Your 2021 Select Standard Formulary - Hampton.gov
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Your 2021 Select 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 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 effect) 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. OTC options. Even though
OTC medications may not be
What if my doctor writes a brand-name prescription? covered by your pharmacy
If your doctor gives you a prescription for a brand-name benefit, they may cost less 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 used to treat complex conditions. These high-cost medications may
be injected, infused or taken by mouth. 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.
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
4Table of Contents
Analgesics - Drugs for Pain.................................................................................................................................7
Analgesics - Drugs for Pain and Inflammation.................................................................................................... 7
Anesthetics..........................................................................................................................................................7
Anti-Addiction / Substance Abuse Treatment Agents......................................................................................... 7
Antibacterials.......................................................................................................................................................8
Anticoagulants.....................................................................................................................................................8
Anticonvulsants - Drugs for Seizures.................................................................................................................. 9
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia................................................................ 9
Antidepressants...................................................................................................................................................9
Antiemetics - Drugs for Nausea and Vomiting.................................................................................................. 10
Antifungals.........................................................................................................................................................10
Antigout Agents................................................................................................................................................. 10
Antimigraine Agents.......................................................................................................................................... 10
Antineoplastics - Drugs for Cancer....................................................................................................................10
Antiparasitics..................................................................................................................................................... 11
Antiparkinson Agents........................................................................................................................................ 11
Antiplatelets.......................................................................................................................................................11
Antipsychotics - Drugs for Mood Disorders....................................................................................................... 11
Antivirals............................................................................................................................................................11
Anxiolytics - Drugs for Anxiety...........................................................................................................................12
Bipolar Agents - Drugs for Mood Disorders.......................................................................................................12
Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders..............................................12
Cardiovascular Agents - Drugs for Heart and Circulation Conditions............................................................... 12
Central Nervous System Agents - Drugs for Attention Deficit Disorder........................................................... 14
Central Nervous System Agents - Drugs for Multiple Sclerosis........................................................................ 14
Central Nervous System Agents - Miscellaneous............................................................................................. 15
Dental and Oral Agents - Drugs for Mouth and Throat Conditions....................................................................15
Dermatological Agents - Drugs for Skin Conditions.......................................................................................... 15
Diabetes - Antidiabetic Agents.......................................................................................................................... 16
Diabetes - Glucose Monitoring.......................................................................................................................... 17
Diabetes - Glycemic Agents.............................................................................................................................. 17
Diabetes - Insulins.............................................................................................................................................18
Electrolytes / Minerals / Metals / Vitamins.........................................................................................................18
