VALTOCO 3 QL
fluoxetine hcl 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
fluvoxamine maleate 1 fluconazole oral tablet 1
FORFIVO XL 3 ST; QL GYNAZOLE-1 3
mirtazapine oral tablet 1 KERYDIN 3 PA
nortriptyline hcl oral ketoconazole external
1 1
capsule cream
paroxetine hcl 1 ketoconazole external
1
sertraline hcl oral tablet 1 shampoo
trazodone hcl oral 1 nystatin external cream 1
TRINTELLIX 3 ST; QL nystatin mouth/throat 1
venlafaxine hcl 1 terbinafine hcl oral 1 QL
venlafaxine hcl er 1 terconazole vaginal
1
cream
VIIBRYD 3 QL
Antigout Agents
VIIBRYD STARTER
3 QL allopurinol oral 1
PACK
Antiemetics - Drugs colchicine oral tablet 1
for Nausea and febuxostat 1 ST
Vomiting Antimigraine Agents
meclizine hcl oral tablet 1 AIMOVIG
metoclopramide hcl SUBCUTANEOUS
1
oral tablet 10 mg SOLUTION AUTO- 2 PA; QL
ondansetron hcl oral INJECTOR 140
1 MG/ML, 70 MG/ML
tablet 4 mg, 8 mg
ondansetron odt 1 eletriptan hydrobromide 1 QL
prochlorperazine EMGALITY 2 PA; QL
1
maleate oral EMGALITY (300 MG
2 PA; QL
scopolamine 1 DOSE)
VARUBI (180 MG NURTEC 2 PA; QL
3 QL
DOSE) rizatriptan benzoate 1 QL
Antifungals sumatriptan succinate
1 QL
ciclopirox external oral
1
solution UBRELVY 2 PA; QL
clotrimazole external Antineoplastics -
1 Drugs for Cancer
cream
clotrimazole- ALECENSA 2 PA; SP
betamethasone 1 ALUNBRIG 2 PA; SP; QL
external cream
anastrozole oral 1
CRESEMBA ORAL 3
CABOMETYX 2 PA; SP
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
9Drug Name Drug Tier Notes Drug Name Drug Tier Notes
CALQUENCE 3 PA; SP Antiparasitics
capecitabine 1 PA; SP ARAKODA 3
IBRANCE ORAL EMVERM 2
3 PA; SP
TABLET hydroxychloroquine
1
IDHIFA 3 PA; SP; QL sulfate oral
KANJINTI 2 PA; SP Antiparkinson Agents
KEYTRUDA 3 PA; SP benztropine mesylate
1
letrozole oral 1 oral
LYNPARZA 2 PA; SP carbidopa-levodopa
1
oral tablet
MVASI 2 PA; SP
INBRIJA 3 PA; SP
NUBEQA 3 PA; SP
KYNMOBI 3 PA; SP; QL
PHESGO 2 PA; SP
KYNMOBI TITRATION
REVLIMID 2 PA; SP 3 PA; SP; QL
KIT
ROZLYTREK 3 PA; SP NOURIANZ 3 PA
RUBRACA 2 PA; SP ONGENTYS 3 ST
RUXIENCE 2 PA; SP pramipexole
1
SPRYCEL 2 PA; SP dihydrochloride
TAGRISSO ORAL ropinirole hcl 1
3 PA; SP; QL
TABLET 40 MG RYTARY 3 ST
TAGRISSO ORAL Antiplatelets
3 PA; SP
TABLET 80 MG
BRILINTA 2
tamoxifen citrate oral 1
clopidogrel bisulfate
TARGRETIN 1
3 PA; SP oral
EXTERNAL
prasugrel hcl 1
TRAZIMERA
INTRAVENOUS Antipsychotics -
SOLUTION 2 PA; SP Drugs for Mood
RECONSTITUTED 420 Disorders
MG ABILIFY MAINTENA 3
VELCADE 2 PA; SP aripiprazole oral tablet 1 QL
VITRAKVI 3 PA; SP ARISTADA 3
XTANDI ORAL ARISTADA INITIO 3
3 PA; SP
CAPSULE INVEGA SUSTENNA 3
ZEJULA 2 PA; SP INVEGA TRINZA 3
ZIRABEV 2 PA; SP LATUDA 3 QL
olanzapine oral tablet 1 QL
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
PERSERIS 3 XOFLUZA (40 MG
3 QL
quetiapine fumarate 1 QL DOSE)
quetiapine fumarate er 1 QL XOFLUZA (80 MG
3 QL
DOSE)
REXULTI 3 QL
Anxiolytics - Drugs
risperidone oral tablet 1 QL for Anxiety
VRAYLAR 3 ST; QL alprazolam oral tablet 1 QL
ziprasidone hcl 1 QL buspirone hcl oral 1
Antivirals clonazepam oral tablet 1 QL
acyclovir oral tablet 1 diazepam oral tablet 1
BIKTARVY 3 hydroxyzine hcl oral
1
CIMDUO 2 tablet
DESCOVY 3 PA hydroxyzine pamoate
1
DOVATO 2 oral
entecavir 1 SP; QL lorazepam oral tablet 1 QL
EPCLUSA 2 PA; SP; QL triazolam 1 QL
Bipolar Agents -
GENVOYA 3
Drugs for Mood
HARVONI 2 PA; SP; QL Disorders
JULUCA 2 lithium carbonate er 1
MAVYRET 2 PA; SP; QL lithium carbonate oral
1
ODEFSEY 3 capsule
PREZCOBIX 2 Blood Products and
Modifiers - Drugs for
RUKOBIA 3
Blood Disorders
SYMFI 2
ADVATE 2 SP
SYMFI LO 2
ADYNOVATE 3 SP
TIVICAY 2
AFSTYLA
TRIUMEQ 2 INTRAVENOUS KIT
TRUVADA ORAL 1000 UNIT, 2000 UNIT, 3 SP
TABLET 100-150 MG, 250 UNIT, 3000 UNIT,
3
133-200 MG, 167-250 500 UNIT
MG ARANESP (ALBUMIN
2 PA; SP
TRUVADA ORAL FREE)
3 PA
TABLET 200-300 MG ELOCTATE 3 SP
valacyclovir hcl oral 1 QL JIVI 3 SP
VEMLIDY 3 SP KOATE 2 SP
VOSEVI 2 PA; SP; QL MULPLETA 2 PA; SP
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
11Drug Name Drug Tier Notes Drug Name Drug Tier Notes
