YOUR 2022 PRESCRIPTION DRUG LIST - TRADITIONAL 3-TIER - UNITEDHEALTHCARE
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Pharmacy | PDL Your 2022 Prescription Drug List Traditional 3-Tier Effective May 1, 2022 This Prescription Drug List (PDL) is accurate as of May 1, 2022 and is subject to change after this date. This PDL applies to members of our UnitedHealthcare, River Valley, Oxford, and Student Resources medical plans with a pharmacy benefit subject to the Traditional 3-Tier PDL. Your estimated coverage and copayment/coinsurance may vary based on the benefit plan you choose and the effective date of the plan.
Table of contents
Understanding your Prescription Drug List (PDL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Medication tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Reading your PDL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Analgesics
Drugs for Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Drugs for Pain and Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Anti-Addiction / Substance Abuse Treatment Agents . . . . . . . . . . . . . . . . . . . . . . . . 10
Antibacterials
Drugs for Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Anticoagulants
Drugs to Treat or Prevent Blood Clots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Anticonvulsants
Drugs for Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Antidementia Agents
Drugs for Alzheimer’s Disease and Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Antidepressants
Drugs for Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Antiemetics
Drugs for Nausea and Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Antifungals
Drugs for Fungal Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Antigout Agents
Drugs for Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Antimigraine Agents
Drugs for Migraines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Antineoplastics
Drugs for Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Antiparasitics
Drugs for Parasitic Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Anti-Parkinson’s Agents
Drugs for Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Antiplatelets
Drugs for Heart Attack and Stroke Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Antipsychotics
Drugs for Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Antivirals
Drugs for Viral Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Anxiolytics
Drugs for Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Bipolar Agents
Drugs for Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Cardiovascular Agents
Drugs for Heart and Circulation Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Central Nervous System Agents
Drugs for Attention Deficit Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Drugs for Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Dental and Oral Agents
Drugs for Mouth and Throat Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2Dermatological Agents
Drugs for Skin Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Diabetes
Glucose Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Non-Insulin Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Drugs for Blood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Drugs for Sexual Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Electrolytes / Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Gastrointestinal Agents
Drugs for Acid Reflux and Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Drugs for Bowel, Intestine and Stomach Conditions . . . . . . . . . . . . . . . . . . . . . . . 28
Genetic or Enzyme Disorder
Drugs for Replacement, Modification, Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 28
Genitourinary Agents
Drugs for Bladder, Genital and Kidney Conditions. . . . . . . . . . . . . . . . . . . . . . . . . 29
Drugs for Prostate Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Hormonal Agents
Hormone Replacement and Birth Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Oral Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Testosterone Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Immunological Agents
Drugs for Immune System Stimulation or Suppression . . . . . . . . . . . . . . . . . . . . . 33
Infertility Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Inflammatory Bowel Disease Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Metabolic Bone Disease Agents
Drugs for Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Ophthalmic Agents
Drugs for Eye Allergy, Infection and Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . 35
Drugs for Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Drugs for Miscellaneous Eye Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Otic Agents
Drugs for Ear Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Respiratory
Drugs for Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Respiratory Tract / Pulmonary Agents
Drugs for Allergies, Cough, Cold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Drugs for Asthma and COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Drugs for Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Drugs for Pulmonary Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Skeletal Muscle Relaxants
Drugs for Muscle Pain and Spasm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Sleep Disorder Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
3Understanding your Prescription Drug List (PDL)
What is a PDL?
This document is a list of the most commonly prescribed medications. It includes About this PDL
both brand-name and generic prescription medications approved by the Food and
Where differences exist between
Drug Administration (FDA). Medications are listed by common categories or classes
this PDL and your benefit plan
and placed in tiers that represent the cost you pay out-of-pocket. They are then
documents, the benefit plan
listed in alphabetical order.
documents rule. This PDL is not
a complete list of medications,
How do I use my PDL? and not all medications listed
You and your doctor can consult the PDL to help you select the most cost-effective may be covered by your plan.
prescription medications. This guide tells you if a medication is generic or a brand- Please look at the benefit plan
name, and if there are coverage requirements or limits. Bring this list with you documents provided by your
when you see your doctor. If your medication is not listed here, please visit your employer or health plan to see
plan’s member website or call the toll-free member phone number on your member which medications are covered
ID card. under your plan.
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 benefit plan. This is how much you will pay when you fill a prescription. See page 6 for
more information.
When does the PDL change?
PDL changes typically occur 2-3 times per year. However, changes that have a positive impact for you — such as coverage for
new medications or cost savings — may occur at any time. You can log in to the member website listed on your member ID card
at any time to check your medication coverage and lower-cost options.
Why are some medications excluded from coverage?
We review medications based on their total value, including effectiveness and safety, how much they cost, and the availability of
alternative medications to treat the same or similar medical conditions. Certain medications may be excluded from coverage or
be subject to prior authorization (sometimes referred to as precertification)1 if similar alternatives are available at a lower cost.
Examples include medications that work the same way, but one is much more expensive than the other, or options that are
available without a prescription (also referred to as over-the-counter medications2). There are also some instances where the
same product can be made by 2 or more manufacturers, but greatly vary in cost. In these instances, only the lower-cost product
may be covered.
You should review your benefit plan documents to confirm if any medications are excluded from your plan. You can log in to
the member website listed on your member ID card at any time to check your medication coverage. Talk to your doctor to see if
there are lower-cost options or over-the-counter medications available.
Who decides which medications are covered?
Thousands of medications are already available and more come to the market regularly. Often, several medications are available
to treat the same condition. The UnitedHealthcare® Pharmacy and Therapeutics Committee, which includes both internal and
external doctors and pharmacists, meets regularly to provide clinical reviews of all medications. Using this information, the PDL
Management Committee, which includes senior UnitedHealth Group® doctors and business leaders, meets to evaluate overall
health care value. They also set coverage and tier status for all medications.
1. Depending on your benefit, you may have notification or medical necessity requirements for select medications.
2. For New York and New Jersey plans, a prescription drug product that is therapeutically equal to an over-the-counter
drug may be covered if it is determined to be medically necessary.
4Medication tips
What is the difference between brand-name and
generic medications? Over-the-counter
Generic medications contain the same active ingredients (what makes the
(OTC) medications
medication work) as brand-name medications, but they often cost less. Once the An OTC medication may be
patent for a brand-name medication ends, the FDA can approve a generic version the right treatment option for
with the same active ingredients. These types of medications are known as generic some conditions. Talk to your
medications. Sometimes, the same company that makes a brand-name medication doctor about available OTC
also makes the generic version. options. Even though these
medications may not be covered
What if my doctor writes a brand-name prescription? by your pharmacy benefit,
they may cost less than a
If your doctor gives you a prescription for a brand-name medication, ask if a generic prescription medication.
equivalent or lower-cost option is available and could be right for you. Generic
medications are usually your lowest-cost option, but not always. For some benefit
plans, if a brand-name drug is prescribed and a generic equal is available, your
cost-share may be the copayment PLUS the cost difference between the brand-
name drug and the generic equivalent.
What if I am taking a specialty medication?
Specialty medications are high-cost and are used to treat rare or complex
conditions that require additional care and support. For most plans, these
medications are managed through the specialty pharmacy program. Take
advantage of personalized support designed to help you get the most out of your
treatment plan. Visit the member website listed on your member ID card or call the
toll-free phone number on your member ID card to learn more.
Please note, not all specialty medications are listed here. If you’re taking a specialty
medication that is on a higher tier, call the toll-free phone number on your member
ID card to talk with a pharmacist about finding lower-cost options.
5Reading your PDL
The PDL gives you choices so you and your doctor can decide your best course of treatment. In this PDL, brand-name
medications are shown in UPPERCASE and generic medications in lowercase.
Tier information
Using lower-tier 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 may apply once you hit your deductible.
In the chart below, overall value indicates medications’ effectiveness and safety, cost and the availability of alternative
medications to treat the same or similar medical condition(s).
Drug Tier Includes Helpful Tips
Tier 1 $ Lower-cost
Use Tier 1 drugs for the
Medications that provide the highest overall value. Mostly
lowest out-of-pocket costs.
generic drugs. Some brand-name drugs may also be included.
Tier 2 $$ Mid-range cost Use Tier 2 drugs, instead of
Medications that provide good overall value. Mainly preferred Tier 3, to help reduce your
brand-name drugs. out-of-pocket costs.
Tier 3 $$$ Highest-cost Ask your doctor if a Tier 1 or
Medications that provide the lowest overall value. Tier 2 option 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 sets how these medications may be covered for you.
E May be excluded from coverage or subject to Prior Authorization in Connecticut, New Jersey and
New York. (Referred to as First Start in New Jersey) — Lower-cost options are available and covered.
H Health Care Reform Preventive — This medication is part of a health care reform preventive benefit and may
be available at no additional cost to you.
H-PA Health Care Reform Preventive with Prior Authorization — May be part of health care reform preventive and
available at no additional cost to you if prior authorization criteria is met.
PA Prior Authorization (sometimes referred to as precertification)3 — Requires your doctor to provide
information about why you are taking a medication to determine how it may be covered by your plan.4
QL Quantity Limits — Specifies the largest quantity of medication covered per copayment or in a defined period
of time.