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer................................................................................19
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.......................................................20
Genitourinary Agents - Drugs for Prostate Conditions...................................................................................... 20
Hormonal Agents - Adrenal............................................................................................................................... 20
Hormonal Agents - Men's Health.......................................................................................................................20
Hormonal Agents - Osteoporosis...................................................................................................................... 20
Hormonal Agents - Pituitary.............................................................................................................................. 21
Hormonal Agents - Sex Hormones and Birth Control........................................................................................21
Hormonal Agents - Thyroid............................................................................................................................... 22
Immunological Agents - Drugs for Immune System Stimulation or Suppression.............................................. 23
Inflammatory Bowel Disease Agents.................................................................................................................24
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.........................................................................................................25
5Ophthalmic 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
6Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Analgesics - Drugs Analgesics - Drugs
for Pain for Pain and
acetaminophen- Inflammation
1 QL
codeine #2 celecoxib oral 1 QL
acetaminophen- diclofenac sodium oral 1
1 QL
codeine #3 diclofenac sodium
1 QL
acetaminophen- transdermal gel 1 %
1 QL
codeine #4 etodolac oral tablet 1
acetaminophen- ibuprofen oral tablet 1
codeine oral tablet 300- 1 QL
15 mg, 300-60 mg INDOMETHACIN
ORAL CAPSULE 20 3 ST
apap-caff- MG
dihydrocodeine oral 1 QL
capsule indomethacin oral
1
capsule 25 mg, 50 mg
BELBUCA 2 PA; QL
ketorolac tromethamine
butalbital-apap-caffeine 1 1 QL
oral
fentanyl 1 PA; QL meloxicam oral 1
hydrocodone- nabumetone oral 1
acetaminophen oral 1 QL
tablet NAPRELAN 3
hydromorphone hcl oral naproxen oral tablet 1
1 QL
tablet Anesthetics
HYSINGLA ER 2 PA; QL lidocaine external patch 1
morphine sulfate er oral lidocaine-prilocaine
1 PA; QL 1
tablet extended release external cream
NUCYNTA 3 QL Anti-Addiction /
oxycodone hcl oral Substance Abuse
1 QL Treatment Agents
tablet
oxycodone- BUNAVAIL 3 QL
1 QL
acetaminophen buprenorphine hcl
1 QL
OXYCONTIN 2 PA; QL sublingual
tramadol hcl oral tablet buprenorphine hcl-
1 QL 1 QL
50 mg naloxone hcl
TREZIX 3 QL CHANTIX 3 QL
XTAMPZA ER 2 PA; QL CHANTIX
CONTINUING MONTH 3 QL
PAK
CHANTIX STARTING
3 QL
MONTH PAK
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
naltrexone hcl oral 1 doxycycline
NARCAN 2 monohydrate oral 1
capsule
ZUBSOLV 2 QL
doxycycline
Antibacterials 1
monohydrate oral tablet
amoxicillin oral capsule 1 levofloxacin oral tablet 1
amoxicillin oral metronidazole oral
suspension 1 1
tablet
reconstituted
metronidazole vaginal 1
amoxicillin oral tablet 1
minocycline hcl oral
amoxicillin-potassium 1
capsule
clavulanate oral
1 mupirocin external 1
suspension
reconstituted nitrofurantoin
1
amoxicillin-potassium macrocrystal oral
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
clarithromycin oral Anticoagulants
1
tablet
ELIQUIS 2 QL
clindamycin hcl oral 1
ELIQUIS DVT/PE
CLINDESSE 3 2 QL
STARTER PACK
DIFICID 3 enoxaparin sodium 1 SP; QL
doxycycline hyclate oral PRADAXA 2 QL
1
capsule
warfarin sodium oral 1
doxycycline hyclate oral
1 XARELTO 2 QL
tablet
XARELTO STARTER
2 QL
PACK
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
Anticonvulsants - XCOPRI (350 MG
Drugs for Seizures 3 ST
DAILY DOSE)
BRIVIACT zonisamide oral 1
3
INTRAVENOUS Antidementia Agents
BRIVIACT ORAL 3 ST - Drugs for
carbamazepine oral Alzheimer's Disease
1 and Dementia
tablet
divalproex sodium er 1 donepezil hcl oral tablet
1
10 mg, 23 mg
divalproex sodium oral
1 memantine hcl oral
tablet delayed release 1
tablet 10 mg, 5 mg
EPIDIOLEX 3 PA; SP
NAMZARIC 2 QL
FYCOMPA 3
Antidepressants
gabapentin oral
1 amitriptyline hcl oral 1
capsule
gabapentin oral tablet 1 bupropion hcl er (sr) 1 QL
lamotrigine er 1 bupropion hcl er (xl)
oral tablet extended
lamotrigine oral tablet 1 1 QL
release 24 hour 150
levetiracetam oral mg, 300 mg
1
tablet BUPROPION HCL ER
NAYZILAM 3 QL (XL) ORAL TABLET
3 ST; QL
oxcarbazepine oral EXTENDED RELEASE
1 24 HOUR 450 MG
tablet
SYMPAZAN 3 PA bupropion hcl oral 1
topiramate oral tablet 1 citalopram
hydrobromide oral 1
TROKENDI XR 3 ST tablet
VALTOCO 10 MG desvenlafaxine
3 QL 1 QL
DOSE succinate er
VALTOCO 15 MG doxepin hcl oral
3 QL 1
DOSE capsule
VALTOCO 20 MG duloxetine hcl oral 1 QL
3 QL
DOSE
escitalopram oxalate
VALTOCO 5 MG 1
3 QL oral tablet
DOSE
fluoxetine hcl oral
VIMPAT 3 1
capsule
XCOPRI 3 ST fluoxetine hcl oral tablet 1
XCOPRI (250 MG fluvoxamine maleate 1
3 ST
DAILY DOSE)
FORFIVO XL 3 ST; QL
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
9Drug Name Drug Tier Notes Drug Name Drug Tier Notes
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 2 PA; QL
metoclopramide hcl eletriptan hydrobromide 1 QL
1
oral tablet 10 mg
EMGALITY 2 PA; QL
ondansetron hcl oral
1 EMGALITY (300 MG
tablet 4 mg, 8 mg 2 PA; QL
DOSE)
ondansetron odt 1
NURTEC 2 PA; QL
prochlorperazine
1 rizatriptan benzoate 1 QL