NEULASTA 3 PA; SP bumetanide oral 1
NEULASTA ONPRO 3 PA; SP BYSTOLIC 2
NIVESTYM 2 PA; SP candesartan cilexetil 1
NOVOEIGHT 2 SP cartia xt 1
NPLATE 3 PA; SP carvedilol 1
NUWIQ 2 SP chlorthalidone 1
RECOMBINATE 2 SP clonidine hcl oral 1
RETACRIT 2 PA; SP CORLANOR 3 PA; QL
SOLIRIS 3 PA; SP digoxin oral tablet 1
ULTOMIRIS 3 PA; SP diltiazem hcl er coated
WILATE 2 SP beads oral capsule
1
extended release 24
XYNTHA 2 SP hour
XYNTHA SOLOFUSE 2 SP doxazosin mesylate
1
ZARXIO 2 PA; SP oral
ZIEXTENZO 3 PA; SP EDARBI 3 ST
Cardiovascular EDARBYCLOR 3 ST
Agents - Drugs for enalapril maleate oral 1
Heart and Circulation
Conditions ENTRESTO 2 QL
amiodarone hcl oral 1 ezetimibe 1
amlodipine besylate ezetimibe-simvastatin 1
1
oral fenofibrate micronized
amlodipine besylate- oral capsule 134 mg, 1
1 200 mg, 67 mg
benazepril hcl
amlodipine besylate- fenofibrate oral tablet 1
1
valsartan fenofibric acid oral
amlodipine-olmesartan 1 capsule delayed 1
release
ANTARA 3
flecainide acetate 1
atenolol oral 1
furosemide oral tablet 1
atenolol-chlorthalidone 1
gemfibrozil oral 1
atorvastatin calcium
1 guanfacine hcl 1
oral
benazepril hcl oral 1 HEMANGEOL 3
bisoprolol fumarate oral 1 hydralazine hcl oral 1
bisoprolol- hydrochlorothiazide
1 1
hydrochlorothiazide oral
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
irbesartan 1 propranolol hcl oral
1
irbesartan- tablet
1
hydrochlorothiazide ramipril 1
isosorbide mononitrate ranolazine er 1
1
er REPATHA 2 PA; QL
labetalol hcl oral 1 REPATHA
lisinopril oral 1 PUSHTRONEX 2 PA; QL
lisinopril- SYSTEM
1
hydrochlorothiazide REPATHA
2 PA; QL
LIVALO 3 ST SURECLICK
losartan potassium oral 1 rosuvastatin calcium 1
losartan potassium-hctz 1 simvastatin oral 1
lovastatin oral 1 sotalol hcl oral 1
metoprolol succinate er 1 spironolactone oral 1
metoprolol tartrate oral 1 TEKTURNA 2
MULTAQ 3 TEKTURNA HCT 2 ST
nadolol oral 1 telmisartan 1
NEXLETOL 2 PA; QL telmisartan-hctz 1
NEXLIZET 2 PA; QL torsemide 1
nifedipine er 1 triamterene-hctz 1
nifedipine er osmotic valsartan 1
1
release valsartan-
1
nitroglycerin sublingual 1 hydrochlorothiazide
olmesartan medoxomil VASCEPA 2 PA
1
oral verapamil hcl er oral
1
olmesartan medoxomil- tablet extended release
1
hctz Central Nervous
olmesartan-amlodipine- System Agents -
1 Drugs for Attention
hctz
Deficit Disorder
omega-3-acid ethyl
1 PA ADDERALL XR 3 PA; ST; QL
esters
PRALUENT 2 PA; QL amphetamine-
1 PA; QL
dextroamphetamine
pravastatin sodium 1
amphetamine-
prazosin hcl oral 1 1 PA; QL
dextroamphetamine er
propranolol hcl er 1 atomoxetine hcl 1 QL
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
dexmethylphenidate hcl REBIF TITRATION
1 PA; QL 3 PA; SP; QL
er PACK
dexmethylphenidate hcl TECFIDERA ORAL
1 PA; QL
oral tablet 10 mg, 5 mg CAPSULE DELAYED 3 PA; SP; QL
guanfacine hcl er 1 RELEASE
JORNAY PM 3 PA; ST; QL VUMERITY 2 PA; SP; QL
methylphenidate hcl er ZEPOSIA 3 PA; SP; QL
(la) oral capsule ZEPOSIA 7-DAY
3 PA; SP; QL
extended release 24 1 PA; QL STARTER PACK
hour 10 mg, 20 mg, 30 ZEPOSIA STARTER
mg, 40 mg 3 PA; SP; QL
KIT
methylphenidate hcl er Central Nervous
1 PA; QL
(xr) System Agents -
methylphenidate hcl er Miscellaneous
oral tablet extended 1 PA; QL ADDYI 3 PA; QL
release
AUSTEDO 3 PA; SP; QL
methylphenidate hcl
1 PA; QL GRALISE ORAL
oral tablet 3 ST; QL
TABLET
VYVANSE 2 PA; QL
HORIZANT 3 PA; QL
Central Nervous
System Agents - INGREZZA 3 PA; SP; QL
Drugs for Multiple phentermine hcl oral
Sclerosis 1 PA
tablet
AMPYRA 3 PA; SP; QL pregabalin oral capsule 1 QL
AUBAGIO 3 PA; SP; QL QSYMIA 3 PA
AVONEX PEN 2 PA; SP; QL SAXENDA 3 PA
AVONEX PREFILLED 2 PA; SP; QL TEGSEDI 3 PA; SP
BAFIERTAM 2 PA; SP; QL TIGLUTIK 3 PA; SP; QL
BETASERON 2 PA; SP; QL VYLEESI 3 PA; QL
COPAXONE 2 PA; SP; QL Dental and Oral
GILENYA 3 PA; SP; QL Agents - Drugs for
Mouth and Throat
KESIMPTA 2 PA; SP; QL Conditions
MAVENCLAD 3 PA; SP chlorhexidine gluconate
1
MAYZENT 3 PA; SP; QL mouth/throat
REBIF 3 PA; SP; QL lidocaine viscous hcl 1
REBIF REBIDOSE 3 PA; SP; QL