RS Refill and Save Program5 — Save money on your copayment when you refill your prescription on time as
prescribed. Program eligibility may vary.
SP Specialty Medication — Specialty medications treat complex or rare conditions and may require special
storage and handling. You may be required to obtain these medications from a specialty pharmacy.
ST Step Therapy (referred to as First Start in New Jersey) — Requires prior authorization and may require you to
try one or more other medications before the medication you are requesting may be covered.6
3 Depending on your benefit, you may have notification or medical necessity requirements for select medications.
4. For certain Student Resources plans, applies to specialty medications and topical retinoids only.
5. Not applicable to Oxford and Student Resources plans.
6. Not applicable to certain Student Resources plans.
6Reading your PDL (continued)
Coverage details
Some drug classes in this PDL have additional/important coverage details. Review this list to see if drug classes that apply
to you are noted.
• Diabetes: blood glucose monitoring, insulin, non-insulin
Diabetic supplies and prescription medications may be subject to different cost-share arrangements for Oxford plans.
Please see your Summary of Benefits and Coverage (SBC) for specifics.
• Diabetes: continuous glucose monitors, sensors
Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit
coverage and cost-share. Diabetic self-management items, including continuous glucose monitors, may be covered
under the consumer pharmacy and/or medical plan depending on the benefit.
• Endocrine: growth hormone
Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit
coverage and cost-share.
• Infertility
Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit
coverage and cost-share. Prior authorization (sometimes referred to as precertification) may be required for Oxford plans
or where a state mandates infertility drug coverage. This is not a covered benefit for Neighborhood Health Plan.
• Medications for sexual dysfunction
Coverage is set by the consumer’s prescription drug benefit plan. Please consult plan documents regarding benefit
coverage and cost-share.
Questions
For the most current list of covered medications or if you have questions:
Call the toll-free phone number on your member ID card
And, if home delivery services
are included in your pharmacy
Visit your plan’s member website listed on your member ID card to: benefit, you can also:
• View your pharmacy benefit and coverage information, including • Refill prescriptions
prescription history • Check the status of your order
• View medication interactions and side effects • Set up reminders for refills
• Locate a participating retail pharmacy by ZIP code • Manage your account
• Look up possible lower-cost medication alternatives
• Compare medication pricing and options
7Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
Analgesics - Drugs for Pain g hydromorphone hcl rectal 1
g acetaminophen-codeine 1 B HYSINGLA ER E PA, ST, QL
g acetaminophen-codeine #2 1 B LIDO BDK E QL
g acetaminophen-codeine #3 1 g lidocaine external ointment 5 % 1 QL
g acetaminophen-codeine #4 1 g lidocaine external patch 5 % 1 PA, QL
B AGONEAZE E QL g lidocaine-prilocaine external cream 1
B ANODYNE LPT E QL g lidocaine-prilocaine external kit E QL
g apap-caff-dihydrocodeine 1 QL B LIDOCANNA E
g bac 1 QL B LIDODERM E PA, QL
B BELBUCA 3 PA, QL B LIDOPRIL E QL
g butalbital-apap-caffeine 1 QL B LIDOPRIL XR E QL
B CONZIP E QL B LIDO-PRILO CAINE PACK E QL
B DILAUDID ORAL 3 B LIVIXIL PAK E QL
B DUROLANE E B LORTAB 3
B EHA E g morphine sulfate (concentrate) oral 1
g endocet 1 solution 100 mg/5ml, 20 mg/ml
B ESGIC 3 QL
g morphine sulfate er oral capsule E PA, ST, QL
extended release 24 hour
B EUFLEXXA E
g morphine sulfate er oral tablet 1 PA, QL
g fentanyl transdermal patch 72 hour 1 PA, QL extended release
100 mcg/hr, 12 mcg/hr, 25 mcg/hr,
50 mcg/hr, 75 mcg/hr
g morphine sulfate oral 1
g fentanyl transdermal patch 72 hour E PA, ST, QL
g morphine sulfate rectal 1
37.5 mcg/hr, 62.5 mcg/hr, MS CONTIN 3 PA, ST, QL
87.5 mcg/hr B NALOCET E QL
B FIORICET 3 QL B NUCYNTA 3 QL
B GELSYN-3 E B NUCYNTA ER 3 PA, QL
B GEN7T E B OXAYDO E QL
B HYALGAN E B OXYCODONE HCL ER E PA, ST, QL
g hydrocodone bitartrate er oral 1 PA, ST, QL g oxycodone hcl oral capsule 1
capsule extended release 12 hour
g oxycodone hcl oral concentrate 1
g hydrocodone bitartrate er oral E PA, ST, QL 100 mg/5ml
tablet er 24 hour abuse-deterrent
g oxycodone hcl oral solution 1
g hydrocodone-acetaminophen oral 1
solution 10-325 mg/15ml,
g oxycodone hcl oral tablet 10 mg, 1
7.5-325 mg/15ml 15 mg, 20 mg, 30 mg
g hydrocodone-acetaminophen oral E
g oxycodone hcl oral tablet 5 mg 1 QL
tablet 10-300 mg, 5-300 mg, B OXYCODONE-ACETAMINOPHEN E
7.5-300 mg ORAL SOLUTION
g hydrocodone-acetaminophen oral 1 B OXYCODONE-ACETAMINOPHEN E
tablet 10-325 mg, 5-325 mg, ORAL TABLET 10-300 MG,
7.5-325 mg 5-300 MG
g hydromorphone hcl er 1 PA, ST, QL g oxycodone-acetaminophen oral 1
g hydromorphone hcl oral 1 tablet 10-325 mg, 2.5-325 mg,
5-325 mg, 7.5-325 mg
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
8Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B OXYCODONE-ACETAMINOPHEN E QL Analgesics - Drugs for Pain and Inflammation
ORAL TABLET 2.5-300 MG B CATAFLAM E
B OXYCONTIN E PA, ST, QL B CELEBREX E QL
B PERCOCET E g celecoxib oral 1 QL
g premium lidocaine 1 QL g diclofenac potassium oral tablet E
B PRILO PATCH E 25 mg
B PRILO PATCH II E g diclofenac potassium oral tablet 1
B PRILOLID E QL 50 mg
B PRILOVIX E QL
g diclofenac sodium er 1
B PRILOVIX LITE E QL
g diclofenac sodium external gel 1 % E
B PRILOVIX LITE PLUS E QL
g diclofenac sodium external solution E
B PRILOVIX PLUS E QL
g diclofenac sodium oral 1
B PRILOVIX ULTRALITE E QL
B DICLOFONO E
B PRILOVIX ULTRALITE PLUS E QL
B EC-NAPROSYN ORAL TABLET 3
DELAYED RELEASE 375 MG
B PRIZOTRAL-II E
B EC-NAPROSYN ORAL TABLET 3
B PROLATE E DELAYED RELEASE 500 MG
B QDOLO E PA, QL g ec-naproxen 1
B RELADOR PAK E QL B ENOVARX-DICLOFENAC SODIUM E
B RELADOR PAK PLUS E QL g etodolac 1
B ROXICODONE ORAL TABLET E g etodolac er 1
15 MG, 30 MG
g ibuprofen oral suspension E
B ROXICODONE ORAL TABLET E QL 100 mg/5ml