maleate oral
scopolamine 1 sumatriptan succinate
1 QL
oral
VARUBI (180 MG
3 QL UBRELVY 2 PA; QL
DOSE)
Antifungals Antineoplastics -
Drugs for Cancer
ciclopirox external
1 anastrozole oral 1
solution
clotrimazole external CABOMETYX 2 PA; SP
1
cream capecitabine 1 PA; SP
clotrimazole- IBRANCE ORAL
3 PA; SP
betamethasone 1 CAPSULE
external cream IDHIFA 3 PA; SP; QL
CRESEMBA ORAL 3 imatinib mesylate 1 PA; SP
fluconazole oral tablet 1 IMBRUVICA ORAL
3 PA; SP
GYNAZOLE-1 3 TABLET
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
KANJINTI 2 PA; SP clopidogrel bisulfate
1
letrozole oral 1 oral
LYNPARZA 2 PA; SP prasugrel hcl 1
MVASI 2 PA; SP Antipsychotics -
Drugs for Mood
NUBEQA 3 PA; SP Disorders
REVLIMID 2 PA; SP aripiprazole oral tablet 1 QL
RUBRACA 2 PA; SP ARISTADA 3
RUXIENCE 2 PA; SP ARISTADA INITIO 3
SPRYCEL 2 PA; SP INVEGA SUSTENNA 3
tamoxifen citrate oral 1 INVEGA TRINZA 3
TARGRETIN LATUDA 3 QL
3 PA; SP
EXTERNAL
olanzapine oral tablet 1 QL
temozolomide 1 PA; SP
PERSERIS 3
TRAZIMERA 2 PA; SP
quetiapine fumarate 1 QL
XTANDI 3 PA; SP
quetiapine fumarate er 1 QL
ZEJULA 2 PA; SP
REXULTI 3 QL
ZIRABEV 2 PA; SP
risperidone oral tablet 1 QL
Antiparasitics
SAPHRIS 2 QL
ARAKODA 3
VRAYLAR ORAL
EMVERM 2 3 ST; QL
CAPSULE
hydroxychloroquine VRAYLAR ORAL
1
sulfate oral CAPSULE THERAPY 3 QL
Antiparkinson Agents PACK
benztropine mesylate ziprasidone hcl 1 QL
1
oral Antivirals
carbidopa-levodopa acyclovir oral capsule 1
1
oral tablet
acyclovir oral tablet 1
INBRIJA 3 PA; SP
BIKTARVY 3
NOURIANZ 3 PA
CIMDUO 2
pramipexole
1 DESCOVY 3 PA
dihydrochloride
ropinirole hcl 1 DOVATO 2
RYTARY 3 ST entecavir 1 SP; QL
Antiplatelets EPCLUSA 2 PA; SP; QL
BRILINTA 2 GENVOYA 3
HARVONI 2 PA; SP; QL
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
11Drug Name Drug Tier Notes Drug Name Drug Tier Notes
JULUCA 2 lithium carbonate oral
1
MAVYRET 2 PA; SP; QL capsule
ODEFSEY 3 Blood Products /
Modifiers / Volume
oseltamivir phosphate Expanders - Drugs for
1 QL
oral Bleeding Disorders
PREZCOBIX 2 ADYNOVATE 3 SP
SYMFI 2 AFSTYLA
SYMFI LO 2 INTRAVENOUS KIT
TAMIFLU ORAL 1000 UNIT, 2000 UNIT, 3 SP
3 QL 250 UNIT, 3000 UNIT,
CAPSULE 75 MG
500 UNIT
TIVICAY 2
ARANESP (ALBUMIN
TRIUMEQ 2 2 PA; SP
FREE)
TRUVADA 3 PA ELOCTATE 3 SP
valacyclovir hcl oral 1 QL JIVI 3 SP
VEMLIDY 3 SP MULPLETA 2 PA; SP
VOSEVI 2 PA; SP; QL NEULASTA 3 PA; SP
XOFLUZA (40 MG NEULASTA ONPRO 3 PA; SP
3 QL
DOSE)
NIVESTYM 2 PA; SP
XOFLUZA (80 MG
3 QL NOVOEIGHT 3 SP
DOSE)
Anxiolytics - Drugs NUWIQ 3 SP
for Anxiety RETACRIT 2 PA; SP
alprazolam oral tablet 1 QL ULTOMIRIS 3 PA; SP
buspirone hcl oral 1 ZARXIO 2 PA; SP
clonazepam oral tablet 1 QL ZIEXTENZO 3 PA; SP
diazepam oral tablet 1 Cardiovascular
Agents - Drugs for
hydroxyzine hcl oral
1 Heart and Circulation
tablet
Conditions
hydroxyzine pamoate
1 amiodarone hcl oral 1
oral
lorazepam oral tablet 1 QL amlodipine besylate
1
oral
triazolam 1 QL
amlodipine besylate-
Bipolar Agents - 1
benazepril hcl
Drugs for Mood
Disorders amlodipine besylate-
1
valsartan
lithium carbonate er 1
amlodipine-olmesartan 1
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
atenolol oral 1 flecainide acetate 1
atenolol-chlorthalidone 1 furosemide oral tablet 1
atorvastatin calcium gemfibrozil oral 1
1
oral guanfacine hcl 1
benazepril hcl oral 1 HEMANGEOL 3
bisoprolol fumarate 1 hydralazine hcl oral 1
bisoprolol- hydrochlorothiazide
1 1
hydrochlorothiazide oral
bumetanide oral 1 irbesartan 1
BYSTOLIC 2 irbesartan-
1
candesartan cilexetil 1 hydrochlorothiazide
cartia xt 1 isosorbide mononitrate
1
carvedilol 1 er
chlorthalidone 1 labetalol hcl oral 1
clonidine hcl oral 1 lisinopril oral 1
CORLANOR 3 PA; QL lisinopril-
1
hydrochlorothiazide
digoxin oral tablet 1
LIVALO 3 ST
diltiazem hcl er coated
beads oral capsule losartan potassium oral 1
1
extended release 24 losartan potassium-hctz 1
hour lovastatin 1
dilt-xr 1 metoprolol succinate er 1
doxazosin mesylate metoprolol tartrate oral 1
1
oral
MULTAQ 3
EDARBI 3 ST
nadolol oral 1
EDARBYCLOR 3 ST
NEXLETOL 2 PA; QL
enalapril maleate oral 1
NEXLIZET 2 PA; QL
ENTRESTO 2 QL
nifedipine er 1
ezetimibe 1
nifedipine er osmotic
ezetimibe-simvastatin 1 1
release
fenofibrate micronized nitroglycerin sublingual 1
oral capsule 134 mg, 1
200 mg, 67 mg olmesartan medoxomil
1
oral
fenofibrate oral tablet 1
olmesartan medoxomil-
fenofibric acid oral 1
hctz
capsule delayed 1
release
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
olmesartan-amlodipine- verapamil hcl er oral
1 1
hctz tablet extended release
omega-3-acid ethyl Central Nervous
1 PA
esters System Agents -
PRALUENT 2 PA; QL Drugs for Attention
Deficit Disorder
pravastatin sodium 1
ADDERALL XR 3 PA; ST; QL
prazosin hcl oral 1
amphetamine-
propranolol hcl er 1 1 PA; QL
dextroamphetamine
propranolol hcl oral amphetamine-
1 1 PA; QL
tablet dextroamphetamine er
ramipril 1 atomoxetine hcl 1 QL
ranolazine er 1 dexmethylphenidate hcl
1 PA; QL
REPATHA 2 PA; QL er
REPATHA dexmethylphenidate hcl
1 PA; QL
PUSHTRONEX 2 PA; QL oral tablet 10 mg, 5 mg
SYSTEM EVEKEO ODT 3 PA; QL
REPATHA guanfacine hcl er 1
2 PA; QL
SURECLICK
JORNAY PM 3 PA; ST; QL
rosuvastatin calcium 1
methylphenidate hcl er
simvastatin oral 1 (la) oral capsule
sotalol hcl oral 1 extended release 24 1 PA; QL
spironolactone oral 1 hour 10 mg, 20 mg, 30
mg, 40 mg
TEKTURNA 2
METHYLPHENIDATE
TEKTURNA HCT 2 ST 3 PA; ST; QL
HCL ER (XR)
telmisartan 1 methylphenidate hcl er
telmisartan-hctz 1 oral tablet extended 1 PA; QL
torsemide 1 release
triamterene-hctz 1 methylphenidate hcl
1 PA; QL
oral tablet
valsartan 1
VYVANSE 2 PA; QL
valsartan-
1 Central Nervous
hydrochlorothiazide
System Agents -
VASCEPA 2 PA Drugs for Multiple
verapamil hcl er oral Sclerosis
capsule extended AMPYRA 3 PA; SP; QL
release 24 hour 120 1
mg, 180 mg, 240 mg, AUBAGIO 3 PA; SP; QL
360 mg AVONEX PEN 2 PA; SP; QL