REBIF REBIDOSE
3 PA; SP; QL
TITRATION PACK
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
Dermatological FINACEA EXTERNAL
Agents - Drugs for 3
FOAM
Skin Conditions FINACEA EXTERNAL
3 ST
ABSORICA 3 PA GEL
ABSORICA LD 3 PA fluocinonide external
1
ACZONE EXTERNAL cream
2
GEL 7.5 % fluocinonide external
1
adapalene external gel 1 PA solution
AMZEEQ 3 FLUOROPLEX 3
betamethasone FLUOROURACIL
dipropionate external 1 EXTERNAL CREAM 2
cream 0.5 %
BRYHALI 3 fluorouracil external
1
cream 5 %
claravis 1 PA
hydrocortisone external
clindamycin phosphate- 1
cream
benzoyl peroxide 1
external gel 1-5 % hydrocortisone external
1
ointment 1 %, 2.5 %
clindamycin phosphate
1 imiquimod external
external lotion 1
cream 5 %
clindamycin phosphate
1 metronidazole external
external solution 1
cream
clindamycin phosphate
1 metronidazole external
external swab 1
gel
clindamycin phosphate
1 MIRVASO 3
gel 1 % external
CLINDAMYCIN mometasone furoate
1
PHOSPHATE GEL 1 % 3 ST external cream
EXTERNAL ONEXTON 3
clobetasol propionate pimecrolimus 1 ST
1
external cream QBREXZA 3 QL
clobetasol propionate RETIN-A MICRO
1
external ointment PUMP EXTERNAL 2 PA
clobetasol propionate GEL 0.06 %, 0.08 %
1
external solution RHOFADE 3
DUPIXENT 2 PA; SP; QL SERNIVO 3
ENSTILAR 3 QL SOOLANTRA 3
EPIDUO FORTE 3 TACLONEX 3 QL
EUCRISA 2 ST
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
tacrolimus external pioglitazone hcl 1
1
ointment RYBELSUS 2 ST; QL
tretinoin external cream 1 PA SOLIQUA 2 ST; QL
triamcinolone acetonide SYMLINPEN 120 3 PA
1
external cream
SYMLINPEN 60 3 PA
triamcinolone acetonide
1 SYNJARDY 2 ST
external ointment
ZILXI 3 ST SYNJARDY XR 2 ST
Diabetes - TRADJENTA 2 ST
Antidiabetic Agents TRIJARDY XR 2 ST
BYDUREON BCISE TRULICITY 2 ST; QL
2 ST; QL
AUTOINJECTOR VICTOZA 2 ST; QL
BYETTA 10 MCG PEN 2 ST; QL XIGDUO XR 2 ST
BYETTA 5 MCG PEN 2 ST; QL Diabetes - Glucose
FARXIGA 2 ST Monitoring
glimepiride 1 ACCU-CHEK
glipizide er 1 FASTCLIX LANCET 2
KIT
glipizide ir 1
ACCU-CHEK GUIDE
glyburide oral 1 3 ST; QL
TEST STRIPS
GLYXAMBI 2 ST ACCU-CHEK
INVOKANA 3 ST SOFTCLIX LANCET 2
JANUMET 2 ST DEVICE KIT
JANUMET XR 2 ST CONTOUR CONTROL
2
SOLUTION
JANUVIA 2 ST
CONTOUR MONITOR
JARDIANCE 2 ST 2
DEVICE
JENTADUETO 2 ST CONTOUR MONITOR
2
JENTADUETO XR 2 ST KIT W/DEVICE
metformin hcl er 1 CONTOUR NEXT
2
metformin hcl er (mod) 1 PA CONTROL SOLUTION
metformin hcl er (osm) 1 CONTOUR NEXT EZ
2
KIT W/DEVICE
metformin hcl oral
1 CONTOUR NEXT
tablet
MONITOR KIT 2
OZEMPIC W/DEVICE
SUBCUTANEOUS
SOLUTION PEN- 2 ST; QL CONTOUR NEXT ONE
2
INJECTOR 2 KIT
MG/1.5ML
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
CONTOUR NEXT GLUCAGON
2 QL
TEST STRIPS EMERGENCY KIT 1 3 Made by Lilly
CONTOUR TEST MG INJECTION 1 MG
2 QL
STRIPS GLUCAGON Made by
2
DEXCOM G4 / G5 / G6 EMERGENCY KIT Fresenius
RECEIVER, GVOKE HYPOPEN 1-
2
TRANSMITTER, PACK
SENSOR (INCLUDING 2 GVOKE HYPOPEN 2-
PLATINUM, 2
PACK
PLATINUM
PEDIATRIC) GVOKE PFS 2
DEXCOM G4 / G5 / G6 Diabetes - Insulins
RECEIVER, BD AUTOSHIELD DUO
2
TRANSMITTER, PEN NEEDLES
SENSOR (INCLUDING 2 BD ULTRA-FINE
PLATINUM, 2
INSULIN SYRINGES
PLATINUM
PEDIATRIC) DEVICE BD ULTRA-FINE PEN
2
NEEDLES
FREESTYLE LIBRE 14
2 BD VEO INSULIN SYR
DAY READER 2
U/F 1/2UNIT
FREESTYLE LIBRE 14
2 HUMALOG KWIKPEN 2
DAY SENSOR
FREESTYLE LIBRE 2 HUMALOG MIX 50/50
2 2
READER KWIKPEN
FREESTYLE LIBRE 2 HUMALOG MIX 50/50
2 2
SENSOR VIAL
FREESTYLE LIBRE HUMALOG MIX 75/25
2 2
READER KWIKPEN
FREESTYLE LIBRE HUMALOG MIX 75/25
2 2
SENSOR SYSTEM VIAL
V-GO 20 2 HUMALOG U-100
2
JUNIOR KWIKPEN
V-GO 30 2
HUMALOG VIAL 2
V-GO 40 2
HUMULIN 70/30
Diabetes - Glycemic 2
KWIKPEN
Agents
HUMULIN 70/30 VIAL 2
BAQSIMI ONE PACK 2
HUMULIN N KWIKPEN 2
BAQSIMI TWO PACK 2
HUMULIN N VIAL 2
glucagon emergency kit
1 HUMULIN R U-500
1 mg injection 1 mg 2
KWIKPEN
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
HUMULIN R U-500 TRESIBA
2 2
VIAL FLEXTOUCH
HUMULIN R VIAL 2 Electrolytes / Minerals
LANTUS SOLOSTAR 2 / Metals / Vitamins
LANTUS U-100 VIAL 2 cyanocobalamin