5 MG
g ibuprofen oral tablet 400 mg, 1
B SUBSYS E PA, QL 600 mg, 800 mg
B SUPARTZ FX E B INDOCIN 3 PA
g tramadol hcl er (biphasic) E (generic for g indomethacin er 1
Ryzolt), QL
B INDOMETHACIN ORAL CAPSULE E
B TRAMADOL HCL ER ORAL E QL 20 MG
CAPSULE EXTENDED RELEASE
24 HOUR
g indomethacin oral capsule 25 mg, 1
50 mg
g tramadol hcl er oral tablet extended 1 (generic for
release 24 hour Ultram ER), QL
B KETOROLAC TROMETHAMINE 3 ST, QL
NASAL
g tramadol hcl oral tablet 100 mg E
g ketorolac tromethamine oral 1
g tramadol hcl oral tablet 50 mg 1
B LODINE E
B TREZIX 1 QL
g meloxicam oral capsule E QL
B TRILURON E
g meloxicam oral tablet 1
B ULTRAM E
B MOBIC E
B VEXATROL E QL
g nabumetone oral 1
B VTOL LQ 2 PA, QL
B NAPRELAN E
B XTAMPZA ER 2 PA, QL
B NAPROSYN ORAL SUSPENSION E PA
B ZEBUTAL 3 QL
B NAPROSYN ORAL TABLET E
B ZTLIDO 3 PA, QL
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
9Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g naproxen oral suspension E PA B BACTRIM 3
g naproxen oral tablet 1 B BACTRIM DS 3
g naproxen oral tablet delayed 1 g cefadroxil 1
release g cefdinir 1
g naproxen sodium er oral tablet E g cefuroxime axetil 1
extended release 24 hour 375 mg,
500 mg
B CENTANY 3 QL
B NAPROXEN SODIUM ER ORAL E
B CENTANY AT E
TABLET EXTENDED RELEASE g cephalexin 1
24 HOUR 750 MG B CIPRO ORAL TABLET 3
g naproxen sodium oral tablet 1 g ciprofloxacin hcl oral 1
275 mg, 550 mg g clarithromycin er 1
B PENNSAID E g clarithromycin oral 1
B RELAFEN E B CLEOCIN ORAL CAPSULE 3
B RELAFEN DS E 150 MG, 300 MG
B SPRIX 3 ST, QL B CLEOCIN ORAL CAPSULE 75 MG 2
B TIVORBEX E g clindamycin hcl oral 1
B VALCOPREP-100 E B CLINDESSE 2
B VENNGEL ONE E g coremino E PA
B VIVLODEX E QL B DIFICID 3 QL
B ZIPSOR E B DORYX E
Anti-Addiction / Substance Abuse Treatment Agents B DORYX MPC E
B APO-VARENICLINE E g doxycycline hyclate oral capsule 1
g buprenorphine hcl sublingual 1 QL g doxycycline hyclate oral tablet 1
g buprenorphine hcl-naloxone hcl 1 QL 100 mg, 20 mg
B KLOXXADO 2 QL g doxycycline hyclate oral tablet E
g naloxone hcl injection 1 150 mg, 50 mg, 75 mg
g naltrexone hcl oral 1
g doxycycline hyclate oral tablet E
delayed release 100 mg, 150 mg,
B NARCAN 2 QL 200 mg, 50 mg, 75 mg
B SUBOXONE E PA, QL B DOXYCYCLINE HYCLATE ORAL E
g varenicline tartrate 1 PA, H TABLET DELAYED RELEASE
B ZUBSOLV 1 QL 80 MG
Antibacterials - Drugs for Infections
g doxycycline monohydrate oral 1
capsule 100 mg, 50 mg
B ACTICLATE E
g doxycycline monohydrate oral E
g amoxicillin 1 capsule 150 mg, 75 mg
g amoxicillin-potassium clavulanate 1 g doxycycline monohydrate oral 1
g amoxicillin-potassium clavulanate er E suspension reconstituted
B AUGMENTIN E g doxycycline monohydrate oral 1
B AUGMENTIN ES-600 E tablet
g avidoxy 1 B FLAGYL 3
g azithromycin oral 1 B KEFLEX 3
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
10Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g levofloxacin oral 1 g jantoven 1
B LYMEPAK E B LOVENOX E QL
g metronidazole oral 1 B PRADAXA 2 QL
g metronidazole vaginal 1 g warfarin sodium oral 1
B MINOCYCLINE HCL ER ORAL E PA B XARELTO 2 QL
CAPSULE EXTENDED RELEASE B XARELTO STARTER PACK 2 QL
24 HOUR
Anticonvulsants - Drugs for Seizures
g minocycline hcl er oral tablet E PA
extended release 24 hour 105 mg,
B BRIVIACT 3 PA
115 mg, 55 mg, 65 mg, 80 mg g carbamazepine er 1
g minocycline hcl er oral tablet E PA g carbamazepine oral 1
extended release 24 hour 135 mg, B CARBATROL 3
45 mg, 90 mg B DEPAKOTE 3 PA
g minocycline hcl oral capsule 1 B DEPAKOTE ER 3 PA, ST
g minocycline hcl oral tablet E B DEPAKOTE SPRINKLES 3 PA, ST
B MINOLIRA E PA B DIASTAT ACUDIAL 3 QL
g mondoxyne nl oral capsule 100 mg 1 B DIASTAT PEDIATRIC 2 QL
g mondoxyne nl oral capsule 75 mg E g diazepam rectal 1 QL
g mupirocin calcium 1 QL g divalproex sodium er 1
g mupirocin external 1 QL g divalproex sodium oral 1
B NUVESSA E B ELEPSIA XR E PA, ST
B NUZYRA ORAL 3 QL g epitol 1
g penicillin v potassium 1 g gabapentin oral capsule 1
B SOLODYN E PA g gabapentin oral solution 1
g sulfamethoxazole-trimethoprim oral 1 250 mg/5ml
g sulfatrim pediatric 1 g gabapentin oral tablet 1
B TARGADOX E B KEPPRA ORAL 3 PA, ST
g vandazole 1 B KEPPRA XR 3 PA, ST
B VIBRAMYCIN ORAL CAPSULE 3 B LAMICTAL 3 PA, ST
B VIBRAMYCIN ORAL SUSPENSION 3 B LAMICTAL ODT ORAL KIT 21 X 3 PA, ST
RECONSTITUTED 25 MG & 7 X 50 MG, 42 X 50 MG &
B XENLETA ORAL 3 14X100 MG
B XEPI 3 QL B LAMICTAL ODT ORAL KIT 25 & 50 3 PA, ST
B XIMINO E PA & 100 MG
B ZITHROMAX ORAL 3
B LAMICTAL ODT ORAL TABLET 3 PA, ST
DISPERSIBLE
B ZITHROMAX TRI-PAK 3
B LAMICTAL STARTER 3 PA, ST
B ZITHROMAX Z-PAK 3
B LAMICTAL XR 3 PA, ST
Anticoagulants - Drugs to Treat or Prevent Blood Clots
g lamotrigine er 1 PA, ST
B ELIQUIS 2 QL
g lamotrigine oral kit 1 PA, ST
B ELIQUIS DVT/PE STARTER PACK 2 QL
g lamotrigine oral tablet 1
g enoxaparin sodium 1 QL
g lamotrigine oral tablet chewable 1
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
11Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g lamotrigine oral tablet dispersible 1 PA, ST g bupropion hcl er (xl) oral tablet 1
g lamotrigine starter kit-blue 1 extended release 24 hour 150 mg,
300 mg
g lamotrigine starter kit-green 1
B BUPROPION HCL ER (XL) ORAL E QL
g lamotrigine starter kit-orange 1 TABLET EXTENDED RELEASE
g levetiracetam er 1 24 HOUR 450 MG
g levetiracetam oral 1 g bupropion hcl oral 1
B NAYZILAM 3 PA, QL B CELEXA E
B NEURONTIN 3 PA, ST g citalopram hydrobromide 1
g oxcarbazepine 1 B CYMBALTA E QL
B OXTELLAR XR E ST g desvenlafaxine succinate er 1 QL
B QUDEXY XR E ST g doxepin hcl oral capsule 1
g roweepra 1 g doxepin hcl oral concentrate 1
B SPRITAM E ST B DRIZALMA SPRINKLE 3 PA, QL
g subvenite 1 g duloxetine hcl oral capsule delayed 1 QL
g subvenite starter kit-blue 1 release particles 20 mg, 30 mg,
60 mg
g subvenite starter kit-green 1
g duloxetine hcl oral capsule delayed E
g subvenite starter kit-orange 1
release particles 40 mg
B TEGRETOL 3 B EFFEXOR XR E
B TEGRETOL-XR 3 g escitalopram oxalate 1
B TOPAMAX 3 PA, ST g fluoxetine hcl oral capsule 1
B TOPAMAX SPRINKLE 3 PA, ST g fluoxetine hcl oral capsule delayed 1 QL
g topiramate er E ST release
g topiramate oral 1 g fluoxetine hcl oral solution 1
B TRILEPTAL 3 PA, ST g fluoxetine hcl oral tablet 10 mg 1 QL