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
14Drug Name Drug Tier Notes Drug Name Drug Tier Notes
AVONEX PREFILLED 2 PA; SP; QL GRALISE 3 ST; QL
BAFIERTAM 2 PA; SP; QL HORIZANT 3 PA; QL
BETASERON 2 PA; SP; QL phentermine hcl oral
1 PA
COPAXONE 2 PA; SP; QL tablet
PA; 3P; SP; pregabalin oral capsule 1 QL
GILENYA 3
QL QSYMIA 3 PA
glatiramer acetate 1 PA; SP; QL SAXENDA 3 PA
MAVENCLAD (10 TEGSEDI 3 PA; SP
3 PA; 3P; SP
TABS) TIGLUTIK 3 PA; SP; QL
MAVENCLAD (4 VYLEESI 3 PA; QL
3 PA; 3P; SP
TABS)
Dental and Oral
MAVENCLAD (5 Agents - Drugs for
3 PA; 3P; SP
TABS) Mouth and Throat
MAVENCLAD (6 Conditions
3 PA; 3P; SP
TABS) chlorhexidine gluconate
1
MAVENCLAD (7 mouth/throat
3 PA; 3P; SP
TABS) lidocaine viscous hcl 1
MAVENCLAD (8 Dermatological
3 PA; 3P; SP
TABS) Agents - Drugs for
MAVENCLAD (9 Skin Conditions
3 PA; 3P; SP
TABS) ABSORICA 3 PA
PA; 3P; SP; ABSORICA LD 3 PA
MAYZENT 3
QL
ACZONE EXTERNAL
REBIF 3 PA; SP; QL 2
GEL 7.5 %
REBIF REBIDOSE 3 PA; SP; QL AMZEEQ 3
REBIF REBIDOSE betamethasone
3 PA; SP; QL
TITRATION PACK dipropionate external 1
REBIF TITRATION cream
3 PA; SP; QL
PACK BRYHALI 3
TECFIDERA 2 PA; SP; QL claravis 1 PA
VUMERITY 2 PA; SP; QL clindamycin phosphate-
VUMERITY benzoyl peroxide 1
2 PA; SP; QL
(STARTER) external gel 1-5 %
Central Nervous clindamycin phosphate
System Agents - 1
external lotion
Miscellaneous clindamycin phosphate
1
ADDYI 3 PA; QL external solution
AUSTEDO 3 PA; SP; QL
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
15Drug Name Drug Tier Notes Drug Name Drug Tier Notes
clindamycin phosphate QBREXZA 3 QL
1
external swab RETIN-A MICRO
CLINDAMYCIN PUMP EXTERNAL 2 PA
PHOSPHATE GEL 1 % 3 ST GEL 0.06 %, 0.08 %
EXTERNAL RHOFADE 3
clindamycin phosphate SERNIVO 3
1
gel 1 % external
SOOLANTRA 3
clobetasol propionate
1 TACLONEX 3 QL
external cream
clobetasol propionate tacrolimus external
1 1
external ointment ointment
clobetasol propionate tretinoin external cream 1 PA
1
external solution triamcinolone acetonide
1
DUPIXENT external cream
SUBCUTANEOUS triamcinolone acetonide
2 PA; SP; QL 1
SOLUTION external ointment
PREFILLED SYRINGE Diabetes -
ENSTILAR 3 QL Antidiabetic Agents
EPIDUO FORTE 3 BYDUREON 2 ST; QL
EUCRISA 2 ST BYDUREON BCISE
2 ST; QL
FINACEA EXTERNAL AUTOINJECTOR
3
FOAM BYETTA 10 MCG PEN 2 ST; QL
FINACEA EXTERNAL BYETTA 5 MCG PEN 2 ST; QL
3 ST
GEL FARXIGA 2 ST
fluocinonide external glimepiride 1
1
cream
glipizide er 1
FLUOROPLEX 3
glipizide ir 1
hydrocortisone external
1 glyburide oral 1
cream
hydrocortisone external GLYXAMBI 2 ST
1
ointment INVOKANA 3 ST
metronidazole external JANUMET 2 ST
1
cream JANUMET XR 2 ST
metronidazole external JANUVIA 2 ST
1
gel
JARDIANCE 2 ST
MIRVASO 3
JENTADUETO 2 ST
mometasone furoate
1 JENTADUETO XR 2 ST
external cream
ONEXTON 3 metformin hcl er 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
metformin hcl er (mod) 1 PA DEXCOM G4 / G5 / G6
metformin hcl er (osm) 1 RECEIVER,
TRANSMITTER,
metformin hcl oral SENSOR (INCLUDING 2
1
tablet PLATINUM,
OZEMPIC 2 ST; QL PLATINUM
pioglitazone hcl 1 PEDIATRIC)
RYBELSUS 2 ST; QL DEXCOM G4 / G5 / G6
RECEIVER,
SOLIQUA 2 ST; QL TRANSMITTER,
SYMLINPEN 120 3 PA SENSOR (INCLUDING 2
SYMLINPEN 60 3 PA PLATINUM,
PLATINUM
SYNJARDY 2 ST PEDIATRIC) DEVICE
SYNJARDY XR 2 ST FREESTYLE LIBRE 14
2
TRADJENTA 2 ST DAY READER
TRIJARDY XR 2 ST FREESTYLE LIBRE 14
2
TRULICITY 2 ST; QL DAY SENSOR
VICTOZA 2 ST; QL FREESTYLE LIBRE
2
READER
XIGDUO XR 2 ST
FREESTYLE LIBRE
Diabetes - Glucose 2
SENSOR SYSTEM
Monitoring
ONETOUCH ULTRA 3 ST; QL
ACCU-CHEK
FASTCLIX LANCET 2 ONETOUCH VERIO
3 ST; QL
KIT TEST STRIPS
ACCU-CHEK GUIDE V-GO 20 2
3 ST; QL
TEST STRIPS V-GO 30 2
ACCU-CHEK V-GO 40 2
SOFTCLIX LANCET 2 Diabetes - Glycemic
DEVICE KIT Agents
CONTOUR MONITOR 2 BAQSIMI ONE PACK 2
CONTOUR CONTROL 2 BAQSIMI TWO PACK 2
CONTOUR NEXT GLUCAGON
2 2 Made by Lilly
CONTROL EMERGENCY KIT
CONTOUR NEXT GLUCAGON Made by
2 2
MONITOR EMERGENCY KIT Fresenius
CONTOUR NEXT GVOKE PFS 2
2 QL
TEST
CONTOUR TEST 2 QL
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
Diabetes - Insulins NOVOFINE
BD AUTOSHIELD DUO AUTOCOVER PEN 2
2 NEEDLE
PEN NEEDLES
BD ULTRA-FINE NOVOFINE PEN
2 2
INSULIN SYRINGES NEEDLE
BD ULTRA-FINE PEN NOVOFINE PLUS PEN
2 2
NEEDLES NEEDLE
BD VEO INSULIN SYR NOVOLIN 70/30
2 2
U/F 1/2UNIT FLEXPEN
HUMALOG KWIKPEN 2 NOVOLIN 70/30 VIAL 2
HUMALOG MIX 50/50 NOVOLIN N FLEXPEN 2
2
KWIKPEN NOVOLIN N VIAL 2
HUMALOG MIX 50/50 NOVOLIN R FLEXPEN 2
2
VIAL NOVOLIN R VIAL 2
HUMALOG MIX 75/25 NOVOLOG FLEXPEN 2
2
KWIKPEN
NOVOLOG MIX 70/30
HUMALOG MIX 75/25 2
2 FLEXPEN
VIAL
NOVOLOG MIX 70/30
HUMALOG U-100 2
2 VIAL
JUNIOR KWIKPEN
NOVOLOG PENFILL 2
HUMALOG VIAL 2
NOVOLOG U-100 VIAL 2
HUMULIN 70/30
2 NOVOTWIST PEN
KWIKPEN 2
NEEDLE
HUMULIN 70/30 VIAL 2
TOUJEO MAX
HUMULIN N KWIKPEN 2 2
SOLOSTAR
HUMULIN N VIAL 2 TOUJEO SOLOSTAR 2
HUMULIN R U-500 TRESIBA 2
2
KWIKPEN
TRESIBA
HUMULIN R U-500 2
2 FLEXTOUCH
VIAL
Electrolytes / Minerals
HUMULIN R VIAL 2 / Metals / Vitamins
LANTUS SOLOSTAR 2 cyanocobalamin
LANTUS U-100 VIAL 2 injection solution 1000 1
LEVEMIR U-100 mcg/ml
2
FLEXTOUCH ergocalciferol oral
1
LEVEMIR U-100 VIAL 2 capsule
folic acid oral tablet 1
klor-con m20 1
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
LOKELMA 3 Gastrointestinal
multivitamin/fluoride Agents - Drugs for
oral tablet chewable 1 Bowel, Intestine and
0.25 mg, 0.5 mg, 1 mg Stomach Conditions
NASCOBAL 3 CLENPIQ 3
potassium chloride crys dicyclomine hcl oral
1 1
er capsule
potassium chloride er 1 dicyclomine hcl oral
1
tablet
potassium citrate er 1
diphenoxylate-atropine
sodium fluoride oral 1
1 oral tablet
tablet chewable
gavilyte-g 1
VELTASSA 3
glycopyrrolate oral
vitamin d 1
tablet 1 mg, 2 mg
(ergocalciferol) oral
1 GLYCOPYRROLATE
capsule 1.25 mg 3
(50000 ut) ORAL TABLET 1.5 MG
Gastrointestinal hyoscyamine sulfate sl 1