injection solution 1000 1
LEVEMIR U-100 mcg/ml
2
FLEXTOUCH
ergocalciferol oral
LEVEMIR U-100 VIAL 2 1
capsule
LYUMJEV KWIKPEN 2 folic acid oral tablet 1
1
LYUMJEV VIAL 2 mg
NOVOFINE klor-con m20 1
AUTOCOVER PEN 2 LOKELMA 3
NEEDLE
NASCOBAL 3
NOVOFINE PEN
2 potassium chloride crys
NEEDLE 1
er
NOVOFINE PLUS PEN
2 potassium chloride er 1
NEEDLE
NOVOLIN 70/30 potassium citrate er 1
2
FLEXPEN sodium fluoride oral
1
NOVOLIN 70/30 VIAL 2 tablet chewable
NOVOLIN N FLEXPEN 2 VELTASSA 3
NOVOLIN N VIAL 2 vitamin d
(ergocalciferol) oral
NOVOLIN R FLEXPEN 2 1
capsule 1.25 mg
NOVOLIN R VIAL 2 (50000 ut)
NOVOLOG FLEXPEN 2 Gastrointestinal
Agents - Drugs for
NOVOLOG MIX 70/30
2 Acid Reflux and Ulcer
FLEXPEN
NOVOLOG MIX 70/30 DEXILANT 2 QL
2
VIAL esomeprazole
NOVOLOG PENFILL 2 magnesium oral
1 QL
capsule delayed
NOVOLOG U-100 VIAL 2 release
NOVOTWIST PEN famotidine oral
2
NEEDLE suspension 1
TOUJEO MAX reconstituted
2
SOLOSTAR famotidine oral tablet
1
TOUJEO SOLOSTAR 2 20 mg, 40 mg
TRESIBA 2
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
lansoprazole oral PYLERA 2
capsule delayed 1 QL SUPREP BOWEL
release 3
PREP KIT
misoprostol oral 1 SYMPROIC 2 ST; QL
omeprazole oral TRULANCE 3 ST; QL
capsule delayed 1 QL
release VIBERZI 3 PA; QL
pantoprazole sodium ZELNORM 3 PA; QL
oral tablet delayed 1 QL Genetic or Enzyme
release Disorder - Drugs for
rabeprazole sodium Replacement,
oral tablet delayed 1 QL Modification,
release Treatment
sucralfate oral tablet 1 CERDELGA 3 PA; SP
Gastrointestinal CREON 2
Agents - Drugs for NITYR 3 PA; SP
Bowel, Intestine and
ORFADIN 3 PA; SP
Stomach Conditions
STRENSIQ
CLENPIQ 3 SUBCUTANEOUS
dicyclomine hcl oral SOLUTION 28 2 PA; SP
1
capsule MG/0.7ML, 40 MG/ML,
dicyclomine hcl oral 80 MG/0.8ML
1
tablet ZENPEP 2
diphenoxylate-atropine ZOLGENSMA 3 PA; SP
1
oral tablet Genitourinary Agents
glycopyrrolate oral - Drugs for Bladder,
1
tablet 1 mg, 2 mg Genital and Kidney
GLYCOPYRROLATE Conditions
3
ORAL TABLET 1.5 MG AURYXIA 3
hyoscyamine sulfate sl 1 DEPEN TITRATABS 2 SP
hyoscyamine sulfate MYRBETRIQ 2
1
sublingual oxybutynin chloride er 1
lactulose oral solution 1 oxybutynin chloride oral
1
LINZESS 2 ST; QL tablet
MOTEGRITY 3 ST; QL phenazopyridine hcl
MOVANTIK 2 ST; QL oral tablet 100 mg, 200 1
mg
OMECLAMOX-PAK 2
peg 3350-kcl-na bicarb-
1
nacl
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
sildenafil citrate oral Hormonal Agents -
tablet 100 mg, 25 mg, 1 QL Men's Health
50 mg ANDRODERM 2 PA
solifenacin succinate 1 testosterone cypionate
1 PA
STENDRA 3 QL intramuscular
tadalafil oral 1 QL testosterone
tolterodine tartrate er 1 transdermal gel 1.62 %,
10 mg/act (2%), 20.25
TOVIAZ 3 mg/1.25gm (1.62%),
VELPHORO 3 20.25 mg/act (1.62%), 1 PA
Genitourinary Agents 25 mg/2.5gm (1%),
- Drugs for Prostate 40.5 mg/2.5gm
Conditions (1.62%), 50 mg/5gm
(1%)
alfuzosin hcl er 1
XYOSTED 3 PA
dutasteride oral 1
Hormonal Agents -
finasteride oral tablet 5 Osteoporosis
1
mg
OSPHENA 3
tamsulosin hcl 1
Hormonal Agents -
terazosin hcl oral Pituitary
capsule 1 mg, 10 mg, 5 1
mg ACTHAR 2 PA; SP
Hormonal Agents - cabergoline 1
Adrenal clomiphene citrate oral 1
dexamethasone oral FENSOLVI (6 MONTH) 3 PA; SP; QL
1
tablet FOLLISTIM AQ 2 PA; SP
hydrocortisone oral 1 ganirelix acetate
methylprednisolone solution prefilled
1 1 PA; SP
oral tablet therapy pack syringe 250 mcg/0.5ml
prednisolone sodium subcutaneous
1
phosphate oral solution ganirelix acetate
prednisone oral tablet 1 solution prefilled PA; Made by
1
syringe 250 mcg/0.5ml Organon; SP
prednisone oral tablet subcutaneous
1
therapy pack
LUPRON DEPOT (1-
TAPERDEX 12-DAY 3 MONTH)
2 PA; SP
TAPERDEX 6-DAY 3 INTRAMUSCULAR KIT
TAPERDEX 7-DAY 3 7.5 MG
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
LUPRON DEPOT (3- dotti 1
MONTH) drospirenone-ethinyl
2 PA; SP 1
INTRAMUSCULAR KIT estradiol
22.5 MG
DUAVEE 2
LUPRON DEPOT (4-
MONTH) ELESTRIN 3
2 PA; SP
INTRAMUSCULAR KIT eluryng 1
30MG ENDOMETRIN 2
LUPRON DEPOT (6- enskyce 1
MONTH)
2 PA; SP estarylla 1
INTRAMUSCULAR KIT
45MG estradiol oral 1