B TROKENDI XR E ST g fluoxetine hcl oral tablet 20 mg 1
B VALTOCO 3 PA, QL g fluoxetine hcl oral tablet 60 mg E
B VIMPAT ORAL 3 PA g fluvoxamine maleate 1
B XCOPRI 3 PA g fluvoxamine maleate er 1 QL
B ZONEGRAN 3 PA, ST B FORFIVO XL E QL
g zonisamide oral 1 B LEXAPRO E
Antidementia Agents - Drugs for Alzheimer's Disease g mirtazapine oral 1
and Dementia g nortriptyline hcl oral 1
B ARICEPT E B PAMELOR E
g donepezil hcl oral tablet 10 mg, 1 g paroxetine hcl 1
5 mg
g paroxetine hcl er 1 QL
g donepezil hcl oral tablet 23 mg E
B PAXIL CR E QL
g donepezil hcl oral tablet dispersible 1
B PAXIL ORAL SUSPENSION 3
Antidepressants - Drugs for Depression
B PAXIL ORAL TABLET E
g amitriptyline hcl oral 1
B PRISTIQ E QL
g bupropion hcl er (sr) 1
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
12Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B PROZAC E Antifungals - Drugs for Fungal Infections
B REMERON E g ciclodan 1
B REMERON SOLTAB E g ciclopirox external 1
B SERTRALINE HCL ORAL CAPSULE E g ciclopirox treatment E
g sertraline hcl oral concentrate 1 B CRESEMBA ORAL 3
g sertraline hcl oral tablet 1 B DIFLUCAN E
g trazodone hcl oral 1 B EXTINA 3 ST
B TRINTELLIX 3 ST, QL g fluconazole oral 1
g venlafaxine hcl 1 B GYNAZOLE-1 3
g venlafaxine hcl er oral capsule 1 g ketoconazole external cream 1 QL
extended release 24 hour g ketoconazole external foam 1 ST
g venlafaxine hcl er oral tablet E QL g ketoconazole external shampoo 1
extended release 24 hour
g ketodan external foam 1 ST
B VIIBRYD 3 QL
B LOPROX EXTERNAL SHAMPOO E
B VIIBRYD STARTER PACK 3
g nyamyc 1 QL
B WELLBUTRIN SR E
g nystatin external 1 QL
B WELLBUTRIN XL E
g nystatin mouth/throat 1
B ZOLOFT E
g nystop 1 QL
Antiemetics - Drugs for Nausea and Vomiting
g terbinafine hcl oral 1 QL
B BONJESTA E PA
g terconazole 1
B DICLEGIS E PA
B XOLEGEL 3
g doxylamine-pyridoxine E PA
Antigout Agents - Drugs for Gout
B GIMOTI E QL
g allopurinol oral 1
g metoclopramide hcl oral solution 1
B COLCHICINE ORAL CAPSULE E
g metoclopramide hcl oral tablet 1
g colchicine oral tablet E
g metoclopramide hcl oral tablet E
dispersible
B COLCRYS E
g ondansetron hcl oral 1
g febuxostat 1 ST, QL
g ondansetron odt 1
B GLOPERBA 3 PA
g prochlorperazine maleate oral 1
B MITIGARE 2
g promethazine hcl oral tablet 1
B ULORIC E ST, QL
g promethazine hcl rectal 1
B ZYLOPRIM 3
g promethegan 1 Antimigraine Agents - Drugs for Migraines
B REGLAN 3
B AIMOVIG 2 PA, ST
g scopolamine 1
B AIMOVIG SUBCUTANEOUS 2 PA, ST, QL
SOLUTION AUTO-INJECTOR
B TRANSDERM-SCOP (1.5 MG) E 140 MG/ML
TRANSDERMAL PATCH 72 HOUR
1 MG/3DAYS
B AMERGE E QL
B ZOFRAN E
g eletriptan hydrobromide 1 QL
B ZUPLENZ E QL
B EMGALITY 2 PA, ST, QL
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
13Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B EMGALITY (300 MG DOSE) 2 PA, ST, QL B KOSELUGO 3 PA, QL, SP
B IMITREX ORAL E QL g letrozole oral 1 H-PA
B IMITREX STATDOSE REFILL E QL B LYNPARZA 2 PA, QL, SP
B IMITREX STATDOSE SYSTEM E QL g mercaptopurine oral 1
B IMITREX SUBCUTANEOUS E QL B NUBEQA 2 PA, QL, SP
B MAXALT E QL B ODOMZO 2 PA, QL, SP
B MAXALT-MLT E QL B ORGOVYX 3 PA, QL, SP
g naratriptan hcl 1 QL B PURIXAN 3 PA, SP
B ONZETRA XSAIL E QL B REVLIMID 2 PA, QL, SP
B RELPAX E QL B ROZLYTREK 2 PA, QL, SP
B REYVOW 2 PA, ST, QL B SOLTAMOX E
g rizatriptan benzoate 1 QL B STIVARGA 2 PA, QL, SP
g sumatriptan succinate oral 1 QL g tamoxifen citrate oral tablet 10 mg 1
g sumatriptan succinate refill 1 QL g tamoxifen citrate oral tablet 20 mg 1 H-PA
g sumatriptan succinate 1 QL B TARGRETIN EXTERNAL 3 QL, SP
subcutaneous B TARGRETIN ORAL 1 SP
B UBRELVY 2 PA, ST, QL B TASIGNA 2 PA, ST, QL, SP
B ZEMBRACE SYMTOUCH E QL B UKONIQ 3 PA, QL, SP
B ZOLMITRIPTAN NASAL SOLUTION E ST, QL B VERZENIO 2 PA, QL, SP
2.5 MG
B VITRAKVI 2 PA, QL, SP
g zolmitriptan oral 1 QL
B XELODA E QL, SP
g zolmitriptan solution 5 mg nasal E ST, QL
B ZEJULA 2 PA, QL, SP
B ZOMIG NASAL SOLUTION 2.5 MG 3 ST, QL
Antiparasitics - Drugs for Parasitic Infections
B ZOMIG NASAL SOLUTION 5 MG 1 ST, QL
B ARAKODA 3 QL
B ZOMIG ORAL E QL
g atovaquone-proguanil hcl 1
Antineoplastics - Drugs for Cancer
g hydroxychloroquine sulfate oral E
B ALECENSA 2 PA, QL tablet 100 mg, 300 mg, 400 mg
B ALUNBRIG 2 PA, QL, SP g hydroxychloroquine sulfate oral 1
g anastrozole oral 1 H-PA tablet 200 mg
B ARIMIDEX E B KRINTAFEL 1 QL
g bexarotene E SP B MALARONE 3
B CALQUENCE 2 PA, QL, SP g permethrin external 1
g capecitabine 1 QL, SP B PLAQUENIL E
B ERIVEDGE 2 PA, QL, SP Antiparkinson Agents - Drugs for Parkinson's Disease
B ERLEADA 2 PA, QL, SP B APOKYN 3 PA, QL, SP
B FEMARA E g carbidopa-levodopa 1
g fluorouracil external solution 1 g carbidopa-levodopa er 1
B GAVRETO 3 PA, QL, SP B DUOPA 3 PA
B IBRANCE 2 PA, QL, SP B INBRIJA 3 PA, QL, SP
B IDHIFA 2 PA, QL, SP B KYNMOBI 3 PA, QL, SP
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
14Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B KYNMOBI TITRATION KIT 3 PA, SP g ziprasidone hcl 1 QL
B MIRAPEX ER E B ZYPREXA ORAL E QL
B NOURIANZ 3 PA, QL B ZYPREXA ZYDIS E QL
g pramipexole dihydrochloride 1 Antivirals - Drugs for Viral Infections
g pramipexole dihydrochloride er E g acyclovir oral 1
g ropinirole hcl 1 B ATRIPLA E ST, QL
g ropinirole hcl er E B BARACLUDE ORAL SOLUTION 2 SP
B RYTARY E B BARACLUDE ORAL TABLET E SP
B SINEMET 3 B CIMDUO 2 QL
Antiplatelets - Drugs for Heart Attack and Stroke B DESCOVY E PA, ST, QL
Prevention B DOVATO 2 QL
B BRILINTA 3 QL g efavirenz-emtricitab-tenofovir E ST, QL
g clopidogrel bisulfate oral 1 g efavirenz-lamivudine-tenofovir 1 QL
B PLAVIX E g emtricitabine-tenofovir df oral tablet 1 QL
B ZONTIVITY 3 QL 100-150 mg, 133-200 mg,
Antipsychotics - Drugs for Mood Disorders 167-250 mg
B ABILIFY E QL
g emtricitabine-tenofovir df oral tablet 1 QL, H
200-300 mg
B ABILIFY MYCITE E PA, QL
g entecavir 1 SP
B ABILIFY MYCITE MAINTENANCE E PA, QL
KIT
B EPCLUSA ORAL PACKET 2 SP
B ABILIFY MYCITE STARTER KIT E PA, QL
B EPCLUSA ORAL TABLET 2 PA, QL, SP
ORAL TABLET 10 MG, 15 MG, 200-50 MG
2 MG, 20 MG, 5 MG B EPCLUSA ORAL TABLET 2 PA, QL, SP
B ABILIFY MYCITE STARTER KIT E PA, QL 400-100 MG
ORAL TABLET 30 MG B GENVOYA 3 QL
g aripiprazole oral solution 1 B HARVONI ORAL PACKET 2 QL