Agents - Drugs for hyoscyamine sulfate
1
Acid Reflux and Ulcer sublingual
DEXILANT 2 QL lactulose oral solution 1
esomeprazole LINZESS 2 ST; QL
magnesium oral MOTEGRITY 3 ST; QL
1 QL
capsule delayed
release MOVANTIK 2 ST; QL
famotidine oral tablet 1 OMECLAMOX-PAK 2
lansoprazole oral PYLERA 2
capsule delayed 1 QL SUPREP BOWEL
3
release PREP KIT
omeprazole oral SYMPROIC 2 ST; QL
capsule delayed 1 QL TRULANCE 3 ST; QL
release
VIBERZI 3 PA; QL
pantoprazole sodium
oral tablet delayed 1 QL ZELNORM 3 PA; QL
release Genetic or Enzyme
rabeprazole sodium Disorder - Drugs for
oral tablet delayed 1 QL Replacement,
release Modification,
Treatment
sucralfate oral tablet 1
CERDELGA 3 PA; SP
CREON 2
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
19Drug Name Drug Tier Notes Drug Name Drug Tier Notes
NITYR 3 PA; SP terazosin hcl oral
STRENSIQ capsule 1 mg, 10 mg, 5 1
SUBCUTANEOUS mg
SOLUTION 28 2 PA; SP Hormonal Agents -
MG/0.7ML, 40 MG/ML, Adrenal
80 MG/0.8ML dexamethasone oral
1
ZENPEP 2 tablet
Genitourinary Agents hydrocortisone oral 1
- Drugs for Bladder, methylprednisolone
Genital and Kidney 1
oral
Conditions
prednisolone oral
AURYXIA 3 1
solution
DEPEN TITRATABS 2 SP prednisolone sodium
1
MYRBETRIQ 2 phosphate oral solution
oxybutynin chloride er 1 prednisone oral tablet 1
oxybutynin chloride oral prednisone oral tablet
1 1
tablet therapy pack
phenazopyridine hcl TAPERDEX 12-DAY 3
oral tablet 100 mg, 200 1 TAPERDEX 6-DAY 3
mg
TAPERDEX 7-DAY 3
sildenafil citrate oral
tablet 100 mg, 25 mg, 1 QL Hormonal Agents -
50 mg Men's Health
solifenacin succinate 1 ANDRODERM 2 PA
STENDRA 3 QL testosterone cypionate
1 PA
intramuscular
tadalafil oral 1 QL
testosterone
tolterodine tartrate er 1 transdermal gel 1.62 %,
TOVIAZ 3 10 mg/act (2%), 20.25
VELPHORO 3 mg/1.25gm (1.62%),
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
alfuzosin hcl er 1 (1%)
dutasteride oral 1 XYOSTED 3 PA
finasteride oral tablet 5 Hormonal Agents -
1 Osteoporosis
mg
tamsulosin hcl 1 OSPHENA 3
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
Hormonal Agents - Hormonal Agents -
Pituitary Sex Hormones and
ACTHAR 2 PA; SP Birth Control
cabergoline 1 apri 1
FOLLISTIM AQ 2 PA; SP aviane 1
ganirelix acetate BIJUVA 3
solution prefilled blisovi 24 fe 1
1 PA; SP
syringe 250 mcg/0.5ml blisovi fe 1.5/30 1
subcutaneous
blisovi fe 1/20 1
ganirelix acetate
PA; Made by CLIMARA PRO 2
solution prefilled
1 Organon/Merc
syringe 250 mcg/0.5ml cryselle-28 1
k; SP
subcutaneous DIVIGEL 3
LUPRON DEPOT (1- dotti 1
MONTH)
2 PA; SP drospirenone-ethinyl
INTRAMUSCULAR KIT 1
7.5 MG estradiol
LUPRON DEPOT (3- DUAVEE 2
MONTH) ELESTRIN 3
2 PA; SP
INTRAMUSCULAR KIT eluryng 1
22.5 MG
ENDOMETRIN 2
LUPRON DEPOT (4-
MONTH) enskyce 1
2 PA; SP
INTRAMUSCULAR KIT estarylla 1
30MG estradiol oral 1
LUPRON DEPOT (6- estradiol transdermal 1
MONTH)
2 PA; SP estradiol vaginal 1
INTRAMUSCULAR KIT
45MG ESTROGEL 3
NOCDURNA 3 etonogestrel-ethinyl
1
NORDITROPIN estradiol
2 PA; SP
FLEXPRO EVAMIST 3
NUTROPIN AQ femynor 1
2 PA; SP
NUSPIN 10 gianvi 1
NUTROPIN AQ IMVEXXY
2 PA; SP 3
NUSPIN 20 MAINTENANCE PACK
NUTROPIN AQ IMVEXXY STARTER
2 PA; SP 3
NUSPIN 5 PACK
ORILISSA 2 PA; QL isibloom 1
junel 1.5/30 1
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
junel 1/20 1 norgestimate-ethinyl
1
junel fe 1.5/30 1 estradiol triphasic
junel fe 1/20 1 nortrel 1/35 (21) 1
junel fe 24 1 nortrel 1/35 (28) 1
kariva 1 NUVARING 3
kurvelo 1 PREMARIN ORAL 2
larin fe 1/20 1 PREMARIN VAGINAL 2
larissia 1 PREMPHASE 2
lessina 1 PREMPRO 2
levonorgest-eth est & progesterone
1 QL 1
eth est micronized oral
levonorgest-eth estrad sprintec 28 1
91-day oral tablet 0.15- sronyx 1
1 QL
0.03 &0.01 mg, 0.15- syeda 1
0.03 mg
TAYTULLA 3
levonorgestrel-ethinyl
estrad oral tablet 0.1-20 tri femynor 1
1
mg-mcg, 0.15-30 mg- tri-lo-marzia 1
mcg tri-lo-sprintec 1
LO LOESTRIN FE 3 tri-previfem 1
low-ogestrel 1 tri-sprintec 1
MAKENA 2 PA; SP vienva 1
medroxyprogesterone viorele 1
1 QL
acetate intramuscular
xulane 1
medroxyprogesterone
1 Hormonal Agents -
acetate oral
Thyroid
microgestin fe 1/20 1
ARMOUR THYROID 3 ST
MIRENA (52 MG) 3
euthyrox 1
mono-linyah 1
levothyroxine sodium
NATAZIA 2 1
oral
nikki 1 levoxyl 1
norethindrone acetate liothyronine sodium oral 1
1
oral
methimazole oral 1
norethindrone acet-
1
ethinyl est
norethindrone oral 1
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
NATURE-THROID FIRAZYR 3 PA; SP; QL
ORAL TABLET 113.75 HAEGARDA 3 PA; SP
MG, 130 MG, 146.25
MG, 16.25 MG, 195 HUMIRA 2 PA; SP
3 ST
MG, 260 MG, 32.5 MG, HUMIRA PEDIATRIC
2 PA; SP
325 MG, 48.75 MG, 65 CROHNS START
MG, 81.25 MG, 97.5 HUMIRA PEN 2 PA; SP
MG
HUMIRA PEN-
np thyroid oral tablet 60 2 PA; SP
1 CD/UC/HS STARTER
mg
HUMIRA PEN-
SYNTHROID 3 ST PS/UV/ADOL HS 2 PA; SP
TIROSINT 3 START
TIROSINT-SOL 3 INFLECTRA 2 PA; SP
Immunological leflunomide oral 1
Agents - Drugs for
methotrexate oral 1
Immune System
Stimulation or methotrexate sodium
1
Suppression oral
ACTEMRA ACTPEN 3 PA; 3P; SP mycophenolate mofetil
1 SP
oral capsule
ACTEMRA
3 PA; 3P; SP mycophenolate mofetil
SUBCUTANEOUS 1 SP
oral tablet
azathioprine oral 1
mycophenolate sodium 1 SP
CIMZIA 2 PA; SP
ORENCIA CLICKJECT 3 PA; 3P; SP
CIMZIA PREFILLED
2 PA; SP ORENCIA
KIT
SUBCUTANEOUS
CIMZIA STARTER KIT 2 PA; SP SOLUTION 3 PA; 3P; SP
COSENTYX PREFILLED SYRINGE
SENSOREADY (300 3 PA; SP 125 MG/ML
MG) OTEZLA 2 PA; SP
COSENTYX PROGRAF ORAL
3 PA; SP 3 SP
SENSOREADY PEN CAPSULE
cyclosporine modified RASUVO 2 PA; QL
1 SP
oral capsule
RENFLEXIS 2 PA; SP
ENBREL MINI 3 PA; SP
RINVOQ 2 PA; SP
ENBREL
SUBCUTANEOUS RUCONEST 3 PA; SP; QL
3 PA; SP
SOLUTION SIMPONI 2 PA; SP
PREFILLED SYRINGE SIMPONI ARIA 2 PA; SP
ENBREL SURECLICK 3 PA; SP sirolimus oral tablet 1 SP
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
SKYRIZI (150 MG PROLIA 2 PA; SP; QL
2 PA; SP
DOSE) RAYALDEE 3