NOCDURNA 3 estradiol transdermal 1
NORDITROPIN estradiol vaginal 1
2 PA; SP
FLEXPRO estradiol-norethindrone
1
NUTROPIN AQ acet
2 PA; SP
NUSPIN 10 ESTROGEL 3
NUTROPIN AQ etonogestrel-ethinyl
2 PA; SP 1
NUSPIN 20 estradiol
NUTROPIN AQ EVAMIST 3
2 PA; SP
NUSPIN 5
IMVEXXY
ORILISSA 2 PA; QL 3
MAINTENANCE PACK
SOMATULINE DEPOT 3 PA; SP IMVEXXY STARTER
3
SUPPRELIN LA 2 PA; SP; QL PACK
TRIPTODUR 3 PA; SP; QL isibloom 1
Hormonal Agents - junel 1.5/30 1
Sex Hormones and
junel 1/20 1
Birth Control
junel fe 1.5/30 1
apri 1
junel fe 1/20 1
aurovela fe 1/20 1
junel fe 24 1
aviane 1
kurvelo 1
BIJUVA 3
larin fe 1/20 1
blisovi 24 fe 1
larissia 1
blisovi fe 1.5/30 1
lessina 1
blisovi fe 1/20 1
levonorgest-eth est &
CLIMARA PRO 2 1 QL
eth est
cryselle-28 1
DIVIGEL 3
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
levonorgest-eth estrad sprintec 28 1
91-day oral tablet 0.15- syeda 1
1 QL
0.03 &0.01 mg, 0.15-
0.03 mg tri femynor 1
levonorgestrel-ethinyl tri-estarylla 1
estrad oral tablet 0.1-20 tri-lo-marzia 1
1
mg-mcg, 0.15-30 mg- tri-lo-mili 1
mcg
tri-lo-sprintec 1
LO LOESTRIN FE 3
tri-sprintec 1
loryna 1
vienva 1
MAKENA 2 PA; SP
xulane 1
medroxyprogesterone
1 QL Hormonal Agents -
acetate intramuscular
Thyroid
medroxyprogesterone
1 ARMOUR THYROID 3 ST
acetate oral
MIRENA (52 MG) 3 euthyrox 1
mono-linyah 1 levothyroxine sodium
1
oral tablet
NATAZIA 2
levoxyl 1
nikki 1
liothyronine sodium oral 1
norethin ace-eth
1 methimazole oral 1
estrad-fe oral tablet
norethindrone acetate np thyroid oral tablet 30
1 1
oral mg, 60 mg
norethindrone acet- SYNTHROID 3 ST
1
ethinyl est TIROSINT 3
norethindrone oral 1 TIROSINT-SOL 3
norgestimate-ethinyl Immunological
1
estradiol triphasic Agents - Drugs for
nortrel 1/35 (21) 1 Immune System
Stimulation or
nortrel 1/35 (28) 1 Suppression
ORIAHNN 2 PA; QL ACTEMRA ACTPEN 3 PA; 3P; SP
PREMARIN ORAL 2 ACTEMRA
3 PA; 3P; SP
PREMARIN VAGINAL 2 SUBCUTANEOUS
PREMPHASE 2 AVSOLA 2 PA; SP
PREMPRO 2 azathioprine oral 1
progesterone CIMZIA 2 PA; SP
1
micronized oral
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
CIMZIA PREFILLED mycophenolate mofetil
2 PA; SP 1 SP
KIT oral tablet
CIMZIA STARTER KIT 2 PA; SP mycophenolate sodium 1 SP
COSENTYX ORENCIA CLICKJECT 3 PA; 3P; SP
SENSOREADY (300 3 PA; SP ORENCIA
MG) SUBCUTANEOUS
COSENTYX SOLUTION 3 PA; 3P; SP
3 PA; SP
SENSOREADY PEN PREFILLED SYRINGE
cyclosporine modified 125 MG/ML
1 SP
oral capsule OTEZLA 2 PA; SP
ENBREL MINI 3 PA; SP RASUVO 2 PA; QL
ENBREL RINVOQ 2 PA; SP
SUBCUTANEOUS RUCONEST 3 PA; SP; QL
3 PA; SP
SOLUTION
PREFILLED SYRINGE SIMPONI 2 PA; SP
ENBREL SURECLICK 3 PA; SP SIMPONI ARIA 2 PA; SP
FIRAZYR 3 PA; SP; QL SKYRIZI (150 MG
2 PA; SP
DOSE)
GAMMAGARD 3 PA; SP
STELARA
HAEGARDA 3 PA; SP 2 PA; SP
INTRAVENOUS
HUMIRA 2 PA; SP STELARA
2 PA; SP; QL
HUMIRA PEDIATRIC SUBCUTANEOUS
2 PA; SP
CROHNS START tacrolimus oral 1 SP
HUMIRA PEN 2 PA; SP TAKHZYRO 3 PA; SP
HUMIRA PEN- TALTZ 3 PA; 3P; SP
2 PA; SP
CD/UC/HS STARTER
TREMFYA 2 PA; SP
HUMIRA PEN-
PS/UV/ADOL HS 2 PA; SP XELJANZ 2 PA; SP
START XELJANZ XR 2 PA; SP
HUMIRA PEN- XEMBIFY 3 PA; SP
PSOR/UVEIT 2 PA; SP Inflammatory Bowel
STARTER Disease Agents
INFLECTRA 2 PA; SP APRISO 2
leflunomide oral 1 DIPENTUM 3
methotrexate oral 1 hydrocortisone
1
methotrexate sodium (perianal)
1
oral mesalamine oral tablet
1
mycophenolate mofetil delayed release
1 SP
oral capsule PENTASA 3
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
PROCTOFOAM HC 2 Ophthalmic Agents -
sulfasalazine oral tablet 1 Drugs for Eye Allergy,
Infection and
UCERIS RECTAL 3 Inflammation
Metabolic Bone AZASITE 3
Disease Agents -
Drugs for BESIVANCE 3
Osteoporosis ciprofloxacin hcl
1
alendronate sodium ophthalmic
1
oral tablet 10 mg, 5 mg erythromycin
1
alendronate sodium ophthalmic
oral tablet 35 mg, 70 1 QL FLAREX 3
mg INVELTYS 3
BINOSTO 3 QL ketorolac tromethamine
1
FORTEO 3 PA; SP ophthalmic
ibandronate sodium LOTEMAX
1 QL 3 QL
oral OPHTHALMIC GEL
PROLIA 2 PA; SP; QL LOTEMAX
RAYALDEE 3 OPHTHALMIC 3 QL
OINTMENT
TERIPARATIDE