g aripiprazole oral tablet 1 QL B HARVONI ORAL TABLET 2 PA, ST, QL, SP
g aripiprazole oral tablet dispersible 1 QL B ISENTRESS 2
g asenapine maleate E QL B ISENTRESS HD 2
B GEODON ORAL E QL B JULUCA 2 QL
B LATUDA 3 QL B LEDIPASVIR-SOFOSBUVIR 2 PA, ST, QL, SP
g olanzapine oral 1 QL B MAVYRET ORAL TABLET 2 PA, QL, SP
B PERSERIS E B NORVIR ORAL PACKET 2
g quetiapine fumarate 1 B NORVIR ORAL SOLUTION 2
g quetiapine fumarate er 1 QL B NORVIR ORAL TABLET E
B RISPERDAL E B ODEFSEY 3 QL
g risperidone 1 g oseltamivir phosphate oral capsule 1
B SAPHRIS 1 QL g oseltamivir phosphate oral 1 QL
B SEROQUEL E suspension reconstituted
B SEROQUEL XR E QL
B PREZCOBIX 2
B VRAYLAR 3 QL
B PREZISTA 2
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
15Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g ritonavir 1 B HALCION 3
B RUKOBIA 3 PA g hydroxyzine hcl oral 1
B SITAVIG E QL g hydroxyzine pamoate oral 1
B SOFOSBUVIR-VELPATASVIR 2 PA, QL, SP B KLONOPIN E
B STRIBILD 3 QL g lorazepam intensol 1
B SYMFI 2 QL g lorazepam oral concentrate 1
B SYMFI LO 2 QL 2 mg/ml
B TAMIFLU ORAL CAPSULE E
g lorazepam oral tablet 1
B TAMIFLU ORAL SUSPENSION E QL
B LOREEV XR E
RECONSTITUTED g triazolam 1
B TEMIXYS E QL B VALIUM E
g tenofovir disoproxil fumarate 1 H-PA B VISTARIL 3
B TIVICAY 3 B XANAX E
B TIVICAY PD 3 B XANAX XR E
B TRIUMEQ 2 QL Bipolar Agents - Drugs for Mood Disorders
B TRUVADA ORAL TABLET 3 QL g lithium carbonate er 1
100-150 MG, 133-200 MG, g lithium carbonate oral 1
167-250 MG
B LITHOBID 3 PA
B TRUVADA ORAL TABLET E QL
200-300 MG Cardiovascular Agents - Drugs for Heart and Circulation
Conditions
g valacyclovir hcl oral 1 QL
B ACCUPRIL E
B VALTREX E QL
g acetazolamide er 1
B VEMLIDY 3 ST, SP
g acetazolamide oral 1
B VIREAD ORAL TABLET 150 MG, 2
200 MG, 250 MG
B ALDACTONE E
B VIREAD ORAL TABLET 300 MG E
g aliskiren fumarate 1
B VOSEVI 2 PA, QL, SP
B ALTACE E
B XOFLUZA ORAL TABLET 3 QL
B ALTOPREV E
THERAPY PACK g amiodarone hcl oral 1
B ZEPATIER 2 PA, QL, SP g amlodipine besylate oral 1
B ZOVIRAX ORAL 3 g amlodipine besylate-benazepril hcl 1
Anxiolytics - Drugs for Anxiety g amlodipine besylate-valsartan 1
g alprazolam er 1 g atenolol oral 1
g alprazolam intensol 1 g atenolol-chlorthalidone 1
g alprazolam oral 1 g atorvastatin calcium oral tablet 1 QL, H-PA
g alprazolam xr 1 10 mg, 20 mg
B ATIVAN ORAL E
g atorvastatin calcium oral tablet 1 QL
40 mg, 80 mg
g buspirone hcl oral 1
B AVALIDE E
g clonazepam oral 1
B AVAPRO E
g diazepam intensol 1
g benazepril hcl oral 1
g diazepam oral 1
g benazepril-hydrochlorothiazide 1
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
16Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B BENICAR E g fenofibrate oral capsule 150 mg, E
B BENICAR HCT E 50 mg
B BETAPACE E
g fenofibrate oral tablet 120 mg, E
40 mg, 48 mg
B BIDIL 2
g fenofibrate oral tablet 145 mg, 1
g bisoprolol fumarate oral 1 160 mg, 54 mg
g bisoprolol-hydrochlorothiazide 1 B FENOGLIDE E
B BYSTOLIC E g flecainide acetate 1
B CALAN SR 3 B FLOLIPID 3 PA
B CARDIZEM E g furosemide oral 1
B CARDIZEM CD E g gemfibrozil oral 1
B CARDIZEM LA E g guanfacine hcl 1
B CARDURA 3 B HEMANGEOL E
B CAROSPIR 3 PA g hydralazine hcl oral 1
g cartia xt 1 g hydrochlorothiazide oral 1
g carvedilol 1 B HYZAAR E
g chlorthalidone 1 g icosapent ethyl E PA
g clonidine hcl oral 1 B INDERAL LA E
g colesevelam hcl E g irbesartan 1
B COREG E g irbesartan-hydrochlorothiazide 1
B CORGARD 3 g isosorbide mononitrate 1
B CORLANOR 3 PA, QL g isosorbide mononitrate er 1
B COZAAR E B KAPSPARGO SPRINKLE 3
B CRESTOR E QL g labetalol hcl oral 1
g diltiazem hcl er 1 B LASIX 3
g diltiazem hcl er coated beads 1 B LIPITOR E QL
g diltiazem hcl oral 1 B LIPOFEN E
g dilt-xr 1 g lisinopril oral 1
B DIOVAN E g lisinopril-hydrochlorothiazide 1
B DIOVAN HCT E B LOPID 3
g doxazosin mesylate oral 1 B LOPRESSOR 3
B EDARBI 3 g losartan potassium oral 1
B EDARBYCLOR 3 g losartan potassium-hctz 1
g enalapril maleate oral solution 1 PA B LOTENSIN 3
g enalapril maleate oral tablet 1 B LOTENSIN HCT 3
B EPANED 3 PA B LOTREL E
B EXFORGE E g lovastatin oral 1 H
B EZALLOR SPRINKLE 3 PA B LOVAZA E
g ezetimibe 1 g matzim la 1
g ezetimibe-simvastatin 1 B MAXZIDE 3
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
17Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B MAXZIDE-25 3 B PROCARDIA XL E
g metoprolol succinate er 1 g propranolol hcl er 1
g metoprolol tartrate oral tablet 1 g propranolol hcl oral 1
100 mg, 25 mg, 50 mg B QBRELIS 3 PA
g metoprolol tartrate oral tablet E g quinapril hcl 1
37.5 mg, 75 mg
g ramipril 1
B MICARDIS E
B RANEXA E
B MINIPRESS 3
g ranolazine er 1
B MULTAQ 3 PA
B REPATHA 2 PA, ST, QL
g nadolol oral 1
B REPATHA PUSHTRONEX SYSTEM 2 PA, ST, QL
g nebivolol hcl E
B REPATHA SURECLICK 2 PA, ST, QL
B NEXLETOL 2 PA, ST, QL
g rosuvastatin calcium 1 QL
B NEXLIZET 2 PA, ST, QL
g simvastatin oral tablet 10 mg, 1 H-PA
g niacin (antihyperlipidemic) E 20 mg, 40 mg, 5 mg
g niacin er (antihyperlipidemic) 1 g simvastatin oral tablet 80 mg 1
g niacor E g sotalol hcl oral 1
B NIASPAN E B SOTYLIZE 3 PA
g nifedipine er 1 g spironolactone oral 1
g nifedipine er osmotic release 1 B TEKTURNA 3
g nifedipine oral 1 B TEKTURNA HCT 3
B NITRO-BID 2 g telmisartan 1
B NITRO-DUR 3 B TENORETIC 100 E
g nitroglycerin sublingual 1 B TENORETIC 50 E
g nitroglycerin transdermal 1 B TENORMIN E
g nitroglycerin translingual E QL B THALITONE E
B NITROLINGUAL E QL B TOPROL XL E
B NITROMIST 3 QL g torsemide 1
B NITROSTAT 3 g triamterene-hctz 1
B NITRO-TIME 3 B TRICOR E
B NORVASC E g valsartan 1
g olmesartan medoxomil oral 1 g valsartan-hydrochlorothiazide 1
g olmesartan medoxomil-hctz 1 B VASCEPA E PA
g omega-3-acid ethyl esters 1 B VASOTEC E
B PACERONE ORAL TABLET 3 g verapamil hcl er 1
100 MG, 400 MG
g verapamil hcl oral 1
B PACERONE ORAL TABLET 200 MG 3
B VERELAN 3
B PRALUENT E PA, ST, QL
B VERELAN PM 3
g pravastatin sodium 1
B VERQUVO 3 PA, QL
g prazosin hcl oral 1
B VYTORIN E
B PRINIVIL 3
B WELCHOL 1
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
18Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B ZESTORETIC E g methylphenidate hcl er oral tablet E QL
ZESTRIL E extended release 18 mg, 27 mg,
36 mg, 54 mg, 72 mg
B ZETIA E
g methylphenidate hcl er oral tablet E QL
B ZIAC ORAL TABLET 10-6.25 MG, 3 extended release 24 hour