STELARA TYMLOS 2 PA; SP
2 PA; SP
INTRAVENOUS
Metabolic Bone
STELARA Disease Agents -
2 PA; SP; QL
SUBCUTANEOUS Other
tacrolimus oral 1 SP calcitriol oral capsule 1
TAKHZYRO 3 PA; SP Miscellaneous
TALTZ 3 PA; 3P; SP Therapeutic Agents
TREMFYA 2 PA; SP PA; Non-
BOTOX 2
XELJANZ 2 PA; SP Cosmetic; SP
XELJANZ XR 2 PA; SP DUROLANE 2 PA; SP
XEMBIFY 3 PA; SP ENDARI 3 PA
Inflammatory Bowel EUFLEXXA 2 PA; SP
Disease Agents GELSYN-3 2 PA; SP
APRISO 2 Ophthalmic Agents -
DIPENTUM 3 Drugs for Eye Allergy,
Infection and
LIALDA 3 ST Inflammation
mesalamine oral tablet AZASITE 3
1
delayed release
BESIVANCE 3
PENTASA 3
ciprofloxacin hcl
PROCTOFOAM HC 2 1
ophthalmic
sulfasalazine oral tablet 1 erythromycin
1
UCERIS RECTAL 3 ophthalmic
Metabolic Bone INVELTYS 3
Disease Agents - ketorolac tromethamine
Drugs for 1
ophthalmic
Osteoporosis
LOTEMAX
alendronate sodium 3 QL
1 OPHTHALMIC GEL
oral tablet 10 mg, 5 mg
LOTEMAX
alendronate sodium OPHTHALMIC 3 QL
oral tablet 35 mg, 70 1 QL OINTMENT
mg
LOTEMAX SM 3
BINOSTO 3 QL
MOXEZA 2
FORTEO 2 PA; SP
MOXIFLOXACIN HCL
ibandronate sodium INTRAOCULAR 3
1 QL
oral SOLUTION 5 MG/ML
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
moxifloxacin hcl tobramycin-
1 1
ophthalmic dexamethasone
ofloxacin ophthalmic 1 XIIDRA 2 PA
olopatadine hcl Otic Agents - Drugs
1
ophthalmic for Ear Conditions
PAZEO 2 CIPRODEX 2
prednisolone acetate neomycin-polymyxin-hc
1 1
ophthalmic otic suspension
PROLENSA 2 QL ofloxacin otic 1
Ophthalmic Agents - OTOVEL 3
Drugs for Glaucoma Respiratory Tract /
ALPHAGAN P 2 Pulmonary Agents -
AZOPT 2 Drugs for Allergies,
Cough, Cold
BETIMOL 3
azelastine hcl nasal 1 QL
brimonidine tartrate
1 benzonatate 1
ophthalmic
COMBIGAN 2 cetirizine hcl oral
1
solution
dorzolamide hcl-timolol
1 cyproheptadine hcl oral
mal 1
tablet
latanoprost ophthalmic 1
DYMISTA 2 QL
LUMIGAN 2 QL
FASENRA 2 PA; SP
RHOPRESSA 3 QL
FASENRA PEN 2 PA; SP
ROCKLATAN 3 QL
fluticasone propionate
SIMBRINZA 2 1
nasal
timolol maleate hydrocodone polst-
1 1 PA; QL
ophthalmic solution chlorphen polst er susp
ZIOPTAN 3 QL ipratropium bromide
1
Ophthalmic Agents - nasal
Drugs for levocetirizine
Miscellaneous Eye dihydrochloride oral 1
Conditions tablet
polymyxin b- mometasone furoate
1 1 QL
trimethoprim nasal
RESTASIS 2 PA NUCALA 2 PA; SP; QL
RESTASIS OMNARIS 3 QL
2 PA
MULTIDOSE
promethazine hcl oral
1
tablet
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
promethazine-codeine 1 PA; QL EPIPEN 2-PAK 3 ST
promethazine-dm 1 EPIPEN JR 2-PAK 3 ST
pseudoephedrine- FLOVENT DISKUS 2 QL
bromphen-dm oral 1 FLOVENT HFA 2 QL
syrup
fluticasone-salmeterol
QNASL 3 QL inhalation aerosol
QNASL CHILDRENS 3 QL powder breath
XOLAIR 2 PA; SP activated 100-50 1 QL
mcg/dose, 250-50
ZETONNA 3 QL mcg/dose, 500-50
Respiratory Tract / mcg/dose
Pulmonary Agents - ipratropium-albuterol 1 QL
Drugs for Asthma and
Other Lung LONHALA MAGNAIR
3 QL
Conditions REFILL KIT
ADVAIR DISKUS 2 QL LONHALA MAGNAIR
3 QL
STARTER KIT
ADVAIR HFA 2 QL
montelukast sodium
albuterol sulfate hfa 1
oral tablet
aerosol solution 108
1 QL montelukast sodium
(90 base) mcg/act 1
inhalation oral tablet chewable
ALBUTEROL PERFOROMIST 3 QL
SULFATE HFA PROAIR HFA 3 ST; QL
AEROSOL SOLUTION PROAIR RESPICLICK 3 ST; QL
3 QL
108 (90 BASE)
MCG/ACT PULMICORT
2 QL
INHALATION FLEXHALER
albuterol sulfate QVAR REDIHALER 2 QL
1 QL
inhalation SEREVENT DISKUS 2 QL
ALVESCO 3 ST; QL SPIRIVA
2 QL
ANORO ELLIPTA 2 QL HANDIHALER
ARNUITY ELLIPTA 2 QL SPIRIVA RESPIMAT 2 QL
ATROVENT HFA 3 QL STIOLTO RESPIMAT 2 QL
BREO ELLIPTA 2 QL STRIVERDI
2 QL
RESPIMAT
budesonide inhalation 1 QL
SYMBICORT 2 QL
COMBIVENT
2 QL SYMJEPI 3
RESPIMAT
epinephrine injection TRELEGY ELLIPTA 2 QL
1
solution auto-injector VENTOLIN HFA 3 ST; QL
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
26Drug Name Drug Tier Notes Drug Name Drug Tier Notes
wixela inhub 1 QL SUNOSI 2 PA; QL
YUPELRI 3 QL temazepam 1 QL
Respiratory Tract / WAKIX 3 PA; SP; QL
Pulmonary Agents - XYREM 3 PA; SP; QL
Drugs for Cystic
Fibrosis zolpidem tartrate er 1 QL
BETHKIS 2 SP zolpidem tartrate oral 1 QL
PULMOZYME 2 PA; SP
TOBI PODHALER 3 SP; 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
eszopiclone 1 QL
modafinil 1 PA; QL
SILENOR 3 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
ABSORICA............................... 15 apap-caff-dihydrocodeine........... 7 blisovi 24 fe............................... 21
ABSORICA LD..........................15 apri............................................ 21 blisovi fe 1.5/30......................... 21
ACCU-CHEK FASTCLIX APRISO.................................... 24 blisovi fe 1/20............................ 21
LANCET KIT............................. 17 ARAKODA................................ 11 BOTOX..................................... 24
ACCU-CHEK GUIDE KIT ARANESP (ALBUMIN FREE)... 12 BREO ELLIPTA........................ 26
W/DEVICE................................ 17 aripiprazole............................... 11 BRILINTA..................................11
ACCU-CHEK SOFTCLIX ARISTADA................................ 11 brimonidine tartrate................... 25
LANCET DEVICE KIT...............17 ARISTADA INITIO.................... 11 BRIVIACT................................... 9
acetaminophen-codeine..............7 armodafinil................................ 27 BRYHALI...................................15
acetaminophen-codeine #2.........7 ARMOUR THYROID.................22 budesonide............................... 26
acetaminophen-codeine #3.........7 ARNUITY ELLIPTA...................26 bumetanide............................... 13
acetaminophen-codeine #4.........7 atenolol..................................... 13 BUNAVAIL.................................. 7
ACTEMRA................................ 23 atenolol-chlorthalidone..............13 buprenorphine hcl....................... 7