2 PA; SP LOTEMAX SM 3
(RECOMBINANT)
TYMLOS 2 PA; SP MOXEZA 2
XGEVA 2 PA; SP MOXIFLOXACIN HCL
INTRAOCULAR 3
Metabolic Bone SOLUTION
Disease Agents -
Other moxifloxacin hcl
1
ophthalmic solution
calcitriol oral capsule 1
ofloxacin ophthalmic 1
Miscellaneous
Therapeutic Agents olopatadine hcl
1
ophthalmic
PA; Non-
BOTOX 2 prednisolone acetate
Cosmetic; SP 1
ophthalmic
DUROLANE 2 PA; SP
PROLENSA 2 QL
ENDARI 3 PA
Ophthalmic Agents -
EUFLEXXA 2 PA; SP Drugs for Glaucoma
GELSYN-3 2 PA; SP ALPHAGAN P 2
AZOPT 2
BETIMOL 3
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
brimonidine tartrate ofloxacin otic 1
1
ophthalmic OTOVEL 3
COMBIGAN 2 Respiratory Tract /
dorzolamide hcl-timolol Pulmonary Agents -
1
mal Drugs for Allergies,
latanoprost ophthalmic 1 Cough, Cold
LUMIGAN 2 QL allergy relief oral tablet
1
5 mg
RHOPRESSA 3 QL
azelastine hcl nasal 1 QL
ROCKLATAN 3 QL
azelastine-fluticasone 1 QL
SIMBRINZA 2
benzonatate 1
timolol maleate
1 cetirizine hcl oral
ophthalmic solution 1
solution
timolol maleate pf 1
cyproheptadine hcl oral
ZIOPTAN 3 QL 1
tablet
Ophthalmic Agents - DYMISTA 2 QL
Drugs for
Miscellaneous Eye FASENRA 2 PA; SP
Conditions FASENRA PEN 2 PA; SP
neomycin-polymyxin- fluticasone propionate
1
dexameth ophthalmic nasal
1
suspension 3.5-10000- ipratropium bromide
0.1 1
nasal
polymyxin b- levocetirizine
1
trimethoprim dihydrochloride oral 1
RESTASIS 2 PA tablet
RESTASIS mometasone furoate
2 PA 1 QL
MULTIDOSE nasal
TOBRADEX ST 3 NUCALA 2 PA; SP; QL
tobramycin- OMNARIS 3 QL
1
dexamethasone promethazine hcl oral
1
XIIDRA 2 PA tablet
Otic Agents - Drugs promethazine-dm 1
for Ear Conditions pseudoephedrine-
1
CIPRODEX 3 ST bromphen-dm
ciprofloxacin- QNASL 3 QL
1
dexamethasone QNASL CHILDRENS 3 QL
neomycin-polymyxin-hc XOLAIR 2 PA; SP
1
otic
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
ZETONNA 3 QL fluticasone-salmeterol
Respiratory Tract / inhalation aerosol
Pulmonary Agents - powder breath
Drugs for Asthma and activated 100-50 1 QL
Other Lung mcg/dose, 250-50
Conditions mcg/dose, 500-50
mcg/dose
ADVAIR DISKUS 2 QL
ipratropium-albuterol 1 QL
ADVAIR HFA 2 QL
LONHALA MAGNAIR
albuterol sulfate hfa 3 QL
REFILL KIT
aerosol solution 108
1 QL LONHALA MAGNAIR
(90 base) mcg/act 3 QL
inhalation STARTER KIT
ALBUTEROL montelukast sodium
1
SULFATE HFA oral tablet
AEROSOL SOLUTION montelukast sodium
3 ST; QL 1
108 (90 BASE) oral tablet chewable
MCG/ACT PERFOROMIST 3 QL
INHALATION
PROAIR HFA 2 QL
albuterol sulfate
1 QL PROAIR RESPICLICK 2 QL
inhalation
ALVESCO 3 ST; QL PULMICORT
2 QL
FLEXHALER
ANORO ELLIPTA 2 QL
QVAR REDIHALER 2 QL
ARNUITY ELLIPTA 2 QL
SEREVENT DISKUS 2 QL
ATROVENT HFA 3 QL
SPIRIVA
BREO ELLIPTA 2 QL 2 QL
HANDIHALER
BREZTRI SPIRIVA RESPIMAT 2 QL
2 QL
AEROSPHERE
STIOLTO RESPIMAT 2 QL
budesonide inhalation 1 QL
STRIVERDI
BUDESONIDE- 2 QL
RESPIMAT
FORMOTEROL 3 PA; QL
FUMARATE SYMBICORT 2 QL
COMBIVENT SYMJEPI 3
2 QL
RESPIMAT TRELEGY ELLIPTA 2 QL
epinephrine injection VENTOLIN HFA 2 QL
1
solution auto-injector wixela inhub 1 QL
EPIPEN 2-PAK 3 ST YUPELRI 3 QL
EPIPEN JR 2-PAK 3 ST
FLOVENT DISKUS 2 QL
FLOVENT HFA 2 QL
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
26Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Respiratory Tract / temazepam 1 QL
Pulmonary Agents - WAKIX 3 PA; SP; QL
Drugs for Cystic
Fibrosis XYREM 3 PA; SP; QL
PULMOZYME 2 PA; SP zolpidem tartrate er 1 QL
TOBI PODHALER 3 SP; QL zolpidem tartrate oral 1 QL
TRIKAFTA 3 PA; SP; QL
Respiratory Tract /
Pulmonary Agents -
Drugs for Pulmonary
Hypertension
ADEMPAS 2 PA; SP; QL
OPSUMIT 2 PA; SP; QL
ORENITRAM 3 PA; SP
sildenafil citrate oral
1 PA; SP; QL
tablet 20 mg
Skeletal Muscle
Relaxants - Drugs for
Muscle Pain and
Spasm
baclofen oral 1
carisoprodol oral 1
cyclobenzaprine hcl
1
oral
LORZONE 3
metaxalone 1
methocarbamol oral 1
tizanidine hcl oral tablet 1
Sleep Disorder
Agents
armodafinil 1 PA; QL
BELSOMRA 3 ST; QL
DAYVIGO 3 ST; QL
eszopiclone 1 QL
modafinil 1 PA; QL
SILENOR 3 QL
SUNOSI 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.