2.5-6.25 MG
g methylphenidate hcl oral 1
B ZIAC ORAL TABLET 5-6.25 MG 3
B MYDAYIS E QL
B ZOCOR E
B PROCENTRA 3
Central Nervous System Agents - Drugs for Attention
Deficit Disorder
B QUILLICHEW ER E QL
B ADDERALL E
B QUILLIVANT XR E QL
B ADDERALL XR 1 QL
g relexxii E QL
B ADHANSIA XR E QL
B RITALIN E
g amphetamine-dextroamphetamine 1
B RITALIN LA E QL
g amphetamine-dextroamphetamine er E QL
B STRATTERA E QL
B APTENSIO XR E QL
B VYVANSE 3 QL
g atomoxetine hcl 1 QL
B ZENZEDI E
B CONCERTA 1 QL Central Nervous System Agents - Drugs for Multiple
Sclerosis
B DEXEDRINE E QL
B AMPYRA E PA, QL, SP
g dexmethylphenidate hcl 1
B AUBAGIO 3 PA, QL, SP
g dexmethylphenidate hcl er 1 QL
B AVONEX PEN 2 PA, QL, SP
g dextroamphetamine sulfate er 1 QL
B AVONEX PREFILLED 2 PA, QL, SP
g dextroamphetamine sulfate oral 1
solution
B BAFIERTAM 2 PA, QL, SP
g dextroamphetamine sulfate oral E
B BETASERON 2 PA, QL, SP
tablet B COPAXONE E PA, QL, SP
B FOCALIN 3 g dalfampridine er 1 PA, QL, SP
B FOCALIN XR E QL B EXTAVIA E PA, ST, QL, SP
g guanfacine hcl er 1 QL B GILENYA 3 PA, QL, SP
B INTUNIV E QL g glatiramer acetate 1 PA, QL, SP
B JORNAY PM E QL g glatopa 1 PA, QL, SP
B METHYLIN 3 B KESIMPTA 2 PA, QL, SP
g methylphenidate hcl er (cd) 1 QL B MAVENCLAD 3 PA, ST, QL, SP
g methylphenidate hcl er (la) oral 1 QL B MAYZENT 3 PA, QL, SP
capsule extended release 24 hour B PLEGRIDY INTRAMUSCULAR 3 PA, QL
10 mg, 20 mg, 30 mg, 40 mg
B PLEGRIDY STARTER PACK 3 PA, QL, SP
g methylphenidate hcl er (la) oral 1
capsule extended release 24 hour
B PLEGRIDY SUBCUTANEOUS 3 PA, QL, SP
60 mg B REBIF E PA, QL, SP
g methylphenidate hcl er (xr) E QL B REBIF REBIDOSE E PA, QL, SP
g methylphenidate hcl er oral tablet 1 QL B REBIF REBIDOSE TITRATION E PA, QL, SP
extended release 10 mg, 20 mg PACK
B REBIF TITRATION PACK E PA, QL, SP
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
19Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
Central Nervous System Agents - Miscellaneous g sodium fluoride 5000 ppm 1
B AUSTEDO 2 PA, QL, SP g sodium fluoride dental 1
B EXSERVAN E PA, SP g sodium fluoride mouth/throat 1
B LYRICA 3 PA, ST, QL Dermatological Agents - Drugs for Skin Conditions
B LYRICA CR E ST, QL B ABSORICA E PA
B NUEDEXTA 2 PA, QL g accutane 1
g pregabalin 1 QL B ACZONE EXTERNAL GEL 5 % 1 QL
g pregabalin er E ST, QL B ACZONE EXTERNAL GEL 7.5 % 3 QL
B RILUTEK E SP B ADVANCED ALLERGY E
g riluzole 1 SP COLLECTION
B TIGLUTIK 3 PA
B ALA SCALP 3
B ZEPOSIA 3 PA, QL, SP
g ala-cort external cream 1 % E
B ZEPOSIA 7-DAY STARTER PACK 3 PA, QL, SP
g ala-cort external cream 2.5 % 1
B ZEPOSIA STARTER KIT 3 PA, QL, SP
B ALDARA 3 QL
Dental and Oral Agents - Drugs for Mouth and Throat
B ALTRENO E PA, QL
Conditions g amnesteem 1
g cavarest 1 B AMZEEQ 3 PA, QL
g chlorhexidine gluconate mouth/ 1 B ATRALIN E PA, QL
throat B AVAR CLEANSER 3
B CLINPRO 5000 3 B AVAR LS CLEANSER E
B DENTA 5000 PLUS 3 B AVAR-E EMOLLIENT 3
B DENTAGEL 3 B AVAR-E GREEN 3
B FLUORIDEX 3 B AVAR-E LS 3
B FLUORIDEX ENHANCED 3 B AVITA E PA, QL
WHITENING
g azelaic acid external 1
g lidocaine hcl mouth/throat 1
g betamethasone dipropionate aug 1
g lidocaine viscous hcl 1
g betamethasone dipropionate 1
B NAFRINSE DAILY/NEUTRAL 2 external
B NAFRINSE WEEKLY 3 g bp 10-1 1
B PERIDEX 3 g calcipotriene-betameth diprop E QL
g periogard 1 external ointment
B PREVIDENT 5000 BOOSTER PLUS 3 g calcipotriene-betameth diprop E
B PREVIDENT 5000 DRY MOUTH 3 external suspension
B PREVIDENT 5000 ORTHO 3
g calcitriol external 1 QL
DEFENSE B CAPEX 2
B PREVIDENT 5000 PLUS 3 B CARAC E
B PREVIDENT DENTAL 3 g claravis 1
B PREVIDENT MOUTH/THROAT 3 B CLENIA PLUS E
g sf 1 B CLEOCIN-T 3
g sf 5000 plus 1 g clindacin etz external swab 1
g sodium fluoride 5000 plus 1 g clindacin-p 1
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
20Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B CLINDAGEL E QL g desonide external ointment 1 QL
g clindamycin phos-benzoyl perox 1 QL B DESOWEN 3 QL
external gel 1.2-5 % g desrx 1 ST, QL
g clindamycin phosphate external 1 B DIPROLENE 3
foam
B DIPROLENE AF 3
g clindamycin phosphate external 1
lotion
B DUPIXENT SUBCUTANEOUS 3 PA, ST, QL, SP
SOLUTION PEN-INJECTOR
g clindamycin phosphate external 1 QL
solution
B DUPIXENT SUBCUTANEOUS 3 PA, ST, QL, SP
SOLUTION PREFILLED SYRINGE
g clindamycin phosphate external 1
swab
B EFUDEX 3
g clindamycin phosphate gel 1 % E (generic
B ENSTILAR 3 QL
external Clindagel), QL B EUCRISA 3 ST, QL
g clindamycin phosphate gel 1 % 1 QL B EVOCLIN 3
external B FINACEA 3
g clobetasol propionate external 1 QL g fluocinolone acetonide body 1 QL
cream g fluocinolone acetonide external 1 QL
g clobetasol propionate external foam E QL g fluocinolone acetonide scalp 1
g clobetasol propionate external gel 1 QL g fluocinonide external cream 0.05 % 1
g clobetasol propionate external 1 QL g fluocinonide external cream 0.1 % E QL
liquid
g fluocinonide external gel 1
g clobetasol propionate external E QL
lotion g fluocinonide external ointment 1
g clobetasol propionate external 1 QL g fluocinonide external solution 1
ointment B FLUOROPLEX 3
g clobetasol propionate external E QL B FLUOROURACIL EXTERNAL E
shampoo CREAM 0.5 %
g clobetasol propionate external 1 QL g fluorouracil external cream 5 % 1
solution g hydrocortisone external cream 1 % E
B CLOBEX E QL g hydrocortisone external cream 1
B CLOBEX SPRAY E QL 2.5 %
g clodan external shampoo E QL g hydrocortisone external lotion 2.5 % 1
g clotrimazole-betamethasone 1 QL g hydrocortisone external ointment 1
external cream 1 %, 2.5 %
g clotrimazole-betamethasone 1 g imiquimod external cream 3.75 % E QL
external lotion g imiquimod external cream 5 % 1 QL
g dapsone external gel 5 % E QL B IMIQUIMOD PUMP E QL
B DAPSONE EXTERNAL GEL 7.5 % E QL B IMPEKLO E QL
B DERMA-SMOOTHE/FS BODY 3 QL B IMPOYZ E QL
B DERMA-SMOOTHE/FS SCALP 3 g isotretinoin capsule 10 mg oral E (generic
B DESONATE 3 ST, QL Absorica), PA
g desonide external cream 1 QL g isotretinoin capsule 10 mg oral 1 PA
g desonide external gel 1 ST, QL g isotretinoin capsule 20 mg oral E (generic
g desonide external lotion 1 QL Absorica), PA
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
21Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g isotretinoin capsule 20 mg oral 1 PA g sulfacetamide sodium-sulfur E