ACTEMRA ACTPEN.................23 atomoxetine hcl.........................14 buprenorphine hcl-naloxone
ACTHAR................................... 21 atorvastatin calcium.................. 13 hcl............................................... 7
acyclovir.................................... 11 ATROVENT HFA...................... 26 bupropion hcl.............................. 9
ACZONE................................... 15 AUBAGIO..................................14 bupropion hcl er (sr)....................9
ADDERALL XR......................... 14 AURYXIA.................................. 20 bupropion hcl er (xl).................... 9
ADDYI....................................... 15 AUSTEDO.................................15 BUPROPION HCL ER (XL)........ 9
ADEMPAS................................ 27 aviane....................................... 21 buspirone hcl.............................12
ADVAIR DISKUS...................... 26 AVONEX PEN...........................14 butalbital-apap-caffeine...............7
ADVAIR HFA............................ 26 AVONEX PREFILLED.............. 15 BYDUREON..............................16
ADYNOVATE............................12 AZASITE................................... 24 BYDUREON BCISE
AFSTYLA.................................. 12 azathioprine.............................. 23 AUTOINJECTOR...................... 16
AIMOVIG...................................10 azelastine hcl............................ 25 BYETTA 10 MCG PEN............. 16
albuterol sulfate.........................26 azithromycin................................8 BYETTA 5 MCG PEN............... 16
albuterol sulfate hfa...................26 AZOPT...................................... 25 BYSTOLIC................................ 13
ALBUTEROL SULFATE HFA... 26 baclofen.................................... 27 cabergoline............................... 21
alendronate sodium.................. 24 BAFIERTAM............................. 15 CABOMETYX........................... 10
alfuzosin hcl er.......................... 20 BAQSIMI ONE PACK............... 17 calcitriol..................................... 24
allopurinol..................................10 BAQSIMI TWO PACK...............17 candesartan cilexetil................. 13
ALPHAGAN P........................... 25 BD AUTOSHIELD DUO PEN capecitabine..............................10
alprazolam................................ 12 NEEDLES................................. 18 carbamazepine........................... 9
ALVESCO................................. 26 BD ULTRA-FINE INSULIN carbidopa-levodopa.................. 11
amiodarone hcl......................... 12 SYRINGES............................... 18 carisoprodol.............................. 27
amitriptyline hcl........................... 9 BD ULTRA-FINE PEN cartia xt..................................... 13
amlodipine besylate.................. 12 NEEDLES................................. 18 carvedilol...................................13
amlodipine besylate-benazepril BD VEO INSULIN SYR U/F cefdinir........................................ 8
hcl............................................. 12 1/2UNIT.....................................18 cefuroxime axetil......................... 8
amlodipine besylate-valsartan.. 12 BELBUCA................................... 7 celecoxib..................................... 7
amlodipine-olmesartan..............12 benazepril hcl............................13 cephalexin...................................8
amoxicillin................................... 8 benzonatate.............................. 25 CERDELGA.............................. 19
amoxicillin-potassium benztropine mesylate................11 cetirizine hcl.............................. 25
clavulanate..................................8 BESIVANCE............................. 24 CHANTIX.................................... 7
amphetamine- betamethasone dipropionate.... 15 CHANTIX CONTINUING
dextroamphetamine.................. 14 BETASERON............................15 MONTH PAK...............................7
amphetamine- BETHKIS...................................27 CHANTIX STARTING MONTH
dextroamphetamine er.............. 14 BETIMOL.................................. 25 PAK.............................................7
AMPYRA...................................14 BIJUVA..................................... 21 chlorhexidine gluconate............ 15
AMZEEQ...................................15 BIKTARVY................................ 11 chlorthalidone............................13
anastrozole............................... 10 BINOSTO..................................24 ciclopirox................................... 10
ANDRODERM.......................... 20 bisoprolol fumarate................... 13 CIMDUO................................... 11
ANORO ELLIPTA..................... 26 bisoprolol-hydrochlorothiazide.. 13 CIMZIA......................................23
28CIMZIA PREFILLED KIT...........23 dexmethylphenidate hcl............ 14 EPIDIOLEX................................. 9
CIMZIA STARTER KIT............. 23 dexmethylphenidate hcl er........ 14 EPIDUO FORTE....................... 16
CIPRODEX............................... 25 diazepam.................................. 12 epinephrine............................... 26
ciprofloxacin hcl.................... 8, 24 diclofenac sodium....................... 7 EPIPEN 2-PAK......................... 26
citalopram hydrobromide............ 9 dicyclomine hcl..........................19 EPIPEN JR 2-PAK.................... 26
claravis......................................15 DIFICID....................................... 8 ergocalciferol.............................18