27Index of Drugs
ABILIFY MAINTENA................. 10 amphetamine- benzonatate.............................. 25
ABSORICA............................... 15 dextroamphetamine er.............. 13 benztropine mesylate................10
ABSORICA LD..........................15 AMPYRA...................................14 BESIVANCE............................. 24
ACCU-CHEK FASTCLIX AMZEEQ...................................15 betamethasone dipropionate.... 15
LANCET KIT............................. 16 anastrozole................................. 9 BETASERON............................14
ACCU-CHEK GUIDE TEST ANDRODERM.......................... 20 BETIMOL.................................. 24
STRIPS..................................... 16 ANORO ELLIPTA..................... 26 BIJUVA..................................... 21
ACCU-CHEK SOFTCLIX ANTARA................................... 12 BIKTARVY................................ 11
LANCET DEVICE KIT...............16 apap-caff-dihydrocodeine........... 6 BINOSTO..................................24
acetaminophen-codeine..............6 apri............................................ 21 bisoprolol fumarate................... 12
acetaminophen-codeine #2.........6 APRISO.................................... 23 bisoprolol-hydrochlorothiazide.. 12
acetaminophen-codeine #3.........6 ARAKODA................................ 10 blisovi 24 fe............................... 21
acetaminophen-codeine #4.........6 ARANESP (ALBUMIN FREE)... 11 blisovi fe 1.5/30......................... 21
ACTEMRA................................ 22 aripiprazole............................... 10 blisovi fe 1/20............................ 21
ACTEMRA ACTPEN.................22 ARISTADA................................ 10 BOTOX..................................... 24
ACTHAR................................... 20 ARISTADA INITIO.................... 10 BREO ELLIPTA........................ 26
acyclovir.................................... 11 armodafinil................................ 27 BREZTRI AEROSPHERE.........26
ACZONE................................... 15 ARMOUR THYROID.................22 BRILINTA..................................10
adapalene................................. 15 ARNUITY ELLIPTA...................26 brimonidine tartrate................... 25
ADDERALL XR......................... 13 atenolol..................................... 12 BRIVIACT................................... 8
ADDYI....................................... 14 atenolol-chlorthalidone..............12 BRYHALI...................................15
ADEMPAS................................ 27 atomoxetine hcl.........................13 budesonide............................... 26
ADVAIR DISKUS...................... 26 atorvastatin calcium.................. 12 BUDESONIDE-
ADVAIR HFA............................ 26 ATROVENT HFA...................... 26 FORMOTEROL FUMARATE.... 26
ADVATE....................................11 AUBAGIO..................................14 bumetanide............................... 12
ADYNOVATE............................11 aurovela fe 1/20........................ 21 BUNAVAIL.................................. 7
AFSTYLA.................................. 11 AURYXIA.................................. 19 buprenorphine hcl....................... 7
AIMOVIG.....................................9 AUSTEDO.................................14 buprenorphine hcl-naloxone
albuterol sulfate.........................26 aviane....................................... 21 hcl............................................... 7
albuterol sulfate hfa...................26 AVONEX PEN...........................14 bupropion hcl.............................. 8
ALBUTEROL SULFATE HFA... 26 AVONEX PREFILLED.............. 14 bupropion hcl er (sr)....................8
ALECENSA.................................9 AVSOLA....................................22 bupropion hcl er (xl).................... 8
alendronate sodium.................. 24 AZASITE................................... 24 BUPROPION HCL ER (XL)........ 8
alfuzosin hcl er.......................... 20 azathioprine.............................. 22 buspirone hcl.............................11
allergy relief...............................25 azelastine hcl............................ 25 butalbital-apap-caffeine...............6
allopurinol....................................9 azelastine-fluticasone............... 25 BYDUREON BCISE
ALPHAGAN P........................... 24 azithromycin................................7 AUTOINJECTOR...................... 16
alprazolam................................ 11 AZOPT...................................... 24 BYETTA 10 MCG PEN............. 16
ALUNBRIG..................................9 baclofen.................................... 27 BYETTA 5 MCG PEN............... 16
ALVESCO................................. 26 BAFIERTAM............................. 14 BYSTOLIC................................ 12
amiodarone hcl......................... 12 BAQSIMI ONE PACK............... 17 cabergoline............................... 20
amitriptyline hcl........................... 8 BAQSIMI TWO PACK...............17 CABOMETYX............................. 9
amlodipine besylate.................. 12 BD AUTOSHIELD DUO PEN calcitriol..................................... 24
amlodipine besylate-benazepril NEEDLES................................. 17 CALQUENCE............................10
hcl............................................. 12 BD ULTRA-FINE INSULIN candesartan cilexetil................. 12
amlodipine besylate-valsartan.. 12 SYRINGES............................... 17 capecitabine..............................10
amlodipine-olmesartan..............12 BD ULTRA-FINE PEN carbamazepine........................... 8
amoxicillin................................... 7 NEEDLES................................. 17 carbidopa-levodopa.................. 10
amoxicillin-potassium BD VEO INSULIN SYR U/F carisoprodol.............................. 27
clavulanate..................................7 1/2UNIT.....................................17 cartia xt..................................... 12
amphetamine- BELBUCA................................... 6 carvedilol...................................12
dextroamphetamine.................. 13 BELSOMRA.............................. 27 cefdinir........................................ 7
benazepril hcl............................12 cefuroxime axetil......................... 7