g isotretinoin capsule 30 mg oral E (generic external liquid 10-2 %, 9.8-4.8 %
Absorica), PA g sulfacetamide sodium-sulfur 1
g isotretinoin capsule 30 mg oral 1 PA external liquid 10-5 %, 9-4 %,
9-4.5 %
g isotretinoin capsule 40 mg oral E (generic
Absorica), PA
g sulfacetamide sodium-sulfur 1
external lotion 10-5 %
isotretinoin capsule 40 mg oral 1 PA
g sulfacetamide sodium-sulfur E
g isotretinoin oral capsule 25 mg, E (generic external lotion 9.8-4.8 %
35 mg Absorica), PA
g sulfacetamide sodium-sulfur 1
g ivermectin external cream E QL external pad 10-4 %
B KENALOG EXTERNAL E QL g sulfacetamide sodium-sulfur E
B KLISYRI 3 ST, QL external pad 9.8-4.8 %
B METROCREAM 3 g sulfacetamide sodium-sulfur 1
B METROGEL E external suspension 10-5 %
B METROLOTION 3 g sulfacetamide sodium-sulfur E
external suspension 8-4 %
g metronidazole external cream 1
g sulfacetamide sod-sulfur wash 1
g metronidazole external gel 0.75 % 1
B SULFACLEANSE 8/4 E
g metronidazole external gel 1 % E
g sulfamez wash 1
g metronidazole external lotion 1
B SUMADAN WASH E
B MIRVASO 3 PA, QL
B SUMAXIN 3
g mometasone furoate external 1
B SYNALAR E QL
g myorisan 1
B TACLONEX EXTERNAL OINTMENT E QL
g neuac external gel 1 QL
B TACLONEX EXTERNAL 1
B NORITATE E
SUSPENSION
B OLUX E QL g tazarotene external cream 1 PA, QL
B PICATO EXTERNAL GEL 0.015 %, 3 QL B TAZORAC 3 PA, QL
0.05 %
B TEMOVATE 3 QL
B PLEXION E
B TEXACORT 2
B PLEXION CLEANSER E
g tretinoin external cream 1 QL
B PLEXION CLEANSING CLOTH E
g tretinoin external gel 0.01 % E QL
B RETIN-A E PA, QL
g tretinoin external gel 0.025 % E
B RHOFADE 3 PA, QL
g tretinoin external gel 0.05 % E PA, QL
g rosadan external cream 1
g triamcinolone acetonide external 1 QL
g rosadan external gel 1
aerosol solution
B SERNIVO E QL g triamcinolone acetonide external 1
B SOOLANTRA 1 QL cream 0.025 %, 0.1 %
g sss 10-5 1 g triamcinolone acetonide external 1 QL
g sulfacetamide sodium-sulfur 1 cream 0.5 %
external cream 10-2 %, 10-5 % g triamcinolone acetonide external 1
g sulfacetamide sodium-sulfur E lotion
external cream 9.8-4.8 %
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
22Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
g triamcinolone acetonide external 1 g bd ultra-fine pen needles 2
ointment 0.025 %, 0.1 %, 0.5 % B CARETOUCH MONITOR SYSTEM E
g triamcinolone acetonide external E B CARETOUCH TEST E QL
ointment 0.05 %
B CHEMSTRIP BG LOG BOOK 1
g triamcinolone in absorbase E
B CONTOUR MONITOR DEVICE E
B TRIANEX E
B CONTOUR MONITOR KIT E
g triderm external cream 0.1 % 1 W/DEVICE
g triderm external cream 0.5 % 1 QL B CONTOUR NEXT BLOOD E
B TRIDESILON 1 QL GLUCOSE METER
g tritocin E B CONTOUR NEXT EZ KIT 2
B VANOS E QL W/DEVICE
B VECTICAL E QL
B CONTOUR NEXT LINK KIT E
W/DEVICE
B VERDESO E QL
B CONTOUR NEXT MONITOR KIT 2
B WYNZORA E QL W/DEVICE
g zenatane 1 B CONTOUR NEXT ONE KIT 2
B ZILXI 3 PA, ST, QL B CONTOUR NEXT TEST STRIPS 2 QL
B ZYCLARA E QL B CONTOUR TEST STRIPS E QL
B ZYCLARA PUMP E QL B CVS ADVANCED GLUCOSE TEST E QL
Diabetes - Glucose Monitoring B CVS GLUCOSE METER TEST E QL
B ACCU-CHEK AVIVA PLUS TEST E QL STRIPS
STRIPS B D-CARE BLOOD GLUCOSE E QL
B ACCU-CHEK COMPACT PLUS E QL B D-CARE GLUCOMETER E
TEST STRIPS
B DEXCOM G4 / G5 RECEIVER, 3 PA
B ACCU-CHEK FASTCLIX LANCET 1 TRANSMITTER, SENSOR
KIT (INCLUDING PLATINUM,
B ACCU-CHEK FASTCLIX LANCETS 1 PLATINUM PEDIATRIC)
B ACCU-CHEK GUIDE KIT W/DEVICE E B DEXCOM G6 RECEIVER, 3 PA, QL
B ACCU-CHEK GUIDE ME METER E TRANSMITTER, SENSOR
B ACCU-CHEK GUIDE TEST STRIPS 3 QL B EASY TOUCH TEST E QL
B ACCU-CHEK MULTICLIX LANCET 1 B EASYMAX 15 TEST E QL
KIT B EASYMAX NG BLOOD GLUCOSE E
B ACCU-CHEK MULTICLIX LANCETS 1 B EASYMAX V BLOOD GLUCOSE E
B ACCU-CHEK SMARTVIEW TEST E QL B ENLITE GLUCOSE SENSOR 3 PA
STRIPS B EQ BLOOD GLUCOSE TEST E QL
B ACCU-CHEK SOFT TOUCH 1 B EXACTECH R-S-G TEST E QL
LANCETS
B EXACTECH TEST E QL
B ACCU-CHEK SOFTCLIX LANCET 1
DEVICE KIT FORTISCARE G1 TEST STRIP E QL
B ACCU-CHEK SOFTCLIX LANCETS 1
B FORTISCARE T1 GLUCOSE E
SYSTEM
B ACCUTREND GLUCOSE E QL
B FORTISCARE TEST E QL
g bd autoshield duo pen needles 2
B FREESTYLE LIBRE 14 DAY 3 PA
g bd ultra-fine insulin syringes 2 READER
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
23Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B FREESTYLE LIBRE 14 DAY 3 PA B ONETOUCH VERIO IQ SYSTEM E
SENSOR B ONETOUCH VERIO KIT W/DEVICE E
B FREESTYLE LIBRE 2 READER 3 PA B ONETOUCH VERIO REFLECT E
B FREESTYLE LIBRE 2 SENSOR 3 PA B ONETOUCH VERIO SYNC SYSTEM E
B FREESTYLE LIBRE READER 3 PA, QL B ONETOUCH VERIO TEST STRIPS 1 QL
B FREESTYLE LIBRE SENSOR 3 PA B OPTIUM BLOOD GLUCOSE E
SYSTEM MONITOR
B FREESTYLE PRECISION NEO E B OPTIUM GLUCOSE MONITOR E
SYSTEM SYSTEM
B FREESTYLE PRECISION NEO E QL B OPTIUM TEST E QL
TEST
B OPTIUMEZ TEST E QL
B GUARDIAN LINK 3 TRANSMITTER E
B PARADIGM REAL-TIME E
B GUARDIAN REAL-TIME REPLACE 3 PA TRANSMITTER
PED
B PRECISION LINK E
B GUARDIAN SENSOR (3) 3 PA
B PRECISION PCX E QL
B IN TOUCH 3
B PRECISION PCX PLUS TEST E QL
B INSULIN PEN NEEDLES 2
B PRECISION POINT OF CARE TEST E QL
B KROGER BLOOD GLUCOSE KIT E
B PRECISION QID MONITOR E
B KROGER TEST E QL
B PRECISION QID TEST E QL
B MICRODOT TEST E QL
B PRECISION SOF-TACT MONITOR E
B MINILINK REAL-TIME E
TRANSMITTER
B PRECISION SOF-TACT TEST E QL
B MM EASY TOUCH GLUCOSE E
B PRECISION XTRA E
METER B PRECISION XTRA BLOOD E QL
B NEUTEK 2TEK TEST E QL GLUCOSE
B NOVOFINE AUTOCOVER PEN 2
B PRECISION XTRA MONITOR E
NEEDLE B PREMIUM BLOOD GLUCOSE TEST E QL
B NOVOFINE PEN NEEDLE 2 B QUINTET AC BLOOD GLUCOSE E
B NOVOFINE PLUS PEN NEEDLE 2 B QUINTET AC BLOOD GLUCOSE E QL
B NOVOTWIST 2 TEST
B ONETOUCH DELICA PLUS 1
B QUINTET BLOOD GLUCOSE E
LANCETS SYSTEM
B ONETOUCH ULTRA 2 KIT E
B QUINTET BLOOD GLUCOSE TEST E QL
W/DEVICE B RELION BLOOD GLUCOSE TEST E QL
B ONETOUCH ULTRA MINI KIT E B RELION TRUE MET AIR GLUC E
W/DEVICE METER
B ONETOUCH ULTRA TEST STRIPS 1 QL B RELION TRUE METRIX TEST E QL
B ONETOUCH ULTRALINK E STRIPS
B ONETOUCH ULTRASOFT 1
B RELION ULTIMA GLUCOSE E
LANCETS SYSTEM
B ONETOUCH VERIO FLEX SYSTEM E
B RELION ULTIMA TEST E QL
B ONETOUCH VERIO FLEX SYSTEM E
B SURESTEP PRO LINEARITY 1
KIT W/DEVICE
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
24Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B TRUE FOCUS BLOOD GLUCOSE E QL B INSULIN ASPART PENFILL E ST, QL
STRIP B INSULIN LISPRO E QL
B TRUE METRIX AIR GLUCOSE E B INSULIN LISPRO (1 UNIT DIAL) E QL
METER
B INSULIN LISPRO JUNIOR E QL
B TRUE METRIX BLOOD GLUCOSE E QL KWIKPEN
TEST
B INSULIN LISPRO PROT & LISPRO E QL
B TRUE METRIX GO GLUCOSE E
METER
B LANTUS SOLOSTAR 1 QL
B TRUE METRIX METER KIT E
B LANTUS U-100 VIAL 1 QL
B TRUE METRIX PRO BLOOD E QL
B LEVEMIR U-100 FLEXTOUCH E QL
GLUCOSE B LEVEMIR U-100 VIAL E QL
B TRUETRACK BLOOD GLUCOSE E B LYUMJEV KWIKPEN 2 QL
DEVICE B LYUMJEV VIAL 1 QL
B TRUETRACK TEST E QL B NOVOLIN 70/30 FLEXPEN E ST, QL
B ULTIMA E B NOVOLIN 70/30 FLEXPEN RELION E ST, QL
B UNISTRIP1 GENERIC E QL B NOVOLIN 70/30 RELION E ST, QL
Diabetes - Insulin B NOVOLIN 70/30 VIAL E ST, QL
B ADMELOG E QL B NOVOLIN N FLEXPEN E ST, QL
B ADMELOG SOLOSTAR E QL B NOVOLIN N FLEXPEN RELION E ST, QL
B AFREZZA E PA, QL B NOVOLIN N RELION E ST, QL
B BASAGLAR KWIKPEN E QL B NOVOLIN N VIAL E ST, QL
HUMALOG KWIKPEN 2 QL B NOVOLIN R FLEXPEN E ST, QL
B HUMALOG MIX 50/50 KWIKPEN 2 QL B NOVOLIN R FLEXPEN RELION E ST, QL
B HUMALOG MIX 50/50 VIAL 1 QL B NOVOLIN R RELION E ST, QL
HUMALOG MIX 75/25 KWIKPEN 2 QL B NOVOLIN R VIAL E ST, QL
B HUMALOG MIX 75/25 VIAL 1 QL B NOVOLOG FLEXPEN E ST, QL
B HUMALOG SUBCUTANEOUS 1 QL B NOVOLOG FLEXPEN RELION E ST, QL
SOLUTION B NOVOLOG PENFILL E ST, QL
B HUMALOG SUBCUTANEOUS 2 QL B NOVOLOG RELION E ST, QL
SOLUTION CARTRIDGE
B NOVOLOG U-100 VIAL E ST, QL
B HUMALOG U-100 JUNIOR 2 QL
KWIKPEN B SEMGLEE E QL
B HUMALOG VIAL 1 QL B TOUJEO MAX SOLOSTAR 2 QL
B HUMULIN 70/30 KWIKPEN 2 QL B TOUJEO SOLOSTAR 2 QL
B HUMULIN 70/30 VIAL 1 QL B TRESIBA E QL
B HUMULIN N KWIKPEN 2 QL B TRESIBA FLEXTOUCH E QL
B HUMULIN N VIAL 1 QL Diabetes - Non-Insulin Agents
B HUMULIN R U-500 KWIKPEN 2 QL B ACTOS E QL
B HUMULIN R U-500 VIAL 1 QL B ADLYXIN 3 PA, ST, QL
B HUMULIN R VIAL 1 QL B ADLYXIN STARTER PACK 3 PA, ST, QL
B INSULIN ASPART E ST, QL B ALOGLIPTIN BENZOATE E QL
B INSULIN ASPART FLEXPEN E ST, QL B ALOGLIPTIN-METFORMIN HCL E QL
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
25Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B ALOGLIPTIN-PIOGLITAZONE E QL g pioglitazone hcl 1 QL
B AMARYL E B RIOMET E
B BAQSIMI ONE PACK 2 QL B RYBELSUS 2 PA, ST, QL
B BAQSIMI TWO PACK 2 QL B SOLIQUA 2 QL
B BYDUREON BCISE 2 PA, ST, QL B SYMLINPEN 120 3 QL
AUTOINJECTOR B SYMLINPEN 60 3 QL
B BYETTA 10 MCG PEN 2 PA, ST, QL B SYNJARDY 2 QL
B BYETTA 5 MCG PEN 2 PA, ST, QL B SYNJARDY XR 2 QL
B FARXIGA E ST, QL B TRADJENTA 2 QL
g glimepiride 1 B TRIJARDY XR 2 QL
g glipizide er 1 B TRULICITY 2 PA, ST, QL
g glipizide ir 1 B VICTOZA SOLUTION PEN- 2 PA, ST, (2 Pak),
g glipizide xl 1 INJECTOR 18 MG/3ML QL
g glucagon emergency kit 1 mg 1 QL SUBCUTANEOUS
injection 1 mg B VICTOZA SOLUTION PEN- 3 PA, ST, (3 Pak),
B GLUCAGON EMERGENCY KIT E (Eli Lilly), QL INJECTOR 18 MG/3ML QL
1 MG INJECTION 1 MG SUBCUTANEOUS
B GLUCAGON EMERGENCY KIT 2 (Fresenius), QL
B ZEGALOGUE 2 QL
1 MG INJECTION 1 MG Drugs for Blood Disorders
B GLUCOTROL XL 3 B ADVATE 2 SP
B GLUMETZA E PA B ADYNOVATE 3 PA, SP
g glyburide oral 1 B AFSTYLA INTRAVENOUS KIT 1000 3 PA
g glyburide-metformin 1 UNIT, 2000 UNIT, 250 UNIT, 3000
UNIT, 500 UNIT
B GLYXAMBI 2 ST, QL
B AFSTYLA INTRAVENOUS KIT 1500 3 PA, SP
B GVOKE HYPOPEN 1-PACK E QL UNIT, 2500 UNIT
B GVOKE HYPOPEN 2-PACK E QL B ALPHANATE 2 SP
B GVOKE PFS E QL B ARANESP (ALBUMIN FREE) 2 QL, SP
B JANUVIA E ST, QL B DOPTELET 3 PA, QL, SP
B JARDIANCE 2 ST, QL B ELOCTATE 3 PA, SP
B JENTADUETO 2 QL B HEMOFIL M 2 SP
B JENTADUETO XR 2 QL B HUMATE-P 2 SP
B KAZANO 2 QL B JIVI 3 PA, SP
B KOMBIGLYZE XR 2 QL B KOATE 2 SP
g metformin hcl er 1 B KOATE-DVI 2 SP
g metformin hcl er (mod) E PA B KOGENATE FS 2 SP
g metformin hcl er (osm) E PA B KOVALTRY 2 SP
g metformin hcl ir 1 B MULPLETA 2 PA, QL, SP
B NESINA 2 QL B NEULASTA 3
B ONGLYZA 2 QL B NOVOEIGHT 2 SP
B OSENI 2 QL B NUWIQ 2 SP
B OZEMPIC 2 PA, ST, QL
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
26Drug Name Drug Requirements Drug Name Drug Requirements
Tier & Limits Tier & Limits
B RECOMBINATE 2 SP B K-TAB 3
B RETACRIT INJECTION SOLUTION 2 QL, SP B LOKELMA 3 PA, QL
10000 UNIT/ML, 2000 UNIT/ML, g multi-vitamin/fluoride 1
3000 UNIT/ML, 4000 UNIT/ML,
40000 UNIT/ML
g multivitamin/fluoride tablet 1
chewable 0.25 mg oral (rx)
B RETACRIT INJECTION SOLUTION 2
20000 UNIT/ML
B MULTIVITAMIN/FLUORIDE TABLET 3
CHEWABLE 0.25 MG ORAL (RX)
B TAVALISSE 3 PA, QL, SP
g multivitamin/fluoride tablet 1
B WILATE 2 chewable 0.5 mg oral
B ZARXIO 2 B MULTIVITAMIN/FLUORIDE TABLET 3
B ZIEXTENZO 3 SP CHEWABLE 0.5 MG ORAL
Drugs for Sexual Dysfunction g multivitamin/fluoride tablet 1
B ADDYI 3 PA, QL chewable 1 mg oral
B CIALIS E QL
B MULTIVITAMIN/FLUORIDE TABLET 3
CHEWABLE 1 MG ORAL
B IMVEXXY MAINTENANCE PACK 2 QL
B NASCOBAL 3
B IMVEXXY STARTER PACK 2 QL
B POLY-VI-FLOR 3
B INTRAROSA 3 PA, QL
g potassium chloride crys er oral 1
B OSPHENA 3 PA, QL tablet extended release 10 meq,
g sildenafil citrate oral tablet 100 mg, 1 20 meq
25 mg, 50 mg g potassium chloride crys er oral 3
B STENDRA 3 PA tablet extended release 15 meq
g tadalafil oral tablet 10 mg, 20 mg 1 g potassium chloride er 1
g tadalafil oral tablet 2.5 mg, 5 mg 1 ST g potassium chloride oral solution 1
B VIAGRA E 20 meq/15ml (10%), 40 meq/15ml
(20%)
B VYLEESI 3 PA, QL
g potassium citrate er 1
Electrolytes / Vitamins
B PRENA1 PEARL 3
g cyanocobalamin injection solution 1
1000 mcg/ml B QUFLORA GUMMIES E
B CYANOCOBALAMIN INJECTION 3 B QUFLORA PEDIATRIC 3
SOLUTION 2000 MCG/ML B UROCIT-K 10 3
B DRISDOL 3 B UROCIT-K 15 3
B ERGOCAL 3 B UROCIT-K 5 3
g ergocalciferol oral capsule 1 B VELTASSA 3 PA, QL
B FLORIVA PLUS 3 g vitamin d (ergocalciferol) oral 1
g folic acid injection E capsule 1.25 mg (50000 ut)
g folic acid oral tablet 1 mg 1 B VITAPEARL 3
g klor-con 1 Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer
g klor-con 10 1 B ACIPHEX E QL
g klor-con m10 1 B ACIPHEX SPRINKLE E QL
g klor-con m15 3 B CARAFATE E
g klor-con m20 1 B CYTOTEC 3
See page 6, 7 for coverage details. Drugs listed as E or ST are subject to Prior Authorization in CT, NJ and NY (referred to as
First Start in New Jersey).
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