clarithromycin..............................8 digoxin.......................................13 erythromycin............................. 24
CLENPIQ.................................. 19 diltiazem hcl er coated beads... 13 escitalopram oxalate................... 9
CLIMARA PRO......................... 21 dilt-xr......................................... 13 esomeprazole magnesium........19
clindamycin hcl............................8 DIPENTUM............................... 24 estarylla.....................................21
clindamycin phosphate....... 15, 16 diphenoxylate-atropine..............19 estradiol.................................... 21
CLINDAMYCIN PHOSPHATE.. 16 divalproex sodium....................... 9 ESTROGEL.............................. 21
clindamycin phosphate- divalproex sodium er...................9 eszopiclone............................... 27
benzoyl peroxide.......................15 DIVIGEL....................................21 etodolac...................................... 7
CLINDESSE................................8 donepezil hcl............................... 9 etonogestrel-ethinyl estradiol.... 21
clobetasol propionate................16 dorzolamide hcl-timolol mal...... 25 EUCRISA.................................. 16
clonazepam...............................12 dotti........................................... 21 EUFLEXXA............................... 24
clonidine hcl.............................. 13 DOVATO...................................11 euthyrox.................................... 22
clopidogrel bisulfate.................. 11 doxazosin mesylate.................. 13 EVAMIST.................................. 21
clotrimazole...............................10 doxepin hcl..................................9 EVEKEO ODT...........................14
clotrimazole-betamethasone.....10 doxycycline hyclate..................... 8 ezetimibe...................................13
colchicine.................................. 10 doxycycline monohydrate........... 8 ezetimibe-simvastatin............... 13
COMBIGAN.............................. 25 drospirenone-ethinyl estradiol...21 famotidine................................. 19
COMBIVENT RESPIMAT......... 26 DUAVEE................................... 21 FARXIGA.................................. 16
CONTOUR CONTROL............. 17 duloxetine hcl.............................. 9 FASENRA................................. 25
CONTOUR MONITOR.............. 17 DUPIXENT................................16 FASENRA PEN.........................25
CONTOUR NEXT CONTROL...17 DUROLANE.............................. 24 febuxostat................................. 10
CONTOUR NEXT MONITOR... 17 dutasteride................................ 20 femynor..................................... 21
CONTOUR NEXT TEST........... 17 DYMISTA.................................. 25 fenofibrate................................. 13
CONTOUR TEST......................17 EDARBI.....................................13 fenofibrate micronized...............13
COPAXONE..............................15 EDARBYCLOR......................... 13 fenofibric acid............................13
CORLANOR..............................13 ELESTRIN................................ 21 fentanyl....................................... 7
COSENTYX SENSOREADY eletriptan hydrobromide............ 10 FINACEA.................................. 16
(300 MG)...................................23 ELIQUIS......................................8 finasteride................................. 20
COSENTYX SENSOREADY ELIQUIS DVT/PE STARTER FIRAZYR...................................23
PEN...........................................23 PACK.......................................... 8 flecainide acetate...................... 13
CREON..................................... 19 ELOCTATE............................... 12 FLOVENT DISKUS................... 26
CRESEMBA..............................10 eluryng...................................... 21 FLOVENT HFA......................... 26
cryselle-28.................................21 EMGALITY................................10 fluconazole................................10
cyanocobalamin........................ 18 EMGALITY (300 MG DOSE).... 10 fluocinonide...............................16
cyclobenzaprine hcl.................. 27 EMVERM.................................. 11 FLUOROPLEX..........................16
cyclosporine modified............... 23 enalapril maleate.......................13 fluoxetine hcl............................... 9
cyproheptadine hcl....................25 ENBREL....................................23 fluticasone propionate...............25
DEPEN TITRATABS.................20 ENBREL MINI........................... 23 fluticasone-salmeterol............... 26
DESCOVY................................ 11 ENBREL SURECLICK.............. 23 fluvoxamine maleate................... 9
desvenlafaxine succinate er........9 ENDARI.................................... 24 folic acid.................................... 18
dexamethasone........................ 20 ENDOMETRIN..........................21 FOLLISTIM AQ......................... 21
DEXCOM G4 / G5 / G6 enoxaparin sodium......................8 FORFIVO XL...............................9
RECEIVER, TRANSMITTER, enskyce.....................................21 FORTEO................................... 24
SENSOR (INCLUDING ENSTILAR................................ 16 FREESTYLE LIBRE 14 DAY
PLATINUM, PLATINUM entecavir................................... 11 READER................................... 17
PEDIATRIC)..............................17 ENTRESTO.............................. 13 FREESTYLE LIBRE 14 DAY
DEXILANT................................ 19 EPCLUSA................................. 11 SENSOR...................................17
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