28celecoxib..................................... 6 COPAXONE..............................14 EDARBYCLOR......................... 12
cephalexin...................................7 CORLANOR..............................12 ELESTRIN................................ 21
CERDELGA.............................. 19 COSENTYX SENSOREADY eletriptan hydrobromide.............. 9
cetirizine hcl.............................. 25 (300 MG)...................................23 ELIQUIS......................................8
CHANTIX STARTING MONTH COSENTYX SENSOREADY ELIQUIS DVT/PE STARTER
PAK.............................................7 PEN...........................................23 PACK.......................................... 8
chlorhexidine gluconate............ 14 CREON..................................... 19 ELOCTATE............................... 11
chlorthalidone............................12 CRESEMBA................................9 eluryng...................................... 21
ciclopirox..................................... 9 cryselle-28.................................21 EMGALITY..................................9
CIMDUO................................... 11 cyanocobalamin........................ 18 EMGALITY (300 MG DOSE)...... 9
CIMZIA......................................22 cyclobenzaprine hcl.................. 27 EMVERM.................................. 10
CIMZIA PREFILLED KIT...........23 cyclosporine modified............... 23 enalapril maleate.......................12
CIMZIA STARTER KIT............. 23 cyproheptadine hcl....................25 ENBREL....................................23
CIPRODEX............................... 25 DAYVIGO..................................27 ENBREL MINI........................... 23
ciprofloxacin hcl.................... 7, 24 DEPEN TITRATABS.................19 ENBREL SURECLICK.............. 23
ciprofloxacin-dexamethasone... 25 DESCOVY................................ 11 ENDARI.................................... 24
citalopram hydrobromide............ 8 desvenlafaxine succinate er........8 ENDOMETRIN..........................21
claravis......................................15 dexamethasone........................ 20 enoxaparin sodium......................8
clarithromycin..............................7 DEXCOM G4 / G5 / G6 enskyce.....................................21
CLENPIQ.................................. 19 RECEIVER, TRANSMITTER, ENSTILAR................................ 15
CLIMARA PRO......................... 21 SENSOR (INCLUDING entecavir................................... 11
clindamycin hcl............................7 PLATINUM, PLATINUM ENTRESTO.............................. 12
clindamycin phosphate............. 15 PEDIATRIC)..............................17 EPCLUSA................................. 11
CLINDAMYCIN PHOSPHATE.. 15 DEXILANT................................ 18 EPIDIOLEX................................. 8
clindamycin phosphate- dexmethylphenidate hcl............ 14 EPIDUO FORTE....................... 15
benzoyl peroxide.......................15 dexmethylphenidate hcl er........ 14 epinephrine............................... 26
CLINDESSE................................7 diazepam.................................. 11 EPIPEN 2-PAK......................... 26
clobetasol propionate................15 diclofenac sodium....................... 6 EPIPEN JR 2-PAK.................... 26
clomiphene citrate.....................20 dicyclomine hcl..........................19 ergocalciferol.............................18
clonazepam...............................11 DIFICID....................................... 7 erythromycin............................. 24
clonidine hcl.............................. 12 digoxin.......................................12 escitalopram oxalate................... 8
clopidogrel bisulfate.................. 10 diltiazem hcl er coated beads... 12 esomeprazole magnesium........18
clotrimazole.................................9 DIPENTUM............................... 23 estarylla.....................................21
clotrimazole-betamethasone.......9 diphenoxylate-atropine..............19 estradiol.................................... 21
colchicine.................................... 9 divalproex sodium....................... 8 estradiol-norethindrone acet..... 21
COMBIGAN.............................. 25 divalproex sodium er...................8 ESTROGEL.............................. 21
COMBIVENT RESPIMAT......... 26 DIVIGEL....................................21 eszopiclone............................... 27
CONTOUR CONTROL donepezil hcl............................... 8 etodolac...................................... 6
SOLUTION................................16 dorzolamide hcl-timolol mal...... 25 etonogestrel-ethinyl estradiol.... 21
CONTOUR MONITOR dotti........................................... 21 EUCRISA.................................. 15
DEVICE.....................................16 DOVATO...................................11 EUFLEXXA............................... 24
CONTOUR MONITOR KIT doxazosin mesylate.................. 12 euthyrox.................................... 22
W/DEVICE................................ 16 doxepin hcl..................................8 EVAMIST.................................. 21
CONTOUR NEXT CONTROL doxycycline hyclate..................... 7 ezetimibe...................................12
SOLUTION................................16 doxycycline monohydrate........... 7 ezetimibe-simvastatin............... 12
CONTOUR NEXT EZ KIT drospirenone-ethinyl estradiol...21 famotidine................................. 18
W/DEVICE................................ 16 DUAVEE................................... 21 FARXIGA.................................. 16
CONTOUR NEXT MONITOR duloxetine hcl.............................. 8 FASENRA................................. 25
KIT W/DEVICE..........................16 DUPIXENT................................15 FASENRA PEN.........................25
CONTOUR NEXT ONE KIT...... 16 DUROLANE.............................. 24 febuxostat................................... 9
CONTOUR NEXT TEST dutasteride................................ 20 fenofibrate................................. 12
STRIPS..................................... 17 DYMISTA.................................. 25 fenofibrate micronized...............12
CONTOUR TEST STRIPS........17 EDARBI.....................................12 fenofibric acid............................12
29You can also read
